Case 3-PRE CLASS CASE

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Further Explanation:

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Case 3-PRE CLASS CASE

Case 3 and Comparison Case 3--to view HINTS below, go back to the case page

Further Explanation:

Case 3--

Hint 1:  There are too few lung markings in both apices, with curved white lines that are not running in the expected direction of vessels. These are large empty air spaces, or bullae, which are subtle on radiography but are much better seen on cross sectional imaging such as CT.

Hint 2: Just looking at the entire chest, the lungs look a bit too large, but this is somewhat subjective. If you count the ribs, the 11th ribs bilaterally are visible above the diaphragms, which is consistent with enlarged lung volumes, or hyperinflation.

Hint 3: There is actually a very subtle opacity overlying the right clavicle, in a complicated part of the chest where it is easy to miss. The combination of these findings (apical bullae, hyperinflation, and a lung mass) are most consistent with smoke-induced emphysema and lung cancer.

Case 3 Comparison--

Hint 1: The contour of the diaphragms is very abnormal, curving DOWN instead of up, and with slightly scalloped margins. This is the appearance of severe hyperinflation.

Hint 2: Again, the lungs overall look subjectively large, and the 11th ribs are far above the inverted diaphragms.

Hint 3: There are large areas of both lungs that appear to have not enough pulmonary vessels. However these large black areas are not limited to the apices, extending into the lung bases. The combination of these findings (severe hyperinflation and emphysema involving the lung bases) is suggestive of alpha-1-antritrypsin deficiency, a cause of basilar predominant emphysema.