Presentation
Referred with three days history of worsening shortness of breath on rest.
Patient Data
There is opacification of the lower two-thirds of the left hemithorax indicative of large pleural effusion. This is associated with a positive mass effect with displacement of the mediastinum to the right. There is an impression of a large superior mediastinal mass on the left with tracheal deviation to the right. There is evidence of a small right-sided pleural effusion.
There is a Type B aortic dissection extending from the distal aortic arch into the left common iliac artery associated with a large aneurysm of the proximal descending thoracic aorta. There is no active contrast leak identified.
As already noted in the prior chest radiograph, there is a large left-sided pleural effusion with nearly complete collapse and consolidation of the left lung. This is highly likely to be secondary to rupture/leaking of the aneurysm.
The major mesenteric vessels are noted to originate from the true lumen. The left renal artery shows reduced contrast filling and the left kidney is ischemic.
Case Discussion
In a patient presenting of this age with shortness of breath as the main presenting complaint, malignancy often becomes one of the likely diagnosis. In this case, however, CT aortogram showed a large aneurysm of the proximal descending thoracic aorta with a type B aortic dissection. The large pleural effusion on the left was highly likely to be secondary to rupture/leaking of thoracic aortic aneurysm. The patient was diagnosed with chronic aortic dissection and was for palliative measures upon discussion with the vascular team.
This case highlights the importance of always considering other differentials in addition to your provisional diagnosis, both clinically and radiologically.
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