Mystery Quiz

Mystery Quiz

February 4, 2011
Mystery Quiz

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

The patient is an 84 year old man who presents with small amounts of hemoptysis for one week prior to admission. He is a life-long non-smoker who began having cough with sputum production for one year without fever, chills, nightsweats, orthopnea, weight loss, arthralgias or rash. The patient denied unusual occupational exposures, history of prior TB, travel, or owning pets. The past medical history was significant for coronary bypass surgery, hypertension, atrial fibrillation treated…

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Mystery Quiz- The Answer

November 13, 2010
Mystery Quiz- The Answer

Dana Clutter, MD

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

Faculty peer reviewed

The answer to the mystery quiz is bacillary angiomatosis (BA). BA is a disease that most frequently affects individuals infected with the human immunodeficiency virus (HIV) and typically presents with multiple cutaneous papules and nodules. Visceral manifestations also occur and can involve the bone, lungs, lymph nodes, spleen, liver (termed peliosis hepatis) and the central nervous system.(1) Since the relatively…

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Mystery Quiz

November 10, 2010
Mystery Quiz

Dana Clutter, MD

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

A 25 year old woman infected with HIV presents to an HIV/AIDS clinic in Kampala, Uganda, for evaluation of cutaneous lesions on her face, arms and back. Aside from the disfiguring nature of her lesions, she reports being in her usual state of health. She denies any constitutional symptoms and all of her vital signs are stable. Her current CD4+ T cell count is 1 cell/cmm and she has…

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Mystery Quiz- The Answer

July 9, 2010

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

The answer to the mystery quiz is pleural effusion that is loculated in both the horizontal and right oblique fissures. Pleural effusion is seen as blunting of the right costophrenic angle and tracking of fluid laterally (Image 3, arrowhead). The horizontal fissure thickens due to fluid which becomes an ovoid density more medially (Image 3, arrow). This ovoid density, representing loculated fluid in the horizontal fissure, is often referred to as a…

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Mystery Quiz

July 4, 2010
Mystery Quiz

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

The patient is a 61 year old man presenting with one month of worsening shortness of breath. The patient has a history of alcoholism and was diagnosed with atrial fibrillation during a hospital admission for detox three years earlier. Warfarin therapy was not begun due to a history of poor medication compliance. One year prior to admission an echocardiogram showed a normal global ejection fraction and mild mitral regurgitation. One month prior to admission,…

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Mystery Quiz- The Answer

March 28, 2010
Mystery Quiz- The Answer

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

The answer to the mystery quiz is progressive massive fibrosis. This condition is a severe form of silicosis. The chest radiograph (Image 3) shows bullous disease of the right upper lobe, increased density of the right hilum, increased density and upward retraction of the left hilum (also seen in Image 4), increased density in peripheral areas of both lungs, and an air crescent sign in the left upper lobe (also…

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Mystery Quiz

March 17, 2010
Mystery Quiz

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

The patient is a 39yo male followed in pulmonary clinic for chronic breathlessness and intermittent sputum production, sometimes blood tinged. Symptoms were first noted eleven years earlier at which time pulmonary function testing revealed mixed obstructive and restrictive defects. The patient experienced some improvement with bronchodilators, occasional courses of oral steroids and antibiotics, but was never entirely free of his symptoms. Over an interval of ten years, the patient required…

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Mystery Quiz- The Answer

October 27, 2009
Mystery Quiz- The Answer

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

The answer to the mystery quiz is thoracic splenosis. The key to the solution is the past medical history of a gunshot wound. Shrapnel is seen on the plain CXR (Image 1) as well as in the soft tissue of the back (Image 5). The CXR also shows a lateral diaphragmatic abnormality (Image 1, arrow) likely due to adhesions. The left upper quadrant is notable for colonic gas where one…

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Mystery Quiz

October 23, 2009
Mystery Quiz

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

A 61 year old man was referred to the pulmonary service for an abnormal pulmonary function test (PFT). The patient was a lifelong smoker and had symptoms suggestive of obstructive sleep apnea. The PFT showed a mixed obstructive and restrictive defect. The latter abnormality was considered to be out of proportion to the patient’s obesity, hence a chest CT scan was obtained to evaluate for possible parenchymal lung disease (shown…

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Mystery Quiz- The Answer

July 23, 2009
Mystery Quiz- The Answer

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

The answer to the mystery quiz is bland alveolar hemorrhage. The CXR (image 1) shows cardiomegaly with mild increase in opacification of the right middle and right lower lobes. The CT images show areas of multifocal ground glass opacification, that is, the underlying interstitium is visible through the opacification, and the variably sized opacities are widely distributed throughout the lungs (images 2, 3, and 4). Image 4 shows prominent interstitium…

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Mystery Quiz

July 18, 2009
Mystery Quiz

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

The patient is a 74 year old man complaining of hemoptysis for four days. The patient has a history of hypertension, but had not been followed medically for many years until two weeks earlier when he presented with leg swelling, breathlessness, and atrial flutter. He was admitted, diuresed, begun on antihypertensive medications including hydralazine, aspirin, and anti-coagulated with enoxaparin and warfarin. After discharge, the patient felt well for a few days before…

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Mystery Quiz- The Answer

May 1, 2009
Mystery Quiz- The Answer

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

The answer to the mystery quiz is sarcoidosis. The CXR shows diffuse, bilateral infiltration with a predominantly nodular pattern. The pulmonary hila are also prominent. The CT image shows innumerable 2-3mm nodules, many of which have a perilymphatic distribution. The lymphatics, in parallel with the pulmonary vasculature, course through the interstitium. Hence, the perilymphatic nodularity has an interstitial distribution and appears as “studding” along the interstitium which is…

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