Differential Diagnosis for the Presented Case

The patient's imaging findings reveal several key points that need to be considered for a comprehensive differential diagnosis. These include a calcified subpleural nodule in the right lower lobe, a focal isodense lesion in the left adrenal gland, degenerative changes of the spine and sacroiliac joints, a small fatty umbilical hernia, and evidence of cholecystectomy among others.

• Single Most Likely Diagnosis

  • Calcified granuloma: This is the most likely diagnosis for the 3.7 mm calcified subpleural nodule given its appearance and location. Calcified granulomas are common and usually represent healed infections, such as histoplasmosis or tuberculosis.
  • Benign adrenal lesion (e.g., adrenal adenoma): For the 16.4 x 12.1 mm focal isodense lesion in the left adrenal gland, although the evaluation is limited by the absence of IV contrast, the size and density suggest a possible benign adrenal adenoma, which is a common incidental finding.

• Other Likely Diagnoses

  • Hamartoma: Another possibility for the calcified subpleural nodule, although less common than a calcified granuloma.
  • Non-functioning adrenal adenoma: Given the lesion's characteristics, it could also be a non-functioning adrenal adenoma, which would require further evaluation to confirm.
  • Degenerative disc disease: The mild decrease in the height of the L1 vertebral body and degenerative changes of the spine and sacroiliac joints suggest ongoing degenerative processes.

• Do Not Miss Diagnoses

  • Malignancy (e.g., lung cancer, adrenal carcinoma): Although less likely given the appearance of the lesions, it's crucial not to miss a potential malignancy. The adrenal lesion's significance and the subpleural nodule's nature necessitate careful consideration and possibly further imaging or biopsy.
  • Infection (e.g., tuberculosis, histoplasmosis): Especially for the calcified granuloma, ensuring that the patient does not have an active infection is important.
  • Pheochromocytoma: Although the adrenal lesion's characteristics do not strongly suggest this, it's a diagnosis that could have significant clinical implications and should be considered, especially if the patient has symptoms like hypertension.

• Rare Diagnoses

  • Hydatid cyst: A rare possibility for the calcified subpleural nodule, especially if the patient has a history of travel to or residence in endemic areas.
  • Adrenal metastasis: If the patient has a known history of cancer, this could be a consideration for the adrenal lesion, although the primary diagnosis would likely be known.
  • Lymphoma: Involvement of the adrenal glands or lung could be seen in lymphoma, a rare but important consideration if other systemic symptoms or lymphadenopathy are present.

Next Steps

• Correlate findings with prior imaging to assess for any changes over time.
• Consider further imaging (e.g., MRI for the adrenal lesion, CT with contrast) for better characterization of the lesions.
• Clinical evaluation for symptoms that could suggest malignancy, infection, or endocrine disorders.
• Possibly, biopsy of the lesions if malignancy cannot be ruled out by imaging or if the clinical suspicion remains high despite negative imaging findings.