Patient: Female, 32Final Diagnosis: Complicated hydatid cystSymptoms: Cough with expectoration and fever for the last 4 monthsMedication: Tab. AlbendazoleClinical Procedure: —Specialty: PulmonmologyObjective:Unusual clinical courseBackground:Hydatid cyst, or Echinococcosis, is an important helminthic zoonotic disease in humans that commonly affects the liver and lungs. Uncomplicated hydatid cysts, seen as round opaque lesions on chest radiography, are easily diagnosed, whereas complicated cysts (infected and or perforated) may change the radiographic appearance of the hydatid cyst, causing an incorrect diagnosis and delayed treatment. Although in radiology many signs have been described, the “air bubble” sign, seen in the mediastinal window of CECT as a single or multiple small rounded radiolucent areas with sharp margins within the periphery of a solid mass lesion, is being recognized as a sign with high sensitivity and specificity in the diagnosis of complicated hydatid cysts.Case Report:A 32-year-old female on anti-tubercular treatment for the past 3 months without any improvement was admitted to our hospital. CECT of the chest revealed a mass-like lesion with the “air bubble” sign. After 15 days the patient had a vigorous bout of coughing, leading to expectoration of pieces of whitish yellowish gelatinous membrane for the next 3 days. The ELISA result for Echinococcus was highly positive. On the basis of the “air bubble” sign, positive serology, and expectorated pieces of the membrane, the patient was diagnosed as having a complicated hydatid cyst.Conclusions:Due to the varied presentations of complicated hydatid cyst, the knowledge and awareness of various signs in radiology associated with the hydatid cyst, in particular the “air bubble” sign, is imperative in making a prompt and accurate diagnosis of a complicated hydatid cyst.
Patient: Female, 15Final Diagnosis: Unilateral agenesis of the lungSymptoms: Sore throat with dry coughMedication: —Clinical Procedure: Cect of the chest and bronchoscopySpecialty: PulmonologyObjective:Congenital defects/diseasesBackground:Agenesis of the lung, a rare congenital anomaly, arises or develops when there is disruption of evolution of the primitive lung bud, leading to complete absence of the lung, bronchi, and the main pulmonary artery. With right-sided agenesis, a variety of cardiac and other congenital malformations are more commonly seen, leading to a poor prognosis.Case Report:A young female, aged 15 years, presented with complaints of sore throat and cough. Her x-ray of the chest showed a homogeneous opacity in the middle and lower zones on the right side with marked shift of the mediastinum to the right side. Upon investigation, she was diagnosed with agenesis of the right lung with scoliosis, without any other congenital anomaly.Conclusions:Especially in adults, it requires a high level of good clinical judgement to identify and diagnose this congenital aberration, as they are often wrongly diagnosed as more common diseases associated with unilateral opaque hemithorax on x-ray. Hence, when confronted with an opaque hemithorax with shift of the mediastinum to the affected side in a young person, “agenesis of the lung” should be an important differential diagnosis while investigating the case.
We read with interest the study by PRENDKI et al. [1], in which the authors proved the diagnostic role of low-dose computed tomography (LDCT) of the thorax in the evaluation of elderly patients with pneumonia. The results showed that addition of LDCT modified the probability of pneumonia in 45% of the patients. However, on comparing with the reference diagnosis, a high discordance rate of 32.2% was found in the LDCT-based diagnosis that needs to be justified [1]. Being an interventional study, the authors should mention the treatment outcomes of all the enrolled patients, particularly those with low probability after LDCT (treated with or without antibiotics). Comparing these outcomes among low/ intermediate/high diagnostic groups before and after LDCT might help to reveal a clear picture. Moreover, in view of clinician-labelled diagnosis being the primary outcome in the study, using multiple physicians for better diagnostic agreement might have increased the authenticity of the results. LDCT has a specific place in the diagnostic algorithm for pneumonia [2] and may even be detrimental if used injudiciously. Consolidation in elderly patients encompasses a variety of other differential diagnoses, notably lung cancer, metastasis and diffuse parenchymal lung diseases, which are likely to be missed if we use LDCT without appropriate settings (like contrast, high-resolution cuts, etc.). This is especially true because clinical features in the elderly are neither sensitive nor specific in differentiating infective from non-infective aetiologies. With narrow differentials, prominent symptoms and concern for radiation exposure, LDCT may find a better place in the evaluation of pneumonia in young patients, but this needs future research. Computed tomography is an important but not a gold standard diagnostic tool in pneumonia [3]. Considering the wide array of possible aetiologies in elderly patients, the decision to use LDCT, conventional computed tomography or no computed tomography should be individualised based on the clinical scenario, ongoing treatment response, availability of computed tomography and its cost-effectiveness.
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