Mystery Quiz

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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Mystery Quiz

December 21, 2012
Mystery Quiz

Elizabeth Mulaikal MD, Vivian Hayashi MD, Robert Smith MD

The patient is a 55 year old African American male with a 60 pack year history of tobacco use and AIDS,who presented with 1 month of intermittent fevers and weight loss. His most recent CD4 count and viral load were 2/cmm and 50,623 copies/mL, respectively. Prior opportunistic infections included pneumocystis pneumonia and thrush. He was previously homeless, but currently resides in a Single Room Occupancy Housing. Upon presentation he complained of occasional night sweats, but no…

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Mystery Quiz- The Answer

June 29, 2012

Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors

The answer to the mystery quiz is thymoma associated with myasthenia gravis. The clue to the case is the intermittent dysphagia and chewing difficulty. If one considers myasthenia in the differential, then an otherwise grossly normal appearing chest radiograph may be viewed more closely, with attention directed to the upper, anterior mediastinum. The chest radiograph shows the ascending aorta (image 3, arrow); on the lateral film, the retrosternal space, which normally contains air, appears…

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Mystery Quiz

June 19, 2012
Mystery Quiz

Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors

The patient is a 61 year old man admitted to the psychiatry service for depression. During the hospitalization the patient reported a three year history of dysphagia and occasional right sided chest pain not clearly associated with exertion. He first noted difficulty chewing and swallowing turkey on Thanksgiving Day. The symptoms were intermittent thereafter and involved solid foods but not liquids. His chewing and swallowing difficulty abated for a year but returned one year…

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Mystery Quiz- The Answer

December 14, 2011
Mystery Quiz- The Answer

Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors
The answer to the mystery quiz is Kaposi’s sarcoma. The CXR shows bilateral confluent airspaceopacities which have a wide differential diagnosis in this case. The CT narrows the differential.  Specifically, the opacities appear to emanate from the central hilar areas, cuff the airways, and fan out into the more distal airspaces (Images 3 and 4).  This appearance is very suggestive of Kaposi’s sarcoma. CT scans may also reveal mediastinal lymphadenopathy and large

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Mystery Quiz

December 9, 2011
Mystery Quiz

Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors

The patient is a 52 year old African-American man who presented with breathlessness and weight loss over one month along with watery stools during the week prior to admission. He had a history of untreated HIV infection, a CD4 cell count of 5/cmm, oral candidiasis, and peri-rectal HSV infection. The patient reported occasional cough with variable sputum production but denied fever, night sweats, hemoptysis, recent travel, or sick contacts. His risk factor for HIV…

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Mystery Quiz

November 30, 2011
Mystery Quiz

Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors

The patient is a 52 year old African-American man who presented with breathlessness and weight loss over one month along with watery stools during the week prior to admission. He had a history of untreated HIV infection, a CD4 cell count of 5/cmm, oral candidiasis, and peri-rectal HSV infection. The patient reported occasional cough with variable sputum production but denied fever, night sweats, hemoptysis, recent travel, or sick contacts. His risk factor for HIV…

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Mystery Quiz- The Answer

June 17, 2011
Mystery Quiz- The Answer

Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors

The answer to the mystery quiz is lymphangitic carcinomatosis (LC). The diffuse interstitial and infiltrative pattern seen on CXR is best appreciated on the CT of the chest. On Images 4, 5 and 6, interlobular septal thickening is apparent (arrow) and is due to tumor infiltration of interstitial lymphatics. Also evident on these images (arrowhead) is diffuse peribronchial thickening due to tumor infiltration of the airways. Image 6 (open arrowhead) additionally shows pleural nodules,…

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Mystery Quiz

June 16, 2011
Mystery Quiz

Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors

The patient is a 62 year old man presenting with increasing breathlessness for the past six weeks. The patient first noted symptoms of mild shortness of breath and cough productive of yellow sputum that he attributed to his yearly winter cold. The sputum cleared and at presentation the patient had largely unproductive cough. A construction worker until six months earlier, the patient’s unlimited exercise tolerance was now limited to minimal exertion. He denied current…

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Mystery Quiz- The Answer

February 11, 2011
Mystery Quiz- The Answer

Vivian Hayashi MD and Robert Smith MD, Mystery Quiz Section Editors

The answer to the mystery quiz is pulmonary artery aneurysm. The chest CT shows a very round lesion in the left lower lobe with possible surrounding ground glass opacity. This perfectly round shadow suggests a vascular origin (Image 4, arrow). The apparent vascularity is further suggested by the sequential axial cuts on the CT (Image 5) which show a tubular dilatation (Image 5b) that bifurcates distally (Image 5d & e).…

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