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An odd case of multiple “cannonball metastases”
  1. S Buchholz,
  2. P Szawarski,
  3. S L Dawson
  1. Department of Integrated Medicine, University Hospitals of Leicester NHS Trust, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
  1. Correspondence to:
 Dr Buchholz; 
 abciximab{at}doctors.org.uk

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Answers on p 547.

An 84 year old woman was admitted to our acute stroke unit with sudden onset of slurred speech and right sided weakness of six hours’ duration. She gave a history of a previous myocardial infarct, chronic obstructive lung disease, and depression. On examination she was comfortable and there were no peripheral stigmata of chronic disease. Neurological examination was consistent with a left hemisphere lacunar stroke syndrome. Respiratory examination was unremarkable except for decreased breath sounds and dullness to percussion at the left base. A right thoracotomy scar in the fifth intercostal space was noted. Abdominal examination was insignificant except for a healed laparotomy scar. Routine blood tests including white cell count, C-reactive protein, and plasma viscosity were unremarkable. Cranial computed tomography showed marked generalised atrophy with evidence of widespread cerebrovascular disease and a small left sided lacunar infarct confirming the clinical diagnosis. There was no evidence of metastatic disease. A chest radiograph (see fig 1) performed on admission was reported by the admitting medical officer as multiple cannonball metastases.

Figure 1

Chest radiograph of patient on admission.

QUESTIONS

  1. What abnormalities are seen on the radiograph?

  2. What is the differential diagnosis?

  3. What important piece of information from the patient’s past medical history is missing and would highlight a possible diagnosis?

  4. What is the most likely diagnosis?

  5. How would you treat this condition?

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