Mystery Quiz

Mystery Quiz-The Answer

November 28, 2016
Mystery Quiz-The Answer

Before you read the answer, please review the original Mystery Quiz posted 11/18/16.

Vivian Hayashi MD, Robert Smith MD

The answer to the mystery quiz is aspiration pneumonia.  The CXR (Image 1) shows a total opacification of the right hemithorax.  Importantly, the tracheal air column is deviated to the side of the opacification.  This indicates loss of volume of the right lung due to endobronchial obstruction from aspiration (e.g. gastric contents), endobronchial tumor or foreign body.  Although one might consider pleural effusion, chylothorax and empyema …

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Mystery Quiz

November 18, 2016
Mystery Quiz

Vivian Hayashi MD, Robert Smith MD

The patient is an 86 year old man who presented with weakness, lethargy and falls.  His history was noteworthy for an episode of empyema nine years earlier that was managed with tube thoracostomy followed by decortication.  Seven years prior to this admission, upper endoscopy revealed Barrett’s esophagus and adenocarcinoma of the distal esophagus.  An esophagectomy and gastric pull-up was performed.  The patient had intermittent episodes of aspiration over the subsequent years.  Prior to the current admission, the patient complained …

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Mystery Quiz

October 28, 2016
Mystery Quiz

Vivian Hayashi MD, Robert Smith MD

The patient is an 86 year old man who presented with weakness, lethargy and falls.  His history was noteworthy for an episode of empyema nine years earlier that was managed with tube thoracostomy followed by decortication.  Seven years prior to this admission, upper endoscopy revealed Barrett’s esophagus and adenocarcinoma of the distal esophagus.  An esophagectomy and gastric pull-up was performed.  The patient had intermittent episodes of aspiration over the subsequent years.  Prior to the current admission, the patient complained …

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Mystery Quiz-The Answer

June 19, 2015
Mystery Quiz-The Answer

Vivian Hayashi MD, Robert Smith MD

The answer to the mystery quiz is methicillin-resistant S. aureus (MRSA) pneumonia. The initial CXR (image 4) showed increased density in the area of the left hilum, hinting at a process in the superior segment of the left lower lobe. The next CXR (image 5) showed an airspace process in the left lower lobe that had rapidly evolved over 2 days. An interstitial process can be seen, as well, along with airspace disease (image 5, arrow). In addition, there …

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Mystery Quiz

June 18, 2015
Mystery Quiz

Vivian Hayashi MD, Robert Smith MD

The patient is a 46 year old female who presented to the emergency room with breathlessness, productive cough, subjective fever, and myalgia for one week. Her history was notable for mild persistent asthma treated with tiotropium, mometasone, formoterol, and albuterol as needed. The patient was homeless and lived in a shelter. She was poorly compliant with her medications. In the ER, the patient had a pulse rate of 102 bpm, was afebrile with normal blood pressure, and had diffuse …

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Mystery Quiz-The Answer

December 17, 2014
Mystery Quiz-The Answer

Vivian Hayashi MD, Robert Smith MD

The answer to the mystery quiz is pleural effusions, specifically, bilateral subpulmonic effusions. The chest radiograph shows a number of findings: (1) the apparent diaphragm shadow is in fact fluid sandwiched between the undersurface of the lung and the actual diaphragm (Image 2a, arrow); (2) the density of this shadow is homogenously white (Image 2a, asterisk) and differs from a normal diaphragm which has a graded density (Image 2b, triangle) due to superimposed air that progressively decreases towards the …

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Mystery Quiz

December 2, 2014
Mystery Quiz

Vivian Hayashi MD, Robert Smith MD

The patient is an 82 year old man with frequent breathlessness. The patient had been admitted several times in the past two years for congestive heart failure. Two years earlier, the patient suffered an NSTEMI. A diagnostic cardiac catheterization revealed triple vessel coronary disease. A decision to perform CABG vs coronary stenting was delayed pending an evaluation of iron-deficiency anemia associated with a positive test for fecal occult blood. A recent echocardiogram showed normal left ventricular function but diastolic …

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Mystery Quiz- The Answer

July 10, 2014
Mystery Quiz- The Answer

Vivian Hayashi MD, Robert Smith MD

The answer to the mystery quiz is rhabdomyolysis due to legionella pneumonia (LP). The presentation of the patient, namely severe rhabdomyolysis complicated by acute kidney injury, obscured the presence of a subtle retrocardiac density that is visible on the CXR (Image 2, asterisk). The upper axial image from an abdominal CT, obtained one day after the CXR, shows the extent of the LLL infiltrate (Image 3). The infiltrate is contained by the major fissure and is characterized by air …

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Mystery Quiz

July 2, 2014
Mystery Quiz

Vivian Hayashi MD, Robert Smith MD

A 51 year old man presented to the emergency room with fever and myalgias for four days. The patient was previously in good health except for occasional asthmatic exacerbations. He noted thigh pain in the few days prior to admission, for which he took about 8 tablets of ibuprofen. Additional symptoms included anorexia, epigastric pain, emesis that was neither bloody nor bilious, and loose stools. The patient also noted that his urine was dark colored and he experienced perioral …

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Mystery Quiz-The Answer

December 20, 2013
Mystery Quiz-The Answer

Vivian Hayashi MD, Robert Smith MD

The answer to the Mystery Quiz is diaphragmatic hernia, specifically a Bochdalek hernia. The CXR shows increased density behind the heart that has a smooth superior border (Image 2, arrows). This density does not obscure the left heart border, denoting a posterior location behind the heart. Furthermore, the lateral aspect of the opacity demonstrates low attenuation (hypo-dense) suggesting the presence of fat (Image 2, asterisk). The left hemidiaphragm is not visible indicating that the abnormality is contiguous with the …

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Mystery Quiz

December 17, 2013
Mystery Quiz

Vivian Hayashi MD, Robert Smith MD

The patient is a 78 year old man who presented to the emergency room with fever, pain, swelling, and erythema of the right leg over a two day period. The patient denied abdominal symptoms, cough or breathlessness over his baseline. His past medical history included Waldenstrom’s macroglobulinemia ten years earlier that responded to treatment with chlorambucil. Other morbidities included severe chronic obstructive pulmonary disease, myocardial infarction 20 years previously, and chronic venous insufficiency resulting in lower extremity edema. The …

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Mystery Quiz-The Answer

January 10, 2013
Mystery Quiz-The Answer

Elizabeth Mulaikal MD, Vivian Hayashi MD, Robert Smith MD

The answer to the mystery quiz is pulmonary Mycobacterium kansasii infection. The patient’s clinical presentation of fevers and night sweats suggested an infectious process or B symptoms due to lymphoma. The initial chest radiograph (image 1) demonstrated a left hilar mass which was noted to be larger on a subsequent chest radiograph (images 2 and 4)) 1 month later. This increase in size over a short duration again suggested an infectious etiology. Importantly and a key …

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