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

The patient is a 42 year old man with a history of non-productive cough for several weeks. Three weeks prior to evaluation by the pulmonary service, the patient presented to the ER with a presumed vasovagal syncopal event that occurred on a subway platform. The patient’s prior medical history included allergic sinusitis and nasal polypectomy. Other than cough, the patient denied constitutional symptoms. The patient was not taking any medications.…

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

The answer to the mystery quiz is allergic bronchopulmonary aspergillosis (ABPA). The CXR shows right upper lobe opacities, two of which appear round (Image 3, arrow) and another tubular (Image 3, arrowhead), and a left upper lobe opacity which has the characteristics of subsegmental atelectasis (Image 3, double arrows). The CT scan, performed ten days after the CXR, shows central bronchiectasis of the RUL (Image 4, arrows); tubular branching shadows (Image 6,…

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

The patient is a 42 year old male non-smoker with history of poorly controlled asthma (first diagnosed in 1994, recurrent need for steroid treatments but never intubated), severe seasonal allergies with chronic sinusitis, hepatic steatosis, GERD and gout who presented with complaints of five to ten days of myalgias, productive cough, wheezing and chest tightness. His medications included albuterol, fluticasone and formoteral inhalers, montelukast, colchicine, indomethacin prn, and fexofenadine. Exam was significant for…

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