A 70-year-old man visited the emergency department with a 3-day history of right upper quadrant pain. He was febrile (temperature, 37.6°C) and his white blood cell count was 19 × 103/μL. His abdomen was soft and tender at the right upper quadrant with a positive Murphy sign.
He had a history of splenectomy for hereditary spherocytosis at age 40 years and a history of upper gastrointestinal tract bleeding from a gastric ulcer 7 years prior to admission. He had a gallstone disease for the last 12 years. The abdominal ultrasonographic scan showed acute cholecystitis with gallbladder wall thickening and pericholecystic fluid collection, and chest radiography revealed a mass of the right lower lobe (Figure 1). The patient underwent a cholecystectomy and had an eventful postoperative recovery. He was then referred to the chest physicians and had further investigation with a biopsy guided by magnetic resonance imaging (Figure 2) and computed tomography. Unfortunately, the histopathologic examination results of the biopsy specimen were inconclusive; thus, the patient underwent a right thoracotomy.
An erect chest radiograph shows a shadowing of the right lower lobe in continuation with the shade of the heart.
A magnetic resonance image shows a paravertebral mass of the thoracic spine.
A. Metastatic malignant disease
C. Extramedullary hemopoiesis
Stavrothanasopoulou A, Germanos S, Xipolitos A, Ntochas C, Stathopoulou M, Demertzis P, Agelidou A, Vlastos F. Image of the Month—Quiz Case. Arch Surg. 2008;143(12):1231. doi:10.1001/archsurg.143.12.1231