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pmc-6158927-1 | A 67-year-old male underwent total laryngectomy and secondary tracheoesophageal prosthesis placement 15 years prior. He was proficient at the use and care of his TEP. He lost his TEP and presented to his speech language pathologist for replacement. He did not recall how or when the TEP was dislodged; thus, it was unclear if he swallowed or aspirated it. After developing mild dyspnea, an emergency room chest X-ray suggested a foreign body. The patient was subsequently transferred to our head and neck surgery office. He reported increased mucus production, coughing, fullness in his chest, and inability to fully catch his breath.
To examine the airway for possible aspirated TEP, topical 4% lidocaine was sprayed into the stoma. With the patient sitting upright in the examination chair, flexible bronchoscopy was performed using a transnasal esophagoscope (KayPentax EE-1580). The prosthesis was found in the left mainstem bronchus ().
The TEP's one-way valve orientation allowed air inhalation but not exhalation, trapping air in the lung. The prosthesis was retrieved without difficulty by grasping it with biopsy forceps (Olympus Endobronchial Alligator Jaw Forceps, FB 15C-1) passed through the esophagoscope side channel, then withdrawing the entire bronchoscope out of the trachea-stoma. After removal, the airway was reexamined demonstrating no additional foreign body or injury. The patient tolerated the procedure without discomfort and felt immediate relief of dyspnea. Postremoval chest X-ray failed to show any abnormality. |
pmc-6158927-2 | A 72-year-old female 20 years following laryngectomy, free flap reconstruction, and radiation had been using a TEP successfully. While cleaning her prosthesis, it dislodged and was aspirated. She initially presented to an outside hospital acutely short of breath, requiring supplemental oxygen to maintain saturations >90%. CT chest demonstrated a radiopaque foreign body in the right mainstem bronchus ().
She was transferred to the emergency department (ED) at our institution as the local consultants recommended “higher level of care.” The otolaryngology service evaluated the patient in the ED and performed bedside flexible bronchoscopy (Olympus BF-H190) after topical lidocaine spray. The aspirated prosthesis was found in the right mainstem bronchus ().
It was removed atraumatically by grasping with the flexible biopsy forceps then withdrawing the entire bronchoscope. There were no other injuries or remaining foreign bodies. She felt immediate relief. A red rubber catheter was placed through her tracheoesophageal puncture to stent the tract. She was discharged home with next day follow-up with her speech-language pathologist (SLP) for prosthesis replacement. |
pmc-6158927-3 | A 56-year-old male, 8 years postlaryngectomy with free flap reconstruction, proficient at changing his own prosthesis, presented to our clinic with 2 days of worsening dyspnea. The patient had not noticed aspirating his prosthesis after changing it. He underwent flexible bronchoscopy under topical anesthesia while sitting upright. A TEP lodged in the right mainstem bronchus was removed with biopsy forceps via the endoscope channel (). His dyspnea immediately resolved. |
pmc-6158928-1 | A 24-year-old female presented to the Emergency Department of a tertiary hospital in Brisbane with a 48-hour history of diarrhoea and vomiting. Her medical history included primary carnitine deficiency, a rare inherited metabolic disorder that causes cardiomyopathy, which was diagnosed as asymptomatic during her infancy following the death of her infant brother from cardiomyopathy related to the condition. Her diagnosis was established by impaired cultured fibroblast carnitine uptake. Her genotype is unknown. She was prescribed oral carnitine replacement, 400 mg TDS, but had been not compliant with this therapy for the preceding three months. She reported no history suggestive of cardiac failure or arrhythmia. Cardiovascular and respiratory examination was normal. Chest X-ray revealed an increased cardiothoracic ratio. Electrocardiogram demonstrated enlarged peaked T waves and a short QT interval (). Her serum total carnitine level was 4 μmol/l (21–70). Intravenous carnitine replacement was commenced, and she was admitted for telemetry and cardiac evaluation. Her gastrointestinal symptoms resolved early in her admission and did not reoccur.
Echocardiography performed within 24 hours of commencing carnitine replacement revealed a dilated cardiomyopathy. The left ventricle was severely dilated with a left ventricular end diastolic volume index of 104 ml/m2 (normal < 76 ml/m2) with mild concentric wall thickening with a maximum wall thickness of 16 mm. The ejection fraction was 40% by Simpson's method with global hypokinesis. Grade II diastolic dysfunction was present. The right ventricle was severely dilated with mild systolic dysfunction ().
The patient was transitioned from IV to PO carnitine, 400 mg TDS, and was commenced on bisoprolol 2.5 mg mane and perindopril 2.5 mg mane. Plasma carnitine concentration normalized within 24 hours and was sustained within normal limits for the duration of the admission on serial testing. Continuous telemetry monitoring demonstrated a single run of polymorphic ventricular tachycardia with a rate of 150 bpm. A CT coronary angiogram revealed no coronary atheroma. Screening for other causes of cardiomyopathy was not undertaken given the known carnitine deficiency.
A cardiac MRI performed five days after the initial echocardiogram showed dramatic improvement in cardiac function. The left ventricular volume normalized, and the ejection fraction improved to 55%. The right ventricle normalized in size and function. Moderate concentric thickening of the left ventricle persisted with a maximum wall thickness of 17 mm. Delayed enhancement imaging was normal (). |
pmc-6158940-1 | A 24-year-old male with a past medical history of HIV not on antiretroviral treatment presented to the emergency department of a large community hospital with complaints of bilateral lower extremity swelling of two weeks duration and worsening abdominal discomfort. He reported a 6-month history of mild to moderate constant abdominal pain, dull in nature, associated with distention and early satiety. He denied pain in the lower extremities. A review of systems was positive for night sweats, intermittent dry cough, shortness of breath on exertion, fatigue, poor appetite, and a 30-pound weight loss. The patient admitted to drinking alcoholic beverages on social occasions but denied tobacco or illicit drug use. He had previously been diagnosed with HIV at another hospital three years prior, but he had not been taking the antiretroviral treatment (ART) for two years.
In the emergency department, the patient's vital signs were normal and there were no signs of hypotension, sepsis, or hypoxia. On physical examination he appeared cachectic and had oral candidiasis and a large protuberant abdomen. On abdominal examination there was a large, firm, nontender mass palpated extending from the epigastrium to the periumbilical region, as well as hepatomegaly and right upper quadrant tenderness. Marked bilateral lower extremity edema up to the knee level was also noted.
Initial laboratory tests demonstrated an anion gap metabolic acidosis (anion gap 17 and HCO3 23 meq/L). Venous lactate and lactate dehydrogenase levels were both markedly elevated at 9.4 mmol /L (normal range = 0.5-1.0 mmol/L) and 2445 U/L, respectively. Aspartate aminotransferase (AST) was elevated at 63 U/L, but alanine aminotransferase (ALT) and alkaline phosphatase (ALP) were within normal limits. Uric acid was measured as 9.6 mg/dL. The remainder of the metabolic panel, including creatinine and glomerular filtration rate (GFR), was normal. The patient's renal function remained stable throughout the course of his hospital admission. Complete blood count demonstrated a normocytic anemia (white blood cells 4.2 cells/μL, hemoglobin 8.1 g/dL, platelet count 176 platelets/μL, and mean corpuscular volume 85 fL), likely due to chronic disease. Lab results also showed a CD4 count of 38 cells/μL (3.0%), a CD8 count of 1023 cells/μL (84.0%), and an HIV viral load of 354,120 copies/mL, consistent with acquired immunodeficiency syndrome (AIDS). Infectious disease was consulted for recommendations, and the patient was started on ART (dolutegravir, tenofovir, and emtricitabine) on hospital day 3.
Computed tomography (CT) with contrast of the abdomen revealed a large soft-tissue mass (16.3 cm × 14.1 cm × 20 cm) with internal vascularity that appeared to arise from the left hepatic lobe (). Additional findings included innumerable small hypodense lesions throughout the liver parenchyma and mass effect on the inferior vena cava (IVC) by a 3.6 cm × 2.9 cm aortocaval lymph node. Additionally, there appeared to be bilateral suprarenal soft-tissue masses and sclerotic lesions within the pelvis and lower thoracic spine, suggestive of metastatic disease with bone involvement. A chest radiograph demonstrated left hilar adenopathy, a small left pleural effusion, and a left lower lobe nodular opacity. Ultrasound-guided core biopsy of the hepatic mass was performed and revealed a high-grade diffuse large B-cell lymphoma (DLBCL) (CD19+/CD20+/ CD34-/KAPPA+) with germinal center formation (FIGURE). Immunohistochemistry was positive for C-MYC, and ki-67 reactivity was greater than 90%. A bone marrow biopsy demonstrated severe hypocellularity (<5% cellularity) with atypical lymphoid infiltrate.
On hospital day 5, the patient was started on his first cycle of chemotherapy consisting of etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and a double dose of rituximab (EPOCH-RR). Given that bone marrow involvement was present, he also received intrathecal methotrexate. By hospital day #8 the lactic acidosis resolved and was measured as 1.0 mmol/L (normal value = 0.5-1.0 mmol/L). He subsequently developed neutropenia and neuropathic pain of the hands and feet within several days of initiating chemotherapy and was treated with G-CSF until the neutropenia resolved. The patient was discharged on hospital day #26 but was readmitted the following day after an echocardiogram showed a left ventricular ejection fraction (LVEF) of 20% (normal range = 55-70%) which had decreased from 49% obtained 3 weeks earlier. He was started on Carvedilol and Lisinopril for Doxorubicin induced cardiomyopathy.
The patient completed cycles 2 and 3 of EPOC-RR without doxorubicin (due to induced cardiomyopathy) and doses of cyclophosphamide and etoposide were increased by 20% with no complications. Repeat echocardiogram also showed improvement in LVEF to 45-49% and he was discharged in stable condition. Outpatient PET-CT after the third cycle of chemotherapy showed a complete radiologic response with no remaining FDG-avid lesions. Given the complete radiologic response, the patient completed one additional cycle of EPOC-RR (fourth cycle) and was advised to follow-up with medical oncology in 3 months. |
pmc-6158946-1 | An 80-year-old man with a past medical history of diabetes mellitus presented to his primary care physician after several weeks of left-sided congestion and epistaxis that he had attributed to seasonal allergies. He denied significant weight loss, headaches, visual changes or weakness. A computed tomography (CT) scan of the sinuses showed abnormal soft tissue causing contiguous opacification of the left nasal cavity, frontal, maxillary and ethmoid sinuses ().
After a biopsy confirmed carcinoma, the patient was referred for further surgical management. A repeat CT confirmed a 1.5 cm polypoid opacity in the superior left nasal cavity with likely involvement of the anterior cranial base. The patient then underwent an endoscopic craniofacial resection of the sinonasal mass.
Grossly, the specimen was received as multiple fragments of pink-purple ragged soft tissue measuring 3.5 cm in aggregate. Microscopic examination revealed a low-grade sinonasal non-ITAC consisting of a mixture of back-to-back glands, anastomosing cords, and solid areas with squamoid morular metaplasia (Figures –, x100). Immunohistochemical stains showed that the tumor cells were positive for CK7 in the areas of glandular morphology (), and they were negative for CK20, SOX10, CK5/6, p40, p63, and DOG1. CDX2 showed focal weak nuclear staining exclusively within the squamoid morules (), and β-catenin likewise showed nuclear staining restricted to squamoid morules with membranous staining throughout the rest of the tumor ().
Next-generation sequencing was performed by Foundation Medicine (Cambridge, MA). The analysis identified a missense mutation (S37C) in CTNNB1, the gene encoding β-catenin.
The patient received postoperative radiotherapy and has no evidence of disease at 10 months after surgery. |
pmc-6158946-2 | A 25-year-old Asian female with a past medical history of myotonic muscular dystrophy presented to an otolaryngologist with complaints of otalgia. She reported intermittent right ear pain of mild severity, as well as sneezing, itchy nose, and watery eyes for one month. Nasal endoscopy revealed a lobulated, fleshy mass just medial to the right middle turbinate. A CT scan of the sinuses revealed a 3.0 cm mass in the right nasal cavity extending to the roof of the nasal cavity, without an obvious cranial base defect ().
It was unclear by imaging characteristics whether the mass represented a nasal polyp, papilloma, or malignant tumor. A biopsy was then performed, which revealed a proliferation of cytologically bland cuboidal cells forming crowded glandular structures, together with many squamoid morules as well as more confluent areas of squamoid metaplasia (Figures and ). Immunohistochemical stains showed tumor cell expression of CK7 and SOX-10 in the glandular but not squamoid areas of the tumor (Figures and ). CK20, CK5/6, and DOG1 were negative. Nuclear β-catenin and CDX2 were strongly expressed in the areas of squamoid morular metaplasia (Figures and ).
These findings supported the diagnosis of a low-grade sinonasal non-ITAC. NGS was performed by Foundation Medicine, which detected a missense mutation (S33C) in CTNNB1.
The patient subsequently underwent endonasal craniofacial resection of the tumor to negative margins. Given the low-grade histology and the pathologic stage of T1N0M0, the patient did not require adjuvant chemotherapy or radiation and will undergo close clinical surveillance. |
pmc-6158949-1 | A 30-year-old Caucasian woman, without significant past medical history, presented to our hospital with “flu-like symptoms.” She admitted to four days of fatigue, myalgias, nausea, nonbilious emesis, and nonbloody diarrhea. She complained of abdominal pain, anorexia, and dark urine. She took no medications and family history was noncontributory. She denied tobacco and illicit drug use and admitted to rare alcohol use. She worked as a substitute teacher for elementary-aged children. She denied recent travel and lived in the United States for the duration of her life. She admitted to frequenting multiple restaurants. She denied sick contacts. On arrival to the emergency department, her blood pressure was 120/64 mmHg, heart rate was 49 beats per minute (bpm), respiratory rate was 20 breaths per minute, and temperature was 36.4°C. Physical examination was significant for mild scleral icterus and right upper quadrant abdominal tenderness, without peritoneal signs or fluid wave that would indicate ascites. She had intact mentation, no asterixis, and no stigmata of liver disease including no palmar erythema and no telangiectasias. Skin examination revealed no rash.
Lab work revealed severe elevations in liver transaminases, aspartate aminotransferase (AST) was 6,769 U/L, alanine aminotransferase (ALT) was 8,479 U/L, INR was elevated at 2.0, and acute viral hepatitis panel was positive for hepatitis A IgM only. EBV IgG and IgM were positive, but heterophile assay and EBV PCR was negative (). Limited abdominal ultrasound revealed diffuse gallbladder wall thickening and edema with trace-free fluid in the right upper quadrant and no evidence of stones, sludge, or sonographic Murphy's sign, with findings consistent with hepatocellular disease. Hepatic echotexture was homogenous without evidence of focal hepatic lesions. There was mild intrahepatic biliary ductal dilatation with common bile duct measuring 2 mm. A mildly enlarged peripancreatic lymph node was also seen. No pancreatic ductal dilatation was present. Supportive care was initiated with intravenous fluids and close monitoring of her laboratory values. A urinalysis revealed orange, turbid urine positive for bilirubin, 15 mg/dL ketones, 30 mg/dL of protein, 3+ blood with 11–24 RBCs, >50 WBCs, 4+ bacteria, 2+ leukocyte esterase, no nitrites, no casts, and >50 squamous cells. She was started on IV ceftriaxone for presumed urinary tract infection.
On day 2, the patient developed severe left-sided flank pain. CT abdomen pelvis revealed no obstructing renal calculus but redemonstrated diffuse gallbladder wall thickening felt to be secondary to hepatitis. There was diffuse low-attenuation of the liver and perihepatic ascites, a moderate amount of free fluid in the pelvis, and a small right-sided pleural effusion (). Her pain worsened, and she complained of diaphoresis and lightheadedness. She was found to be bradycardic with heart rates as low as 30 s. Blood pressure was within normal limits. ECG revealed sinus bradycardia only. Troponin was negative. On day 3, she developed chest pain described as a burning sensation in the midepigastric region. Pain was relieved with an antacid, and a proton pump inhibitor was initiated. ECG revealed a rate of 60 bpm, a junctional rhythm, normal axis, and new T wave inversions in V1 and V2 (). An ECG without these abnormalities obtained prior is also shown (). Troponin was elevated at 6.21, trended up to 10.60, and the patient was transferred to the cardiac intensive care unit. Hepatic panel revealed improvement in transaminases ().
She received aspirin and started on IV heparin. Repeat troponin was 16.4. A transthoracic echocardiogram revealed diffuse global hypokinesis of the left ventricle. The estimated ejection fraction was 30% without evidence of pericardial effusion. A CT angiography of her coronaries revealed normal coronary arteries, aorta, and pericardium (Figures –). IV heparin was discontinued. A presumed diagnosis of myocarditis was made.
The patient continued to feel better, troponins began to trend down (), and hepatic indices improved (). A follow-up echocardiogram revealed an improved ejection fraction of 45%. Our patient was discharged home with plan for follow-up to continue monitoring labs. Two months after discharge, a repeat echocardiogram was obtained revealing an ejection fraction of 56%, normal left ventricular size and systolic function, and no wall motion abnormalities. |
pmc-6158966-1 | A 37-year-old (G4P3) woman was referred to the University of the Ryukyus Hospital at 32 weeks of gestation for the evaluation of a fetus with an intrathoracic cystic lesion. An US examination revealed a 39 × 30 × 44-mm sized monocystic lesion in the mediastinum, in which the aortic arch was displaced upward (). Magnetic resonance imaging (MRI) revealed that a fetal cystic lesion was located in the posterior mediastinum without communication to surrounding organs (). A mucosal layer in the cyst could not be depicted by US and MRI; these findings were consistent with a bronchogenic cyst. Thereafter, her pregnancy course was uneventful. At 38 3/7 weeks of gestation, an elective cesarean section was performed because of her previous cesarean section. A female neonate without any external anomalies, weighing 2,442 g, with Apgar scores of 8 and 9, and requiring no resuscitation was born. Computed tomography (CT) scan revealed a monocystic lesion in the posterior mediastinum consistent with a bronchogenic cyst. Four weeks after delivery, the neonate was admitted to the pediatric surgery ward because of respiratory distress due to mass effect. CT scan revealed enlargement of the mediastinal cystic lesion (), and surgery was performed. At right lateral thoracotomy, a 105 × 65 mm of solitary smooth-walled cyst containing serosanguineous fluid was found in the posterior mediastinum, which was excised completely. Histologic examination revealed an inner lining of gastric mucosa and an outer smooth muscle coat (), leading to the diagnosis of the mediastinal gastric duplication cyst. The neonate made an uneventful recovery and was discharged on the seventh postoperative day. |
pmc-6158977-1 | An 83-year-old woman, with a height of 1 meter and 65 cm and a weight of 85 kg (BMI = 31.22), was transferred to our department because of a reverse pertrochanteric-subtrochanteric fracture AO 31-A3 (). The patient had a cardiovascular disease of moderate severity, though her social life was very active, and the Harris Hip Score (HHS) [] and the Short Form 12 Health Survey (SF-12) [] were both 94 points (). The anesthetic risk was ASA 3 [], and she did not require intensive care after surgery. After reduction, internal fixation was done using a short Affixus® nail (Zimmer Biomet™, Warsaw, Indiana, USA) which is 180 mm long. The shaft was 9 mm wide, the lag screws were 100 mm long, and one distal static locking screw was used (). In the 1st postoperative day, rehabilitation began, and by the 2nd day, she was walking with total progressive weight-bearing. She was discharged on the 7th postoperative day. Six months after surgery, at the last control, the HHS was 66 and the SF-12 was 74, and the radiographs showed subtrochanteric nonunion and medial displacement of the distal fragment (). Thereafter, the patient seek medical assistance in another hospital. Six months later, she underwent radiographic studies which showed incomplete breakage of the nail at the hole for the locking screw (), though no surgical treatment was indicated. There was no pain in the hip, and 2 years following primary surgery, radiographs done in the other hospital showed further incomplete nail breakage at the hole for the lag screw (). No further treatment was planned, and later on, the patient reported mild pain while flexing the hip. One year later, i.e., three years after surgery, the patient seek further assistance because of the sudden severe hip pain, and the radiographs showed complete fracture of the nail at both the proximal and the distal holes (). The HHS was 26 points and the SF-12 was 35 (see ). She underwent revision surgery, with removal of the broken nail () and total hip arthroplasty with a 46 mmØ Plasmacup® acetabular cup with a 28 mmØ bearing liner in polyethylene (Aesculap, B. Braun, Melsugen, Assia, Germany) fixed with two screws of 24 and 32 mm length, a 28 mmØ Prevision® metal femoral head, and a 240 mm long modular revision stem (Aesculap, B. Braun, Melsugen, Assia, Germany), with proximal segment P1/0 mm and distal segment 12 mmØ, with the addition of three free metal cable cerclages (). Twelve months after the revision surgery, the HHS was 80 points and the SF-12 was 90 points (Figures and ). |
pmc-6159110-1 | The patient was a 75-year-old woman without a chief complaint. Abdominal ultrasound for cancer screening revealed a retroperitoneal hypoechoic mass measuring 26 × 22 × 18 mm in the perirenal space, at the level of the left renal upper pole. Subsequently, she was referred to our hospital for examination. |
pmc-6159113-1 | A 57-year-old female was referred to Oncology for consideration of adjuvant treatment following right breast wide local excision with sentinel lymph node biopsy in August 2011 for Grade 2, lymph node-negative, ER-positive and HER2-negative invasive ductal carcinoma. She stated that she had been treated for a skin condition called “urticaria pigmentosa” (UP) many years earlier. She went on to have adjuvant radiotherapy to the right breast and hormonal therapy.
The patient’s baseline DEXA scan revealed increased density in the lumbar spine, which prompted further investigations including X-ray of the lumbosacral spine and CT scan of the chest, abdomen and pelvis (). These showed multiple bony sclerotic foci in the thoracolumbar spine and acetabulum consistent with metastatic bone disease. No soft tissue changes were noted on CT. The patient also had an isotope bone scan () which showed only subtle focal uptake in the lumbar spine, left sacroiliac joint, left iliac bone and left acetabulum, that was discordant with plain films. At the time the potential explanations provided for the relative lack of uptake on the bone scan were: inactive metastatic disease, perhaps in response to Letrozole; or an aggressive osteoclastic component masking uptake.
Following these imaging results, it was explained to the patient that it was unusual for the X-ray appearances to be more striking than the bone scan abnormalities but that she did indeed have skeletal metastases. Therefore she was started on monthly Zoledronic acid. Her CA-15.3 and bone profile were in normal limits.
A repeat CT scan in 2013 and MRI scan of the spine in 2014 () showed appearances consistent with skeletal metastases. The MRI scan showed no new spinal lesions. Meanwhile the patient remained extremely well with no bone pain. At a recent consultation, she recalled having had multiple investigations in the 1990s, culminating in a bone marrow aspiration. These investigations occurred approximately 250 miles away from her current hospital.
Following this, two dermatology letters from 1993 were obtained and detailed a history of worsening skin problems and described diffuse pigmented patches distributed proximally over her body, typical of UP. Investigations including bone marrow aspirate, abdominal ultrasound scan and skeletal survey, to ensure that disease was limited to the skin, were requested. The results of these investigations were unremarkable, except the bone marrow aspirate which showed mast cells in the bone marrow, suggesting SM. Subsequently, she was commenced on twice-weekly phototherapy (PUVA) and informed that her “bones had small holes in them”.
In the context of SM, her imaging was re-examined by the radiology team. It is now considered that given the lack of uptake on the bone scan and the static nature of the bone lesions between the CT scan in 2013, and MRI scan in 2014, that these radiological abnormalities are more consistent with SM than inactive metastatic breast cancer. The fact that she had otherwise early-stage ER-positive, HER2-negative breast cancer reduces the likelihood of having bone metastasis at presentation. The oncologist explained the revised opinion to the patient and apologized for any anxiety caused regarding her prognosis. She continued on adjuvant letrozole and was referred to a rheumatologist for follow-up for SM. |
pmc-6159113-2 | A 50-year-old female was referred to oncology for consideration of adjuvant treatment following a left-sided mastectomy and axillary clearance in 2012. She was diagnosed with a Grade 2, lymph node-positive, ER-positive, HER2-negative invasive lobular carcinoma. Her CA-15.3 and bone profile were within normal limits.
The patient’s isotope bone scan showed no evidence of metastatic disease () but an X-ray of the pelvis showed sclerotic lesions mostly localized in the iliac wings (), and CT scan of the thorax and abdomen showed multiple small sclerotic nodules throughout the entire skeleton (). In the clinical context, the radiologist suggested that these lesions likely represented metastatic deposits, but that a benign cause such as osteopoikilosis should be considered.
The Breast MDT opinion was that given the normal bone scan, CA-15.3, bone profile and absence of bone-related symptoms, a diagnosis of bone metastasis seemed unlikely. Therefore it was explained to the patient that the bony abnormalities detected on X-ray and CT were most likely to be due to osteopoikilosis. She was subsequently treated with adjuvant chemotherapy followed by radiotherapy to the left chest and left supraclavicular fossa, alongside hormonal therapy. Three years later, there has been no evidence of disease recurrence. Further CT scans performed in 2013 and 2014 showed stable appearances in the bones. |
pmc-6159114-1 | A 55-year-old male was admitted to our hospital with clinical evidence of encephalopathy. Physical examination revealed mild jaundice. The patient’s medical history included hypertension, diabetes mellitus, knee arthrosis and resection of a basal cell carcinoma in the nose. The patient was also considered to have hepatic disease, probably related to alcohol consumption. There was a history of alcohol abuse, but the patient referred abstinence from alcohol consumption for the past 6 years.
Liver function testing revealed normal transaminase levels and a total bilirubin level of 2.16 mg dl–1 (normal, 0.20–1.20 mg dl–1). Serum total protein and albumin were within normal ranges. On haematological studies, no anaemia or coagulopathy was observed. Serum ammonia level was elevated, at 174 μmol l–1. Serologic markers for hepatitis B and C were negative; α-fetoprotein was also negative. Laboratory findings on admission are summarized in .
Abdominal ultrasonography revealed a diffuse heterogenic echostructure in the liver (). Abdominal CT showed the presence of an abnormal short portal vein, with systemic drainage into the inferior cava vein below the liver, and the superior mesenteric vein and splenic vein draining into the abnormal portal vein () (). The venous phase and multiplanar curve reformatted images better depicted this short, dilated shunt vessel (abnormal portal vein) after the confluence of the superior mesenteric vein and splenic vein, and the inferior vena cava (). Various nodular hepatic lesions could also be observed, compatible with vascular shunts and regenerative nodules, with the larger nodule presenting a size of 13 mm in diameter. The benign nature of these nodular lesions was confirmed by their stability through at least 7 years. Furthermore, a dilated and tortuous hepatic artery was also detected () (). Although several imaging examinations had been performed during this 7-year time frame, the vascular malformation had not been diagnosed so far. MRI shows the presence of the shunt with similar findings () ().
During a 6-day period of admission in the internal medicine department, the patient received conservative treatment with enema, lactulose, restricted protein intake and branched-chain amino acids. The serum ammonia level improved to 50–60 μmol l–1, measured at the day of discharge. |
pmc-6159119-1 | A 34-year-old male was referred to our hospital where he presented a 6-month history of unilateral nasal obstruction and frontal headache. Endoscopic examination showed a polypoid mass in the right nasal cavity and permitted biopsy of the lesion. Histological findings documented an olfactory neuroblastoma of Grade II according to Hyams grading system. MRI was performed, revealing a well-circumscribed lesion in the right nasal sinus, hypointense on T1 weighted and hyperintense on T2 weighted sequences (). This disease presentation corresponded to Kadish stage B. After discussion in the multidisciplinary tumour board, a bimodality therapeutic approach consisting of endoscopic resection followed by adjuvant radiotherapy (RT) was chosen. The patient was treated with a wide tumour excision by nasal endoscopic surgery, and postoperative pathology confirmed a moderate grade ON. 20 days later, the patient was planned to receive adjuvant external beam RT, delivered with a step and shoot (S &S) intensity-modulated radiation therapy (IMRT) technique. After proper immobilization (flat headboard and thermoplastic mask), a planning CT simulation with 3 mm slice thickness was performed. Target volume and organs at risk were contoured using the treatment planning system Masterplan, Oncentra (Nucleotron, Crawley, UK). A semi-automatic rigid registration between planning CT scan and diagnostic MRI images was performed to better define the clinical target volume (CTV) that included the preoperative tumour bed. A 5-mm isotropic margin was added to the CTV to obtain the planning target volume (PTV) (). Beam geometry in IMRT plan consisted of five coplanar 6 MV fields. The prescribed dose was 60 Gy in 30 fractions (2 Gy daily) defined as the mean dose planned to the PTV with 95% of the PTV receiving ≥95% of the prescribed dose. Dose–volume histogram was calculated for the IMRT plan for the following volumes: PTVs, spinal cord, brainstem, optic chiasm, eyes, optic nerves and lens. The dose–volume constraints were satisfied: 0.03 cc of the optic chiasm, optic nerves, eyes and brainstem should receive <54 Gy, spinal cord 45 Gy and lens 6 Gy. The dose distribution is shown in . Radiation treatment was well tolerated with Grade 1 skin acute toxicity according to Radiation Therapy Oncology Group scale and nasal obstruction. No treatment interruption occurred. The patient is still under regular follow-up based on MRI and nasal endoscopy; after 2 years of observation, he continues to be free from disease without any late complications of therapy. |
pmc-6159120-1 | A 62-year-old female patient was admitted in April 2016 in another hospital complaining of severe persistent deep throbbing headache in the right retro-orbital region, not responsive to common non-steroidalanti-inflammatory drugs. Neurological examination did not show any signs of focal deficit. Ophthalmic examination of fundus oculi revealed normally appearing retina with normal eye pressure. In that occasion, the patient underwent brain CT, which showed no significant alterations of brain tissue; instead, obliteration of right sphenoidal sinus was observed and it was referred to sinusitis. After 1 month of oral antibiotic and corticosteroid treatments, symptoms partially reversed, with only a latent headache persisting during the follow-up period; however, throbbing headache recrudescence and posterior nasal drip occurred later in March 2017, when the patient came to our attention. |
pmc-6159121-1 | A 16-year-old male presented to the emergency department with acute onset left flank pain and frank haematuria. This patient had a longstanding history of relapsing nephrotic syndrome secondary to minimal change disease, with his most recent relapse occurring 2 weeks prior to this presentation after an attempt to wean his mycophenolate mofetil dosage. His medications on admission were furosemide 60 mg once daily by mouth, prednisone 60 mg once daily by mouth and mycophenolate mofetil 500 mg twice daily by mouth. There was no known family history of VTE or bleeding diatheses. The patient denied recent calf swelling, asymmetry in thigh circumference or leg pain. There was no history of prolonged immobilization, but the patient did report decreased oral intake throughout the week preceding his presentation, secondary to increasing flank pain and associated nausea.
On examination, the abdomen was soft, but the patient was tender to palpation in the left upper quadrant and left flank. Generalized oedema was noted; however, the lower extremities were symmetrical in size with no erythema or tenderness. The patient’s bloodwork showed a haemoglobin of 175 g l–1 (reference range: 131–169 g l–1), haematocrit 0.5 (reference range: 0.38–0.49), platelets 111 x 109 (reference range: 165–397 x 109) and white blood cell count 20.1 x 109 (reference range: 3.9–10.2 x 109). The patient had a normal electrolyte panel, creatinine of 100 μmol l–1 (reference range: 39–103 μmol l–1), urea 9.9 mmol l–1 (reference range: 2.5–7.1 mmol l–1) and albumin 23 mmol l–1 (reference range: 37–56 mmol l–1). His urinalysis showed 23.84 g l–1 protein, a urine protein:creatinine ratio of 1136 g mol–1 (reference range: 0–22 g mol–1), greater than 100 red blood cells hpf–1 (reference range: 0–3/hpf), 10–20 white blood cells hpf–1 (reference range: 0–5/hpf), along with the presence of hyaline and granular casts.
The initial imaging test ordered was a renal ultrasound to rule out renal calculus or renal vein thrombosis. The Doppler ultrasound showed asymmetric renal volumes with no evidence of hydronephrosis or post-renal obstruction. The renal vasculature, however, could not be adequately assessed. A contrast-enhanced CT scan of the abdomen and pelvis was then ordered, which demonstrated enlargement of the left kidney, moderate perinephric free fluid and a delayed left nephrogram []. Acute complete thrombosis was noted of the circumaortic left renal vein, with extension into the IVC, where it was non-occlusive but measured up to 12.0 cm in craniocaudal dimension []. There was significant intraperitoneal free fluid and a small left-sided pleural effusion. At this time, Paediatric Haematology and Nephrology were consulted for further management of the patient’s acute renal vein and IVC thrombosis.
Paediatric Haematology began anticoagulation with unfractionated heparin; however, given the significant thrombus and the patient’s poor clinical status, interventional radiology was consulted to consider potential intervention. After clinical examination and review of the patient’s CT imaging, a decision was made to attempt endovascular pharmacomechanical thrombolysis and thrombectomy.
The patient was transferred to the angiography suite, intubated and placed under general anaesthetic. The patient's right neck and right groin were prepped and draped followed by ultrasound-assisted right internal jugular vein access. A cavogram was performed in the anteroposterior projection, demonstrating the known IVC thrombus, with tailing thrombus extending downstream to at least the level of the right renal vein [].
From the neck access, an Option Elite IVC filter (Argon Medical Devices Inc., Plano, TX) was inserted in a suprarenal position above the level of the IVC thrombus [], which acted as a safeguard against potential periprocedural thromboembolic events. Hand injection venography was then performed, demonstrating no patency of the left renal vein with numerous capsular collaterals extending to venous pathways along the left lateral aspect of the spine [].
At this point, an Angiojet device (Boston Scientific Corporation, Marlborough, MA) was advanced into the left renal vein, at the level of the hilum. Pulse-spray tissue plasminogen activator (tPA) was administered via the Angiojet device into the left renal vein thrombus as the device was slowly withdrawn back to the expected level of the left renal vein/IVC junction. The catheter was then repositioned within the IVC thrombus and the Angiojet device was advanced to the expected left renal vein/IVC junction, at which point pulse-spray tPA was again performed. The Angiojet device was subsequently repositioned in the upstream portion of the left renal vein. As expected, hand injection performed at this time demonstrated minimal patency of the left renal vein with significant persistent thrombus burden.
After waiting for 20 minutes following tPA administration, aspiration thrombectomy was performed using the Angiojet device for a total of 6 minutes, divided between the left renal vein and IVC thrombus. Angiography demonstrated progressive recanalization of the left renal vein with visualization of the anterior limb of the circumaortic left renal vein and restored flow into the IVC []. Balloon angioplasty of the retroaortic limb of the left renal vein was then performed to macerate all remaining thrombus and increase the surface area of thrombus available for exposure to blood flow, which further improved patency of the left renal vein []. Pigtail angiography performed following IVC aspiration thrombectomy showed wide patency, with a large thrombus having been captured by the recently placed IVC filter []. Repeat angiogram demonstrated good flow in the left renal vein [], and as such, no further recanalization intervention was pursued.
Finally, mechanical aspiration thrombectomy of thrombus captured by the IVC filter was performed utilizing the Penumbra aspiration system (Penumbra Inc., Alameda, CA). The patient tolerated the procedure well with no immediate complications and the patient was continued on systemic anticoagulation. The IVC filter was removed without complications 4 days post-intervention, and follow-up renal ultrasound at 6 days post-intervention showed the IVC and left renal vein to be patent without evidence of residual or recurrent thrombus. |
pmc-6159124-1 | A 40-year-old male patient presented to us with a 3-month history of having noticed a painless lump over his forehead. He reportedly ignored the lump, initially assuming it to be a pimple, but became concerned when it continued to grow gradually. He stated that it turned painful, and that was when he came in seeking medical attention. On examination, the lump () over the frontal region was hard, fixed and tender on palpation. CT scan demonstrated that the lesion involved both the outer and the inner tables of the frontal bone (). Upon core needle biopsy, the lesion on haematoxylin and eosin staining () demonstrated pleomorphic tumour cells having predominantly eosinophilic cytoplasm, prominent nucleoli and cells arranged in both trabecular and solid patterns.
Concurrently, a whole body 18-fludeoxyglucose positron emission tomography (18F-FDG-PET) scan was performed to look for potential sites of primary tumour. This revealed a very highly avid lesion (standardized uptake value of 28) in the right lobe of the liver, along with multiple other avid foci involving the liver, lungs and the dorsal vertebrae. The lesions in the liver, lungs and dorsal vertebrae were also visualized on digital reconstruction of CT images ().
Thus, further investigations were focused upon confirmation of HCC as the primary tumour. The patient’s α-fetoprotein (AFP) level was found to be 6889 ng ml−1. Immunohistochemistry showed positivity for HepPar1 and CD10. Negative staining was noted for TTF-1, CEA, ALK-1, LCA, S-100, vimentin and chromogranin. The patient was seropositive for HBsAg and negative for HCV. The patient reportedly was unaware of his prior HBsAg status. His liver functions tests were within normal limits at presentation. Serum CEA, CA 19-9, coagulation tests, liver function tests and other routine investigations were normal at presentation. The patient was a driver by occupation, and as a non-drinker and non-smoker. There was no history suggestive of aflatoxin exposure. There was no history of blood transfusions.
Given the detection of multiple lung and vertebral metastases, radical curative surgery and chemotherapy were not considered. The patient's Karnofsky Performance Status (KPS) at diagnosis was 70. After fixation of vertebral metastasis (), his involved vertebrae were irradiated with a dose of 20 Gy in five fractions with 6-MV beam by a single direct field, calculated using the skin–source distance of 100 cm with a depth of 4 cm. He was then treated with sorafenib (initiated at a dose of 400 mg, twice a day), which was tolerated well without any remarkable toxicity. He was also treated with oral ibandronate (150 mg, once a month) and oral analgesics (non-steroidal anti-inflammatory drugs, tramadol and gabapentin).
There was a clinically visible regression of his forehead lesion (it must be emphasized here that the forehead lesion was not irradiated, and the option of irradiation was reserved for use in case of non-response with sorafenib). Furthermore, there were minimal regressions/stabilizations in the sizes of the thoracic metastases, secondaries elsewhere as well as in the primary. The use of sorafenib had also led to an improvement in his performance status for a span of 6 months (from a pre-treatment KPS value of 70 to approximately 80–90 during the first 6 months while on sorafenib). However, despite the initial response after 6 months of initiation of sorafenib, the patient had progression of his lesions as well as the appearance of new lesions. Although sorafenib was continued, the patient ultimately succumbed to hepatic failure a year after diagnosis. |
pmc-6159126-1 | An 18-year-old female was referred to our institution complaining of pain in the left mid-forearm. Previous medical history included a fracture of both radius and ulna 12 years previously, which had been successfully treated with reduction and by intramedullary pinning (). Several months before the current referral, there was an insidious onset of pain, which was gradually increasing, more intense at night and relieved by salicylates. On physical examination, there was moderate swelling at the old fracture site. There were no signs of local or systemic inflammation. Conventional radiographs of the left forearm revealed a lucent area adjacent to the previous fracture site with surrounding sclerosis and cortical thickening (). Subsequent MRI showed an oval intracortical lesion in the ulna, with central hypointensity to skeletal muscle on both T1 and T2 weighted images. After administration of gadolinium contrast, there was marked peripheral enhancement of the lesion with perilesional bone marrow and soft-tissue oedema (). Because imaging characteristics were highly suggestive of an OO, an additional CT scan was performed (). This examination showed pathognomonic features of an OO with a central calcified nidus at the site of the previous fracture. |
pmc-6159131-1 | A 68-year-old female presented 4 days following the onset of nausea, headache and neck pain. Her symptoms were increasing in severity and associated with left-sided inco-ordination and subtle facial weakness. A CT scan was performed and demonstrated a 3-cm left extra-axial posterior fossa lesion abutting the tentorium suggestive of a meningioma and associated with significant cerebellar oedema but no hydrocephalus. As a result, an MRI of the brain was performed that demonstrated a lesion with marginal enhancement, causing adjacent significant oedema. Diffusion-weighted imaging (DWI) demonstrated no restriction in diffusion and therefore was suggestive of necrosis (). The patient underwent a left posterior fossa craniotomy and excision of the lesion. Histopathology confirmed a fibroblastic meningioma, WHO grade I with extensive infarct-type necrosis but no other atypical features. She recovered well from the procedure and was discharged home. At her 3-month review, the patient had made a full recovery, with resolution of her presenting symptoms and no signs of cerebellar dysfunction. Repeat MRI showed no evidence of recurrent tumour. |
pmc-6159131-2 | A 34-year-old female was transferred from a peripheral hospital 10 days after an elective lower uterine section caesarean section for a breech presentation for which she had an epidural anaesthetic. She presented to her general practitioner with a 2-day history of increasing right leg weakness. She was referred to her local hospital where she presented as no longer able to walk. Her examination demonstrated 0/5 power in right ankle flexion, extension, eversion and inversion with increased tone. Her cranial nerve examination was normal as was her tone and reflexes. An urgent MRI of the spine was undertaken that revealed no evidence of epidural collection or neural compression. She subsequently underwent a CT scan of the brain that demonstrated a dural-based lobulated, heavily calcified left parafalcine mass associated with extensive oedema consistent with a meningioma (). The bulk of the calcification was at the periphery of the lesion with relative sparing of the central elements. 8-mg dexamethasone was administered intravenously prior to transfer to a tertiary centre where an MRI of the brain was undertaken. This showed a left extra-axial parafalcine mass compressing the pre- and postcentral gyri and abutting the paracentral lobule. It was isointense to cortex on T2 weighted images with hypointense peripheral component corresponding to areas of calcification. The mass demonstrated peripheral enhancement and an enhancing dural tail. There was no evidence of restricted diffusion. Overall, it was felt most likely to be a meningioma with some atypical features. She underwent a left frontoparietal craniotomy and resection of the lesion. Histology demonstrated a meningothelial meningioma, WHO grade I with focal areas of necrosis and features, raising the possibility of embolization-related changes. She recovered well and was discharged home after brief inpatient rehabilitation. At her 4-month review, she was walking with 5/5 power in hip and knee flexion and extension and 4/5 power in ankle dorsiflexion and plantaflexion. A 6-month follow-up MRI showed no recurrence. |
pmc-6159137-1 | A 46-year-old female presented to her general practitioner with a painless left supraclavicular mass (). No further history was provided at the time. Initial imaging was performed with both ultrasound () and CT. The CT was performed as a non-contrast scan, as per the patient’s request. The lack of intravenous contrast made interpretation of the mass difficult and the study was of little help forming a differential diagnosis, which from the ultrasound was lymphangioma or cystic hygroma.
The patient was referred to interventional radiology for further investigation and possible treatment of the presumed lymphangioma.
On targeted investigation, she reported having had an elective mastopexy in Russia 3 years prior. Postoperatively, the patient was not satisfied with the result and desired a fuller appearance. The surgeon suggested free liquid silicone injection, as he claimed to have had good aesthetic outcomes from this technique in the past. As the procedure was carried out in Russia, no details were available as to the volume and grade of silicone injected. The patient reports having had an aesthetically pleasing result after the injections. The patient’s history included recent domestic violence, but breast trauma was denied. No other significant history was provided. Upon examination, in addition to the soft oblong left supraclavicular mass, the left breast was noted to be slightly smaller than the right one. No other masses were palpated.
An MRI was performed (3T Siemens Trio Tim magnet; Siemens Healthcare, Erlangen, Germany) () to further define the mass and its vascularity before treatment. Pre- and post-contrast T1, T2 and short tau inversion-recovery (STIR) weighted sequences were performed. Imaging showed a well-defined, T2 and STIR high signal, complex cystic lesion extending from the lower anterior left neck posteriorly into the supraclavicular fossa (). An asymmetry of the injected material into both breasts was also noted, with silicone migrating around the lateral border of the left pectoralis major muscle. A diagnosis of liquid silicone migration was made.
At this time, bilateral mastectomy was advised with cosmetic reconstructions. The patient declined this surgery.
Nearly 1 year later, the patient represented, acutely unwell, septic, with a swollen, tense left biceps region and left upper limb cellulitis. Blood tests confirmed a staphylococcus bacteraemia with a white cell count of 18.6 × 109 l−1 (4–11), neutrophils of 16.9 × 109 l−1 (2–9) and a C-reactive protein of 358 mg l−1 ( <5), normal ranges are given in brackets. An ultrasound scan was performed to exclude abscess formation, and it demonstrated a complex, heterogenous collection with nodular internal echogenic material, extending from the left supraclavicular fossa into the left chest wall as well as along the proximal, medial part of the left arm (). Although the history of silicone migration was known, the volume of the collection visualiszed on this presentation appeared to outweigh the presumed volume of injected silicone material.
After consenting to intravenous contrast administration, she progressed to have a CT of the neck and left upper limb with split bolus intravenous contrast (). This showed extensive hypodense material within the distribution of the previously identified silicone migration site with a new distribution of hypodense material in the left arm, correlating well with the ultrasonographical findings. A slightly enhancing rim surrounding the arm collection suggested superimposed inflammation or infection.
The following day, an MRI was performed to delineate between the silicone and the infective process in the arm (). The volume of silicone within the left breast had decreased significantly from the previous MRI, and silicone was identified throughout the supraclavicular fossa migrating into the biceps compartment of the left arm (). This migrated liquid silicone was now compressing the adjacent lymphatic drainage as well as the veins. Surrounding the migrated silicone were several multiloculated mildly rim-enhancing collections, not following the signal of silicone.
The finding of suspected abscess collections was relayed to the treating surgical team and a large volume of pus (totalling approximately 600 ml) was drained. A CT sinogram was performed that, as expected, demonstrated a fluid pocket extending from the medial aspect of the left arm to the left axilla and supraclavicular fossa. The patient was placed on intravenous cephalexin followed by a long course of oral flucloxacillin. Following this major infective process in her arm, the patient agreed to bilateral mastectomy with reconstruction. |
pmc-6159139-1 | A 29-year-old male presented with progressively worsening symptoms, including altered mental status, lower extremity weakness, nausea and vomiting for 6 months, with symptomatology extending back more than 6 years prior to this decline. He also reported headaches, dizziness, multiple falls, and right facial numbness and tingling during his 6-month decline. Previously, he had had seizures that were controlled with medication. Prior to referral to neurosurgery, his presumptive diagnosis was hydrocephalus, for which he had a ventriculoperitoneal shunt placed. Neurological examination was significant for mild dysarthria, a non-reactive left pupil, nystagmus on primary gaze of the left eye, bilateral nystagmus on horizontal gaze and mild action tremors in both hands.
Initial pre- and post-contrast-enhanced CT scans demonstrated diffuse enhancement of the basimeninges as well as heterogeneously enhancing cystic and solid lesions in the right temporal lobe and left cerebellum. Subsequent contrast-enhanced T1 weighted MRI of the brain demonstrated extensive post-contrast nodular enhancement of the basimeninges associated with an approximately 5 × 4 cm solid and cystic mass in the right temporal lobe (). An additional elongated enhancing mass was seen on the right side of the prepontine cistern measuring 2.3 × 1.1 cm in size, with an associated cystic component that extended towards the midline from this mass (). The left cerebellum was also involved, with a solid, enhancing mass that crossed the midline. On T2 weighted imaging, the cystic components of these lesions demonstrated extremely high signal intensity () that was suppressed on fluid-attenuated inversion-recovery (FLAIR) imaging, while T1 weighted imaging demonstrated hypointense signal.
Initial laboratory findings were significant only for an elevated erythrocyte sedimentation rate and C-reactive protein. CT of the chest was performed, demonstrating no evidence of pulmonary sarcoidosis, and subsequent biopsies of the right temporal lobe and dura were negative for neoplasm or any other abnormality. In addition, analyses of aspirated cyst contents were negative for inflammation or malignancy. A presumptive diagnosis of neurosarcoidosis was considered and the patient was started on prednisone. He had symptomatic improvement with the prednisone and was discharged following recovery from the biopsy.
Follow-up MRI 11 months later demonstrated progression of his disease with an interval increase in size of the intracranial lesions. Views of the spinal axis demonstrated diffuse nodular meningeal enhancement (). The patient underwent a repeat ultrasound-guided brain biopsy. This time, histopathological analysis of the biopsy specimen showed an astrocytoma with protoplasmic features (). Immunohistochemistry for Ki-67 (a cell proliferation marker) showed a labelling rate of approximately 5%, which was somewhat higher than the 0–2% commonly seen in low-grade tumours, suggestive of more aggressive behaviour ().
Owing to the multicentric nature of the tumour, craniospinal radiation therapy was recommended instead of radical surgical resection. After multiple cycles of radiation therapy with cumulative doses totalling 1800 cGy to the brain and 1620 cGy to the spine, the patient underwent repeat MRI. The studies showed a slight interval increase in size of the brain lesions but decrease in nodular enhancement of the spinal meninges. A whole body PET-CT was performed to assess disease status and demonstrated a standard uptake value of 13 in the right temporal lesion and 12 in the left cerebellar lesion, which was consistent with a highly metabolically active tumour. No definite increase in uptake was seen in the spinal region or elsewhere.
Following treatment, the patient continued to take dexamethasone for symptomatic relief. He reported a much improved condition despite mild difficulty ambulating, short-term memory loss, occasional euphoria and swollen tongue. However, his disease progressed () and did not respond to further medical or surgical management, and he ultimately passed away. |
pmc-6159140-1 | A 65-year-old female with long-standing history of hypertension and Type II diabetes mellitus presented to the emergency department complaining of sudden onset of chest pain and dyspnea. Initial evaluation in the emergency department revealed a BP of 210/120 mmHg, sinus tachycardia at 120 beats min–1, and tachypnea. On examination, she had pulmonary oedema with symmetrical and equal pulses in both upper and lower limbs. She was given intravenous furosemide 100 mg, and an electrocardiogram (ECG) was obtained showing sinus rhythm with right bundle branch block (RBBB) and ST segment elevation in leads II, III and AVF (). She underwent emergent coronary angiography which showed normal coronary arteries but with aberrant take-off of the right coronary artery (RCA) from the mid-segment of the left anterior descending (LAD) artery (). Echocardiography showed inferior wall hypokinesis with an ejection fraction of 50%.
Patient was admitted to the hospital where her course was stable and her pulmonary oedema resolved. A cardiac CT angiogram () was subsequently performed and it showed an aberrant origin of the RCA from the lateral aspect of the mid-segment of the LAD. The RCA courses circumferentially around the base of the pulmonary trunk and traverses laterally into the atrioventricular groove. The RCA then bifurcates into acute marginal and posterolateral branches. This rare variant has not been categorized in the classification of coronary anomalies; however, it closely resembles the IB1 type of Shirani and Roberts’s classification with the only exception of the RCA origin at the mid-segment and not the proximal segment of the LAD (). |
pmc-6159141-1 | A 73-year-old female presented to the emergency department with 1-week history of dry cough, intermittent light-headedness precipitated by cough, occasional mild chest pain and reduced exercise tolerance. She completed a course of antibiotics 2 weeks ago for respiratory tract infection with partial resolution of symptoms. Background history included asthma, hypertension and hyperthyroidism with total thyroidectomy 3 years ago for large goitre. Regular medications included bisoprolol, lisinopril, levothyroxine and inhalers. Her vitals were otherwise stable. On general examination, multiple subcutaneous nodules over both arms, chest wall and back were noted, they were non-tender, firm, non-pigmented, varying mobility and size. Masses were palpated in bilateral breasts with bilateral axillary and cervical lymphadenopathy. Rest of systemic examination was unremarkable. After further discussion, she mentioned that she only noticed the lumps on her arm a week ago and was not aware of presence of other masses.
Routine lab investigations revealed acute kidney injury with urea of 24.9 mmol l–1, creatinine 279 mmol l–1, potassium 6.5 mmol l–1 and haemoglobin of 10 g dl–1. She was immediately commenced on treatment for acute renal impairment and hyperkalaemia. Chest X-ray did not show any abnormality. CT of thorax, abdomen and pelvis was arranged once the renal function normalized which revealed multiple heterogeneous soft tissue nodules in neck, anterior chest wall on the left, axillary and inguinal regions, anterior abdomen with hilar and mediastinal lymphadenopathy; probable lesion in tail of pancreas and cortex of right kidney was described ().
Thyroid gland appeared to be normal and no skeletal lesion were seen. Subsequent CT-brain showed heterogeneous nodules in parotid glands bilaterally with multiple soft tissue nodules on the scalp. Possibility of metastatic lesions secondary to breast cancer was considered. PET scan showed diffuse metastatic disease including diffuse soft tissue nodules, peritoneal masses, inguinal lymphadenopathy and intramuscular deposits ().
She was then referred to breast clinic where a biopsy from the breast mass and axillary lymph node was taken. The biopsy results showed fatty tissue infiltrated by poorly differentiated malignant neoplasm with epithelioid and plasmacytoid morphology, with some nucleoli and necrosis. The tumour cells were positive for melanocytic markers including S100 and Melan A. HMB45 was negative and so were other epithelial (pan cytokeratin MNF-116, AE1/AE3, CK5/6, p63) and lymphoid (CD45, CD20) markers. The morphology and immunoprofile was consistent with metastatic malignant melanoma. The sample was tested for genetic mutation including BRAF V600E, NRAS, KIT and NTRK1/2/3 fusion of which BRAF V600E mutation was detected. However, the site of primary cutaneous melanoma could not be found.
She was referred to oncology services and commenced on dabrafenib and trametinib. Unfortunately, patient passed away within 6 months of initial diagnosis. |
pmc-6159141-2 | A 72-year-old male presented to emergency department with tender mass on lower back and posterior aspect of neck. Apparently, he had noticed it on his lower back 6 months ago and had grown in size with another similar swelling appearing on his neck, also they were increasingly painful and sore to touch. He had a history of ongoing sore throat for 3 years for which he was extensively investigated by ENT services. His CT neck and mediastinum did not show any abnormalities at that time. This was followed by laryngoscopy which showed a white patch on the right vocal cord, biopsy of which showed non-specific chronic inflammatory changes and cultures grew candida. Background history included COPD; he was heavy current smoker and smoked about 60 cigarettes per day. His medications included salmeterol/fluticasone propionate and ipratropium bromide inhalers. Vitals were within normal range. On examination, 4 cm nodular, firm, tender, immobile mass on lower back and 3 cm mass on posterior aspect of lower cervical spine were noted.
His laboratory investigation including renal and liver function, full blood count and coagulation profile were normal. A CT of thorax, abdomen and pelvis was arranged which showed 2 × 2 cm mass in right lung lower lobe likely malignant with no hilar or mediastinal lymphadenopathy, also 3 × 3 cm soft tissue mass at C6-C7 level posteriorly and 4 × 2 cm mass was noted on lumbar region with multiple prominent inguinal lymph nodes ().
A referral for bronchoscopy was sent and biopsy of the nodule was planned. While awaiting bronchoscopy appointment, biopsy was taken from mass in lower back and send for histopathology. Histology showed poorly differentiated tumour cells in cohesive groups and sheets with moderate pleomorphism and eosinophilic cytoplasm; immunohistochemistry was positive for AE1/3, cytokeratin 7 and carcinoembryonic antigen antibody stain and periodic-acid schiff. Weak nuclear positivity for TTF-1 was also seen. Overall features were consistent with poorly differentiated adenocarcinoma likely of lung origin.
He was then referred to oncology services and unfortunately passed away within 5 months of diagnosis. |
pmc-6159142-1 | A 55-year-old female patient with a history of systemic lupus erythematosus was admitted to the haematology external consultation service as a result of a clinical picture of fatigue and constitutional syndrome of 5 months’ duration.
She presented with an extrainstitutional CT that demonstrated multiple focal, hypovascular liver lesions with microcalcifications () that occupied all segments of the liver, and was interpreted as possible metastatic disease.
The patient was evaluated without positive findings upon physical examination. The extrainstitutional paraclinical tests showed negative tumour markers and normal tests of liver function.
Because of the imaging findings, it was decided to hospitalize the patient to characterize the hepatic lesions with contrast MRI with gadopentetate dimeglumine (Magnevist), 15 ml, infusion rate 2.2 psi, to stage the possible tumour lesion with a study algorithm of an unknown primary tumour. No specific liver contrast medium was used.
The MRI findings () showed a liver of normal size and morphology, with multiple focal lesions distributed among all segments of the hepatic parenchyma, with variable sizes ranging from a few millimetres to several centimetres, the biggest lesion (in the right lobe) being 5 cm. These lesions appeared hyperintense in T2 sequences and hypointense in T1 sequences, without identification of a fatty component in their interior. Predominant restriction in the periphery was observed in diffusion sequences. After contrast administration, some lesions showed discrete heterogeneous peripheral enhancement, whereas others showed intralesional nodular enhancement. Cholangioresonance sequences were performed with results in normal ranges (). The lesions present very little contrast uptake even in the late 5-min sequences. This uptake is heterogeneous, being central in some lesions and peripheral in others (). Finally, in the MRI in the arterial phase, multiple low-intensity lesions are identified that do not show contrast media uptake (). Phase and out-of-phase sequences were performed without identifying change in intensity signal, suggesting microscopic fat content in the lesions ().
This study was complemented with ultrasound examination (), which demonstrated solid, frank echogenic lesions with multiple punctate echogenic foci in their interiors explained by the presence of calcifications; some exhibited annular hyperechogic halo with less echogenic centres. No alterations of the biliary tract were identified in the MRI or ultrasound image.
Permeability of the intra-abdominal vascular structures was observed and morphological changes of chronic liver disease or cirrhosis could not be identified. No other intra-abdominal lesions or adenopathies were found.
Paraclinical studies (liver function test, carcinoembryonic antigen, clotting time, complete blood count and platelets) were requested but all results were in normal ranges.
The diagnostic possibilities based on the imaging findings were infectious involvement by echinococcus versus metastatic lesions of an unknown primary tumour.
An ultrasound-guided biopsy of the dominant lesion located in the right lobule was performed to clarify the diagnosis. A report was obtained within 3 days of the procedure; the pathology findings of the collected liver samples reported “fragments of liver tissue replaced by a benign lesion of vascular origin characterized by the presence of numerous anastomosing vascular channels within it, lined by endothelial cells without atypia, separated by fibrous connective tissue septa with ectatic and obliterated vessels; findings are consistent with sclerosing cavernous haemangioma” (). |
pmc-6159146-1 | A 54-year-old male presented with progressively worsening neck pain and numbness of the left upper extremity and the left face for 2 weeks. He had no history of recent head or neck injuries. He was followed closely without further treatment because of his fluctuating subjective symptoms. However, the symptoms gradually worsened, and he visited our hospital for intensive examination and treatment 2 months after the onset. Neurological examination revealed a mildly spastic gait and exaggerated deep tendon reflexes in the bilateral upper and lower extremities. He also had mild dysuria and constipation. Muscle strength and vibration sense were normal, and no Babinski sign was present. Peripheral blood examination on admission revealed no significant abnormality. Cerebrospinal fluid examination was within normal limits except for slightly elevated protein (65 mg dl–1; normal, 10–40 mg dl–1). Unenhanced CT of the cervicothoracic spine showed diffuse dorsal epidural calcification at C3-T6. The lesion presented as a crescent shape along the spinal dura mater and had a well-defined border along the vertebral arch (). On MR imaging, the lesion appeared as a hypointense mass on both pre-contrast T1 and T2 weighted images. The lesion displayed heterogeneous enhancement, and caused cervical spinal canal stenosis (). Head CT and MR imaging revealed no significant abnormality. Based on these findings, CPPD crystal deposition disease of the ligamentum flavum was suspected. C5/6 laminectomy to biopsy for confirmation was performed. Perioperative findings revealed an intact ligamentum flavum. A solid, grayish-white lesion was found just beneath the ligamentum flavum (). Histopathological examination of the specimen demonstrated numerous granular calcium crystals within dense fibrous tissue with myxoid change (). Grocott, periodic acid-Schiff and Ziehl-Neelsen stains showed no obvious source of infection (e.g. fungal or tubercular), and there was no evidence of malignancy. These features confirmed the diagnosis of CPPD crystal deposition disease along the spinal dura mater. The patient’s neurological symptoms during the postoperative course was uneventful, and follow-up CT performed 4 months later revealed no regrowth of the calcified lesion. |
pmc-6159148-1 | A 59-year-old female patient presented with abdominal pain and bloating sensation after every meal. At times, pain was severe and was localized to the right hypochondrium. The patient had undergone laparoscopic cholecystectomy for similar complaints 6 months back. On clinical examination, there was positive Murphy’s sign. Laboratory investigations revealed normal bilirubin levels.
Ultrasound examination of abdomen done elsewhere revealed cystic lesion in the right hypochondrium in the gall bladder bed. magnetic resonance cholangiopancreatogram (MRCP) of the abdomen suggested for better evaluation of the cystic lesion. On MRCP (), there is an oblong cystic lesion seen in the gall bladder fossa. This cystic lesion is showing a focal T2* shortening which is interpreted as a remnant stone (,). The lesion is not connecting with the common biliary duct (CBD). Both the CBD and intrahepatic biliary radicles are otherwise unremarkable. Collectively, the MRCP is interpreted as remnant cystic duct with a calculus in situ.
Based on the above findings, the patient was subjected to laparoscopic exploration and the residual cystic duct with calculus were successfully removed. Following surgery, the patient improved dramatically with alleviation of cholestatic symptoms and follow-up ultrasound abdomen every 6 months was unremarkable. |
pmc-6159149-1 | An 85-year-old right-handed male presented with sudden onset right hemiparesis. His medical history was significant for hypertension, dyslipidaemia and prostate cancer. He never smoked cigarettes and had no known diabetes mellitus or atrial fibrillation. Pre-admission cardiovascular medications included aspirin 75 mg and atorvastatin 20 mg daily. Admission National Institutes of Health Stroke Scale was 6. Non-contrast CT head revealed established bilateral corona radiata infarcts. CT angiogram (CTA) demonstrated a left internal carotid artery (ICA) web (). Intravenous thrombolysis was administered with a door to needle time of 21 min. On carotid duplex ultrasonography, an irregular mixed echogenic plaque (query ulcerated) was seen at the origin of the left ICA causing a 0–29% stenosis (). MRI head demonstrated acute infarcts in the left parietal lobe. Magnetic resonance angiogram (MRA) carotid arteries also demonstrated a shelf-like projection arising from the posterior wall of the left ICA consistent with a carotid web ().
For secondary stroke prevention, he was prescribed clopidogrel 75 mg daily and atorvastatin 40 mg. He was subsequently transferred to a stroke rehabilitation centre. |
pmc-6159149-2 | A 38-year-old Middle Eastern male presented to the emergency department with sudden onset dense right hemiparesis, right facial droop and aphasia. His background history included a previous ischaemic stroke 15 months ago treated in a different institution. At that time, he presented with a headache and dysphasia and a CT brain showed a left temporo-parietal infarct. By 6 months later, he had returned to his baseline of full functional independence on treatment with clopidogrel 75 mg once daily and atorvastatin 40 mg daily.
On this admission, CT brain showed a left M1 occlusion and the patient was treated with intravenous alteplase and thrombectomy.
His CT angiogram intracranial confirmed an acute occlusion of the M1 portion of the left middle cerebral artery and revealed two separate foci of soft plaques arising from the posterior wall of the origin of the left and right ICA with accompanying carotid webs on both sides (). His MRA carotids showed a haemorrhagic “plaque” at the origin of the left ICA but no high-grade ICA stenosis or any evidence of dissection (). Axial fat-saturated T1W MRI demonstrated a crescentic hyperintense signal at the posterior aspect of the origin of the left ICA consistent with haemorrhage within the known carotid web (). His carotid Doppler was normal. Extensive stroke work-up did not reveal any other cause for his stroke.
He was started on dabigatran 150 mg twice daily and aspirin 75 mg. He has now been transferred to a stroke rehabilitation centre with residual speech apraxia, improving right limb weakness and ability to comprehend one step commands. |
pmc-6159151-1 | A 63-year-old male presented first with right groin pain and back pain over a period of more than 2 years and received analgesics, which did not help much. A year later, he started to feel pain and swelling in the right gluteal region.
Conventional radiography of the lumbar spine showed mild left convex scoliosis and a partially elicited right iliac wing osteolytic lesion ().
Conventional radiography of the pelvis revealed a large osteolytic lesion involving the right iliac crest and wing with sclerotic margins and no obvious dominant gross matrix calcifications ().
MR examination of the pelvis elicited a huge (about 176 × 129 × 94 mm) mass arising from the superior aspect of the right iliac wing, which is generally T1 homogenous hypointense and T2 heterogeneous hyperintense signal with internal dominant fluid-equivalent signal and peripheral nodular hypointense margin. The mass is saddle shaped, overhanging the right iliac crest with a pelvic (internal) limb displacing and attenuating the right iliopsoas muscle without invasion of the iliac vessels and gluteal (external) limb extending into the gluteal region between the gluteal medius and minimus muscles. No evidence of invasion or encasement of the surrounding structures or adjacent iliac vessels was observed, and there was no defined regional pelvic lymphadenopathy. The whole lesion was surgically excised. There was no defined invasion of the surrounding adjacent soft tissues of the pelvis or the right gluteal region (–). |
pmc-6159152-1 | A 51-year-old female presented to the emergency department with sudden onset of epigastric pain and vomiting. There was no known history of visceral or other arterial aneurysm, pancreatitis or connective tissue disease and the patient was otherwise fit and well. On examination, she was hypotensive (85/60 mmHg), with rebound and four quadrant abdominal tenderness.
Urgent portal venous phase abdominal CT was performed. The anteroposterior scout image showed a large epigastric density displacing the lesser curvature of the stomach inferiorly ( white arrow). Post administration of contrast, images showed extremely rapid extravasation of contrast from a ruptured bilobed 18 mm left gastric artery aneurysm ( black arrow). From the time of contrast injection to the time of imaging (approximately 70 s) a very large volume of contrast had extravasated into the peritoneal cavity, and was evident in the pelvis, left paracolic gutter ( black arrows) and lesser sac, confirming very rapid bleeding. An expanded haematoma was present and centred in the region of the lesser omentum and lesser sac. This haematoma displaced the gastric lesser curvature inferiorly, the pancreatic head and body posteriorly () and the underside of the left lobe of the liver superiorly. The haematoma was seen extending through the oesophageal hiatus, which was also expanded (). There were signs of hypoperfusion complex with flattened inferior vena cava and adrenal hyperattenuation. The patient underwent urgent surgery during which the aneurysm was clipped and resected, and she made an uneventful recovery. |
pmc-6159152-2 | A 57-year-old female presented with abdominal pain radiating to the back, with presyncopal symptoms. There was no known relevant history. Urgent triple phase CT demonstrated a right gastric artery aneurysm, located near the region of its anatomical anastomosis with the left gastric artery. No definite active haemorrhage was seen at the time of the study. A very large volume haemoperitoneum was present. A haematoma with epicentre at the lesser omentum/lesser sac was present. The haematoma displaced the lesser curvature of the stomach inferolaterally and filled the lesser sac. There was mild compressive mass effect on the anterior aspect of the pancreas. Emergent surgery was performed, and the aneurysm oversewn. The patient made complete recovery. |
pmc-6159154-1 | The patient was a 47-year-old, gravida 2, para 2 female. She presented with lower right abdominal pain. MRI revealed a complex solid and cystic lesion measuring 9 cm in the right ovary (, upper left;). Some of the cystic locules showed high signal intensity on T1 weighted image (WI), indicating haemorrhage. A large enhanced solid component showed marked fluorodeoxyglucose (FDG) uptake on positron emission tomography (PET) (). A malignant ovarian tumour was suspected, so she underwent laparotomy. Analysis of an intraoperative frozen section of the tumour suggested a malignant or borderline endometrioid tumour of the ovary. During surgery, peritoneal thickening and adhesion in the Douglas pouch were observed, indicating pelvic endometriosis. Analysis of formalin-fixed paraffin embedded (FFPE) specimens revealed islands of endometrioid tumour cells showing moderate cytologic atypia proliferating within dense fibrous stroma (, upper left). The case was diagnosed as EBT, pT1aN0M0. |
pmc-6159154-2 | The patient was a 65-year-old, gravida 2, para 2 post- menopausal female. She presented with vaginal bleeding. She was pointed out a pelvic mass on clinical examination and ultrasound. MRI showed a multiloculated mass measuring 15 cm of mixed high and low signal intensities on T1WI. Within a cyst, irregular shaped papillary projections were observed at the tumour wall on T2WI and were well enhanced indicating solid components ( upper right, ). This lesion showed restricted water diffusion on diffusion weighted imaging (DWI) (). A malignant ovarian tumour was suspected, and laparotomy was performed. A large right ovarian tumour was found extending into the retroperitoneum, strongly adherent to the pelvic wall. Analysis of intraoperative frozen sections revealed EBT. Final pathological diagnosis was EBT, pT1aN0M0. Intracystic papillary proliferation of atypical endometrioid epithelium was observed (, upper right), with coincidental non-atypical endometriosis. A benign endometrial polyp was detected in the uterine endometrium. |
pmc-6159154-3 | The patient was a 54-year-old, gravida 2, para 2 post-menopausal female. She presented with lower abdominal discomfort and a right ovarian mass was pointed out by pelvic examination. Endometrial cytology detected adenocarcinoma cells. MRI and CT revealed a complex solid and cystic lesion of 8.4 cm diameter within the right ovary. A papillary lesion was observed on the tumour septum on T2WI and enhanced on post-contrast CT ( lower left, ). PET-CT showed strong uptake within the solid component (). Endometrial lesions were indistinct on imaging studies including CT and MRI. Concurrent ovarian and endometrial cancer was suspected, and she underwent surgery. During the surgery, the multiloculated right ovary measuring 8 cm was found to be adherent to the pelvic peritoneum. Blueberry spots, or blue tiny spots on peritoneum were observed in the Douglas pouch, indicating pelvic endometriosis. Intraoperative frozen section analysis suggested EBT. Analysis of FFPE specimens revealed an intracystic proliferation of atypical endometrioid epithelium showing crowded fusing glands ( lower left). The area of confluent glands were smaller than 5 mm, and destructive stromal invasion was absent, justifying the diagnosis of EBT, pT1aN0M0. Coincidental endometrioid carcinoma, Grade 1, pT1aN0M0 was found in the uterine endometrium. |
pmc-6159154-4 | The patient was a 41-year-old, gravida 0 female. She was diagnosed with a left ovarian endometriotic cyst and uterine myomas when she was 34-years-old. At the age of 36, she was diagnosed with breast cancer and underwent left mastectomy and axillary lymphadenectomy, chemotherapy, and radiotherapy. She then commenced gonadotropin-releasing hormone agonist and tamoxifen. MRI at the age of 37 revealed an endometriotic cyst in her left ovary; the cyst showing high intensity on T2WI and intermediate-to-low intensity on T1WI without any solid component (). At the age of 40, she experienced intermittent vaginal bleeding lasting 6 months. Endometrial biopsy under hysteroscopy revealed endometrioid carcinoma, Grade 1. On this occasion the left ovarian tumour was unchanged in size when compared to the previous MRI scan, but there was now solid areas with strong enhancement within the haemorrhagic cyst on MRI ( lower right, ). Those solid lesions showed restricted water diffusion. Endometrial lesion was not recognized on MRI. PET-CT demonstrated FDG uptake in the solid portion of the left ovarian tumour (). A malignant left ovarian tumour with endometrial cancer was suspected. She underwent surgery. The 3-cm left ovarian cyst was adherent to the peritoneum. Intraoperative frozen section analysis demonstrated a seromucinous borderline tumour. In FFPE specimens, a left ovarian cyst was identified, with intracystic proliferation of papillary endometrioid epithelium with cellular and structural atypia (, lower right). The case was diagnosed as EBT of the ovary, pT1aN0M0 and endometrioid carcinoma Grade 1 of the uterine endometrium, pT1aN0M0.
lists patient characteristics, image study findings and pathological findings. lists the results of immunohistochemistry for estrogen receptor, p53, and ARID1A. None of the patients underwent adjuvant therapy, but they were all well without recurrence. All patients provided written informed consent.
lists 122 reported EBT cases in the literature. Case reviews reporting more than 3 cases are included. |
pmc-6159159-1 | A 56-year-old female was recalled for assessment following an incident round screening mammography that demonstrated a new density in the left breast. She was asymptomatic, fit and well, with no significant medical or family history. Bilateral breast examination was normal. |
pmc-6159161-1 | A 4-month-old female infant presented to our ear, nose and throat department with nasal stenting for CNPAS, which was performed elsewhere, with the stents in place. On clinical examination, the stents were seen in the bilateral nares, with partial absence of the nasal septum. Previous CT images were obtained from the parents and reviewed. CT images showed a narrowed pyriform aperture measuring 5.4 mm (). Mild medial angulation of the nasal processes of the maxilla was noted, and a single central mega-incisor was also noted ( and ). CT scan of the brain showed no intracranial abnormalities.
As the surgeons wanted to know the patency of the airway after stent removal and plan for further surgical management, the child was subjected to a CT scan immediately after removal of the stents. These CT images showed a pyriform aperture measurement of 10.3 mm (considered satisfactory; ). A central mega-incisor was noted. The nasal septum was almost completely eroded, which was probably attributed to compression erosion by the stents ( and ). On posterior rhinoscopy, no significant stenosis was seen at the posterior choanae. After removal of the stents, the infant was observed for cyanosis, but no complications were noted. Hence she was discharged and was asked to come back for follow-up. |
pmc-6159162-1 | A previously well 52-year-old male presented to the hospital with a 5-day history of abdominal tenderness, which was maximal in the left iliac fossa. |
pmc-6159163-1 | A 24-year-old black female presented with widespread skin changes on the upper and lower extremities, torso and genitalia. 2 years after the initial presentation, owing to worsening of her skin, she underwent partial vulvectomy. Lesional skin histopathology revealed the diagnosis of granulomatous slack skin cutaneous T-cell lymphoma (GSS CTCL) (). Over the course of 3 years, she received a variety of therapies. However, owing to therapy-related complications, she discontinued treatment. While off therapy, new skin lesions and lymphadenopathy developed. Our patient’s disease progression was clearly demonstrated by 18F-fludeoxyglucose (FDG) positron emission tomography (PET)/CT findings ( and ). |
pmc-6159165-1 | A 33-year-old Sudanese woman, gravida 8, para 7 with 2 months of amenorrhea, was admitted to hospital following complaints of minimal vaginal bleeding, lower abdominal pain, nausea and vomiting on the day of admission. She had undergone a caesarean section 3 years prior. The patient’s physical examination revealed abdominal distention and generalized tenderness during palpation. A bimanual vaginal examination demonstrated an enlarged uterus that seemed to be consistent in size with 8 weeks’ gestation. The patient’s serum beta human chorionic gonadotrophin (β-hCG) level was 7,928 mIU ml–1. |
pmc-6159166-1 | A 2-month-old male infant was referred to our intensive care unit (ICU) from a peripheral facility where he had presented with one day of progressively worsening difficulty in breathing and feeding associated with multiple convulsions of generalized tonic clonic nature. On examination, he was dyspneic, afebrile and tachycardic, with cold extremities, weak pulses and a delayed capillary refill of 4 s. His blood pressure was 98/64 mmHg and blood sugar 14.4 mmol l–1. An arterial blood gas showed a mixed metabolic/respiratory acidosis with a pH of 7.1, hypercapnia (pCO2 55 mmHg) and decreased bicarbonate levels (20 mEq l–1). He had a white cell count of 15.6 × 109 µl–1, largely neutrophils (76%), a reactive thrombocytosis (605 × 109 µl–1), an international normalized ratio (INR) 1.24 and a normal chest radiograph. Further history revealed that the infant had an uneventful natal and postnatal period, but had had 3 weeks of nasal congestion, treated with nasal saline drops, antihistamines, antibiotics and antipyretics.
In the ICU, he was immediately intubated (endotracheal tube 3.5 mm diameter, 11 cm length) and ventilated. He was put on broad spectrum antibiotics (ceftriaxone, clarithromycin) for severe pneumonia/sepsis, phenytoin and morphine.
He was further noted to have a firm, smooth, immobile left submandibular mass, extending to the neck levels II-V. A CT scan was done, revealing a 27 mm × 47 mm × 42 mm parapharyngeal/paravertebral cystic mass obliterating the oropharyngeal airway and acute left LST (); the latter confirmed on MRI (). He was started on low molecular weight heparin (Enoxaparin) at 1 mg/kg–1 and ultrasound-guided aspiration was done. This revealed pus and 20 ml drained and cavity flushed with 40 mg gentamycin and 1 g vancomycin.Staphylococcus aureus was grown on culture of the aspirate. There were no acid fast bacilli, and the human immunodeficiency virus (HIV) test done was negative. Ceftriaxone was then changed to clindamycin, with successful extubation 48 hours later, and transfer to the ward after 2 weeks of ICU care. A repeat MR venogram () done at the end of his 14 day stay in the ward showed partial re-cannulation in the sinuses. |
pmc-6159167-1 | A 55-year-old female with no significant past medical history initially presented in 2006 with vague abdominal pain. Her past social history was negative for alcoholism or smoking. Work up of the patient including physical examination and laboratory indices were all normal. A multi-detector CT of the abdomen and pelvis utilizing a pancreatic mass protocol (arterial, portal venous and delayed phases) was performed which revealed a diffusely enlarged pancreas with extensive parenchymal calcifications (). No discrete mass was identified in the pancreas. Minimal pancreatic ductal dilatation was noted on the CT examination. The patient was diagnosed with chronic pancreatitis and followed clinically for several years. In 2015, the patient presented with recurrent abdominal pain. A CT of the abdomen and pelvis with pancreatic mass protocol was repeated (), which revealed new hypoattenuating masses in the pancreatic neck and tail. Some of the smaller tumours were hypervascular on the arterial phase imaging. There was redemonstration of extensive parenchymal calcifications. No pancreatic atrophy was identified. The pancreatic duct remained minimally dilated. Given the new masses many of which were arterially enhancing, the possibility of neuroendocrine tumour was raised. A MRI of the abdomen with pancreatic mass protocol (T2 with fat saturation, MRCP, in and out of phase T1 and unenhanced T1/arterial/portal/ 5 min delayed post-contrast T1) was performed (). The MRI confirmed multiple well-circumscribed masses throughout the pancreas, many of which had increased T2 signal with cystic change. The pancreatic duct was at most mildly prominent, and no lesions were identified outside of the pancreas. The largest pancreatic mass in the tail measured approximately 3.5 cm, with peripheral enhancement and central hypointense signal (). An endoscopic ultrasound was performed, which confirmed a hypoechoic mass in the tail of the pancreas, two isoechoic masses in the head of the pancreas, and diffuse parenchymal calcifications suggestive of chronic pancreatitis. Fine needle aspiration of the pancreatic masses in the head was performed, with cytology returning as concerning for neuroendocrine tumour. Given the suspicion for pancreatic neuroendocrine tumour, an indium-111 Octreotide scan was requested for further characterization. Fused SPECT-CT imaging was also performed for improved uptake localization (). The indium-111 scan revealed diffuse intense uptake of radiotracer throughout the entire pancreas. No extrapancreatic foci of uptake was identified. On the grounds of the clinical and imaging findings, it was decided the best course of action would be to perform a pylorus-preserving pancreaticoduodenectomy with total resection of the pancreas, splenectomy and cholecystectomy. Sectioning of the pancreas revealed numerous well-circumscribed, solid and tumoural masses ranging from minute up to the largest grossly identified lesion measuring 3.5 cm in diameter (). Many of the nodules were coalescing with only a scant amount of intervening normal pancreatic parenchyma present. The cut surfaces of the nodular masses were solid and showed a variegated pink to orange-red colour. No gross areas of necrosis were identified. Numerous representative histologic sections of the nodular masses were examined. The nodules were comprised of numerous insular nests and trabecular cords of fairly uniform epithelioid neoplastic cells with oval nuclei and speckled chromatin. Many of the nodules showed numerous calcifications and localized amyloid deposition (). Immunohistochemical stains were performed and the neoplastic cells marked strongly for the neuroendocrine markers chromogranin A and synaptophysin (). Multiple immunostains for pancreatic peptides were performed. The neoplastic cells were positive for pancreatic polypeptide and negative for insulin, glucagon and somatostatin. Only a rare mitotic figure was identified but the Ki-67 mitotic index marker was calculated at 5% as measured by the Aperio image analysis system. The findings were consistent with numerous neuroendocrine tumours of the pancreas, Grade II, as per the 2010 WHO criteria for neuroendocrine tumours of the pancreas. The neuroendocrine neoplastic nodules were all confined within the pancreatic parenchyma and all pancreatic resection margins were free of neoplasia. All regional lymph nodes sampled were negative for metastatic disease. |
pmc-6159168-1 | A 64-year-old female patient with background of a right iliac fossa renal transplant presented to the renal outpatient clinic complaining of unilateral swelling of the left lower limb for several weeks. The clinical history did not reveal any risk factors for deep vein thrombosis. On clinical examination the patient had unilateral leg swelling on the left with pedal oedema. Observations were normal and cardiovascular and abdominal system examinations were unremarkable. |
pmc-6159173-1 | A 58-year-old male with Type 2 diabetes mellitus and peripheral neuropathy, presented with left foot swelling and minimal pain. There was no history of trauma. Radiograph () demonstrates multiple healing stress fractures involving the diaphysis of the second, third, fourth and fifth metatarsals. |
pmc-6159173-2 | A 46 year-old female with a history of poorly controlled Type 1 diabetes mellitus and diabetic peripheral neuropathy presented with painless foot swelling. Radiograph performed 6 months prior to presentation () shows an ununited fracture of the proximal shaft of the fifth metatarsal. No specific treatment for the ununited fracture was documented. Six months later, a radiograph () performed for investigation of painless foot swelling demonstrates changes consistent with avascular necrosis of the heads of the second, third and fourth metatarsals. MRI () confirmed the findings. In the setting of diabetic peripheral neuropathy, we postulate that the development of avascular necrosis is most likely secondary to altered biomechanics due to the previous fifth metatarsal fracture and is a result of increased force exerted on the metatarsal heads, poor bone quality and microvascular ischaemia. |
pmc-6159173-3 | A 53-year-old male with Type 1 diabetes, peripheral neuropathy and previous partial amputation of the proximal phalanx of the left great toe presented with a non-healing, minimally painful ulcer at the stump of the left first toe. Radiograph of the left foot () demonstrates established avascular necrosis involving the heads of the left second and third metatarsals. Amputation of the proximal phalanx of the first toe with resultant alteration in biomechanics is the likely initiating factor for osteonecrosis of the metatarsal heads. |
pmc-6159173-4 | A 65-year-old male with Type 2 diabetes mellitus and peripheral neuropathy presented with a painless ulcer in the third toe. Radiograph performed on presentation () shows an ununited fracture of the head of the proximal phalanx of the fourth toe, consistent with previous trauma in an insensate foot. “Pencil point” deformity of the neck of the proximal phalanx of the fourth toe is compatible with bone remodelling, most likely related to chronic microtrauma associated with profound sensory neuropathy and altered biomechanics secondary to previous amputation. A radiograph () performed 5 years earlier shown for comparison demonstrates normal appearance of the proximal phalanx of the fourth toe. |
pmc-6159173-5 | A 52-year-old male patient with a history of diabetes mellitus and peripheral neuropathy presented with fifth toe swelling. MRI () and CT () demonstrate remodelling of the distal phalanx of the fifth toe. The MR appearances are suggestive of chronic microtrauma in the context of diabetic neuropathy with remodelling of the bone with periosteal and soft tissue reaction. |
pmc-6159173-6 | A 62-year-old male with a history of Type 2 diabetes was admitted with a chronic non-healing left calcaneal ulcer. Radiograph of the left calcaneus () was unremarkable. MRI () reveals a non-displaced insufficiency fracture of the calcaneus with no evidence of osteomyelitis. |
pmc-6159173-7 | A 73-year-old male with a history of Type 2 diabetes mellitus presented with a heel ulcer. Radiograph of the left foot () reveals a wedge-shaped avulsion fracture at the posterior calcaneus. |
pmc-6159175-1 | A 20-year-old asymptomatic female, G1P0, with a history of curettage, is presented to the Department of Gynecology and Obstetrics for termination of pregnancy. Her last menstrual period was 17 weeks and 2 days ago. Abdominal ultrasound revealed a clear gestational sac (GS), fetus with heartbeat and placenta previa. Abdominal ultrasound also showed the GS at a distance from the cavity, with a compressed myometrium between the two of them (). The patient received a MRI examination, showing an enlarged uterus of 13.0 cm ×11.7 cm × 7.9 cm, because of pieces of evidence. The MRI demonstrated a foetus with clear organs (), and compressed the lower uterine segment (). The GS was not connected with the uterine cavity and endometrium, but embedded into the myometrium in the right posterior wall of the uterine. A linear hypointensity of the junction zone was observed between the GS and the uterine cavity on T2weighted image ().
This result is likely to be placenta implantation as the myometrium cannot be separated from the placenta. The patient was at risk of the uterine rupture and life- threatening haemorrhage. Emergent management should be performed. Performing uterine artery embolization (UAE) and interventional therapy is inadvisable because of the obstructing myometrium between the cervix and placenta. Employing a surgical exploration of the abdomen was decided that was undertaken under temporary balloon occlusion of the abdominal aorta to reduce the loss of blood. The balloon was placed in the abdominal aorta between the opening of renal artery and iliac artery just before the operation. If the area of the focal damage was heavy, the subtotal hysterectomy or hysterectomy was needed. Otherwise, clinicians can perform excision by laparotomy and hysteroplasty. Given the age of patient, clinicians did their best to perform hysteroplasty instead of hysterectomy. The intramural ectopic GS in the second trimester was successfully excluded without life-threatening haemorrhage (). The patient had an uneventful postoperative course. Her β-hCG titre decreased to 1727 mIU ml–1 on the second day after operation, and then to 440.1 mIU ml–1 on the sixth day. She was discharged 6 days after surgery. |
pmc-6159178-1 | An 80-year-old male was being investigated at a tertiary hospital for iron deficiency anaemia. His medical history, symptomology and physical examination did not indicate a cause. After gastroscopy and colonoscopy were also unremarkable he was referred for capsule endoscopy. The delivery of the capsule in the morning was routine; however, review of the images 8 hlater showed a static picture and no evidence the capsule had entered the stomach. The patient was clinically stable and contacted to present to the emergency department with a suspicion of capsule impaction. |
pmc-6159179-1 | A 72-year-old Caucasian female patient was referred to the respiratory clinic with a 6-month history of exertional breathlessness. She gave a history of yearly chest infections, particularly in winter months. She, however, had no history of childhood respiratory problems or any significant respiratory symptoms during her adult life. She had a 30-pack-year smoking history but she quit 25 years prior to presentation. She worked as a nursing auxillary at a local hospital and had no prior asbestosis. She was on a 1 mg maintenance dose of prednisolone for polymyalgia rheumatica. Otherwise, she had no significant medical condition and was not on any regular medications. Her exercise tolerance was unlimited and she enjoyed a good health.
Her O2 saturation was 95% on room air and her spirometry showed obstructive pattern with FEV1 1.14L (55%), FVC 2.09L (83%) and FEV1/FVC ratio 54%.
An initial chest radiograph 2 years prior to presentation suggested an increased radiolucency of the left lung but this was not investigated further (). Serial CXRs 2 years later showed a relatively unchanged appearance of the left hemithorax with progressively increased opacification in the periphery of the middle and lower zones, and accompanying reduction in lung volume, on the right side ().
The patient underwent a contrast-enhanced CT of the chest in view of the repeated chest infections and lack of complete resolution to rule out the possibility of an adenocarcinoma in situ or endobronchial lesion, respectively. Cross-sectional imaging was also carried out to assess the possibility of an underlying bronchiectasis in the presence of the recurrent chest infections and to further assess the interstitial changes seen on the CXR on the right side.
Her CT showed hypoplastic left pulmonary artery (; arrow), attenuated peripheral pulmonary artery branches on the left (: arrows), hyperinflated left lung with air trapping and cystic bronchiectasis of the lingua and left lower lobe (). Features were in keeping with the diagnosis of Swyer-James-MacLeod syndrome (SJMS). Interestingly, the right lung was small in size with evidence of subpleural reticulation, traction bronchiectasis and ground-glass opacification suggesting an underlying pulmonary fibrosis (). The oligaemia of the left lung is shown as reduced FDG uptake () on PET CT, which was done to investigate a different pathology.
Sputum culture grew pseudomonas species and bronchoalveolar lavage from the right lung showed mixed cellularity with 22% eosinophils and a 36% neutrophils. |
pmc-6159180-1 | An independent, healthy 48-year-old female presented to her general practitioner with a 3-week history of slurred speech, unsteadiness and fatigue. She took occasional iron supplements, but no regular medications.
Her past medical history included iron deficiency anaemia and a melanoma, which had been excised 13 years previously.
One year prior to this presentation she had an admission spanning 4 weeks, with lingering depressive and anxiety symptoms after a presumed viral infection 6 months earlier. She had experienced lethargy, intermittent headaches, nausea, diarrhoea and 16 Kg of unintentional weight loss over a 6-month period. Following investigation with biochemical assessment, endoscopy, colonoscopy and a CT abdomen she was diagnosed with an episode of major depression and started on an antidepressant.
Clinical examination at this presentation demonstrated ataxia, with the patient being unable to walk heel-to–toe. Romberg’s test was negative. She had a subtle dysarthria. No other focal neurology was elicited on neurologic examination. Cardiorespiratory examinations were unremarkable. The general practitioner arranged a CT brain, which identified multifocal haemorrhagic sites in the right cerebellar and both cerebral hemispheres (). These ranged from subcentimetre in size to the largest—a 3-cm right cerebellar lobar bleed. The differential diagnoses postulated in the report were haemorrhagic metastases—possibly recurrent melanoma, or an atypical presentation of amyloid angiopathy.
The patient was commenced on dexamethasone and referred to the neurosurgical department. She was booked for a staging CT chest/abdomen and pre-operative stealth brain MRI, with a view to excise the right cerebellar lesion for histological diagnosis. The MRI confirmed multiple supra- and infratentorial lesions. Haemosiderin staining was seen in multiple sulci at the vertex in keeping with a low volume of subarachnoid blood, and a 4 mm posterior inferior cerebellar artery aneurysm was detected (–). The CT chest identified a mass in the left atrium concerning for an atrial myxoma (). In view of the suspected cardiac mass the neurosurgical biopsy procedure was postponed pending further work up.
Echocardiography showed a large, mobile left atrial mass compatible with an atrial myxoma. There was no associated obstruction despite the mass occupying half of the left atrial volume. Left ventricular function was normal (Ejection Fraction 62%). Without histological support a melanoma deposit remained a possible diagnosis and, after discussion between neurosurgery, cardiology and cardiothoracic teams, a decision was made to proceed with the cerebellar excision. A cardiac MRI was also arranged.
The cerebellar excision was uncomplicated, but histological assessment was non-contributory towards a diagnosis. No melanoma or other malignant cells were identified. The excised material consisted of haemorrhage and some distortion of the underlying vascular architecture, without evidence of vasculitis or amyloid angiopathy. In the interval, the cardiac MRI demonstrated an interatrial septal stalk pathognomonic for atrial myxoma. The new favoured diagnosis was haemorrhagic transformation of embolic ischaemic infarcts secondary to the atrial myxoma.
The patient showed some symptomatic improvement with steroids and was referred to Interventional radiology for formal cerebral angiography assessment to evaluate for cerebral vasculitis. Both internal carotids and vertebral arteries were imaged. The procedure revealed extensive abnormalities, with diffuse irregularity of the medium to small vessels, most pronounced in the peripheral ICA and PCA branches. Distal, fusiform aneurysm formation was identified in at least two distinct sites in the peripheral intracranial branches (,). No central aneurysm was detected around the arterial circle of Willis.
The patient underwent excision of the left atrial mass under therapeutic heparin cover on a cardiopulmonary bypass machine. Histological assessment confirmed a left atrial myxoma, with the friable specimen demonstrating classical stellate mesenchymal tumour cells set in a loose myxoid stroma. The patient had an uncomplicated post-operative course and a normal post-operative echocardiogram. She was discharged home with a follow-up MRI and neurosurgical review booked at 6 weeks. |
pmc-6159181-1 | A 63-year-old female patient was referred to the IR clinic with medically refractory ascites due to Child-Pugh Class B alcoholic-liver disease cirrhosis. The patients’ pre-procedure parameters were as shown in . The patient did not wish to be considered for OLT or TIPSS, and decision was made to insert an alfapump system.
The procedure was tolerated well by patient with no significant discomfort. Oozing of ascitic fluid from the peritoneal catheter access site was noted on day 1, which resolved spontaneously after 2 days and was presumed secondary to the elevated abdominal pressure due to volume of ascites.
On day 15, post-implantation patient’s sodium had improved from 130 mmol l–1 to 135 mmol l–1 and her albumin had decreased minimally from 43 g l–1 to 38 g l but remained within the normal range (). The patient did not require albumin infusion and her nutrition was maintained on oral diet. At last check, patient had 100 litres of ascites drained with a mean daily volume of 74.4 mls in the last 7 days. The patient did not develop renal failure ().
As the patient’s overall nutrition improved significantly following drainage of ascites, combined with decreasing pump volume, the decision was made to switch off the pump 224 days post implantation. The pump was electively explanted on the patient’s wishes immediately thereafter. |
pmc-6159181-2 | A female patient aged 54 years, with Child-Pugh Class B cirrhosis secondary to excess alcohol intake, was referred to IR clinic with medically refractory ascites. Pre-procedure parameters were as documented in . The patient had previous encephalopathy, hence was not a candidate for TIPSS. Following much discussion, she was placed on the active liver transplant waiting list and decision was made to insert the alfapump system as a bridge-to-transplant.
The procedure was tolerated well by the patient with no significant discomfort.
The patient suffered with leakage of ascites from the peritoneal incision, initially 1 week after the procedure and then twice more during follow up. This was managed by increasing the pump output and by aspirating the subcutaneous fluid pocket to dryness. Intermittently the patient complained of bladder spasms (likely due to “dry pumping”), which resolved after adjusting the pump settings.
The patient also suffered with one episode of cellulitis near the skin incision, which responded to oral antibiotic therapy.
There were no significant adverse biochemical outcomes (). The patient underwent OLT 112 days after alfapump implantation. During this time, 77.7 litres of ascites was drained with a mean of 84.6 ml in the final 7 days up to transplant. On day 14 after implantation patient’s sodium levels had improved from 134 mmol l–1 to 137 mmol l–1 and her albumin levels had improved slightly from 30 g l–1 to 32 l–1. Patient required only 500 ml of 20% albumin infusion over the course of 112 days to maintain her nutritional status.
The patient underwent successful OLT and the pump was explanted during the same surgical episode. |
pmc-6159181-3 | A 54-year-old female patient, with Child-Pugh C cirrhosis secondary to alcoholic liver disease, was referred to IR clinic for medically refractory ascites.
Pre-procedure parameters were as outlined in .
The patient tolerated the procedure well, with no complaints of discomfort.
The patient had two episodes of cellulitis (day 32 and 64) and one episode of urinary tract infection (month 8), which required antibiotics and hospital admission.
The patient had small volume ascitic fluid leakage through the pump wound at day 30 and moderate to large volume leakage, again after 4 months, with a large subcutaneous fluid pocket forming around the pump. This was attributed to a migrated bladder tube (seen on ultrasound); hence, pump revision was carried out on day 120 and both bladder and peritoneal tubings were changed.
Bloods on day 15 demonstrated an improvement in albumin; however a persistent acute kidney injury was noted (on background of chronic renal impairment), most likely consequent to hepatorenal syndrome ().
The patient continued to have persistent ascites, in spite of what seemed like adequate pump volume (1100 ml/day), and required 3 LVPs in a 6-month period. Due to patient choice, the pump was finally explanted 289 days after implantation. The patient died 315 days later due to sequelae of background liver pathology. |
pmc-6159182-1 | An 88-year-old female presented to the emergency department with abdominal pain and vomiting. She was mildly tender in her right upper quadrant but was focally more tender in her right lower quadrant. Her blood results showed an elevated white cell count of 12.9 × 109 l–1 and a neutrophil count of 10.4 × 109 l–1. Furthermore her C-reactive protein level was 34 mg/L. An abdominal ultrasound showed multiple calculi within the gallbladder. Gallbladder wall thickness was not assessed. A non-contrast CT scan, due to the patients impaired renal function, was then ordered as the patient’s physical exam findings were not in keeping with a diagnosis of cholecystitis.
The CT showed abnormal dilatation of the proximal small bowel with a possible transition point in the left iliac fossa. Pneumobilia was also noted due to prominence of the hepatic biliary tree (). No evidence of a ductal calculus was observed. The CT scan was reported as showing features of a bowel obstruction with a transition point in the left iliac fossa. The pneumobilia was reported as being possibly an indicator of previous sphincterotomy. There was no evidence of appendicitis or another inflammatory process in the right iliac fossa.
The following day, while proceeding with conservative management, the treating team requested a small bowel follow through to investigate the obstruction. After further review and discussion with the treating team it was revealed that there was no history of an endoscopic retrograde cholangio-pancreatography or cholecystectomy. An addendum was added to the CT report, suggesting that the appearances were indicative of a gallstone ileus from a choledochoduodenal fistula () with a non-calcified gallstone possibly being present at the transition point in the left iliac fossa ().
The patient underwent a laparotomy and a gallstone was found obstructing the distal jejunum. A 41 mm gallstone was removed by vertical enterotomy, later confirmed on histological diagnosis. The patient had an uneventful recovery in hospital and was discharged a few days later to a regional hospital for rehabilitation. A cholecystectomy or fistula closure was not performed and she was not referred for further surgical follow-up on discharge, likely due to the patient’s advanced age and medical comorbidities. |
pmc-6159184-1 | We report the case of a 41-year-old male patient who suffered from a mediastinal neuroblastoma in his childhood (in 1977), having been treated by surgery, chemotherapy and radiotherapy.
At first, he was admitted to his referral hospital, presenting an episode of progressive dyspnea and angina pectoris (NYHA class III). A thoracic X-ray was performed, showing an extensive pericardial calcification without remarkable anomalies in the lung parenchyma.
A thoracic CT revealed the presence of multiple calcifications in the atria walls, interatrial septum, right ventricular free wall, mitral and aortic valves and pericardium. A significant pericardial effusion was also present ().
The patient got worse, displaying signs of cardiac tamponade. Thus a pericardiocentesis was necessary. Nonetheless, the symptoms persisted even after reducing the pericardial effusion. Considering a pericardial window surgery, the patient was referred to our hospital.
Upon his arrival, an electrocardiogram was performed, together with an echocardiography. It displayed the aforementioned calcifications, as well as a moderate–severe effusion (15–25 mm, surrounding the right ventricle free wall and its lower face), and protodiastolic movement of the interventricular septum.
Considering a mixed constrictive–restrictive pathology, an MRI was performed, acquiring axial DP and T2-STIR “black-blood” sequences, standard BALANCED Fast Field Echo sequences (axial, two-chamber view, four-chamber view and short-axis view), as well as delayed-enhancement and phase-contrast sequences (in aortic and pulmonary levels).
The images showed a segmental thickening of the pericardium and hypointense linear images in the interatrial septum and in the posterior wall of the atria (), corresponding to the calcifications that had already been described in the prior CT.
The ventricles were not enlarged, and ejection fraction was normal (54%). Yet, there was a protodiastolic movement of the interventricular septum, evidencing constriction (). The left atria was small sized (7 cm2), and the right atria was normal (19 cm2).
After the administration of paramagnetic contrast, the pericardium and the soft tissue of the anterior thoracic wall enhanced, probably as a result of the recent surgical manipulation. The delayed-enhancement sequence showed small patched enhancing areas, almost transmural, in the interventricular septum () and in the lower and anterior ventricle walls ().
The MRI revealed a normal ventricular function, although with data of a mixed restrictive and constrictive physiology.
A few days after the surgery, the patient improved his symptoms, showed a correct heart rate and haemodynamic stability, so he was finally discharged. |
pmc-6159186-1 | A 22-year-old primigravida at 30 weeks of gestation presented with a painful right inguinal swelling. Pregnancy had been uneventful. Symptoms started at 24 weeks when she noticed a swelling in the right groin which became prominent on standing and disappeared on lying down. On routine obstetric visit, her obstetrician made a provisional diagnosis of inguinal hernia and referred her to surgery department for further management. The surgeon also came to the same clinical diagnosis. As the swelling was not reducible he referred her to the department of radiology for an inguinal sonogram to rule out strangulation.
On physical examination there was a 4 × 2 cm soft tender mass in the right groin following the course of the inguinal canal which became prominent on valsalva and was not spontaneously reducing on supination.
On grey-scale sonography performed using a 14 MHz linear transducer (Voluson 730 expert, GE medical systems, OH, USA) multiple anechoic tortuous tubular compressible channels were noted in the region of palpable mass (). Colour and power Doppler showed vascularity within these tubular channels ( and ). Pulse wave Doppler confirmed venous flow with reversal on valsalva (). As the vascular channels were completely compressible, echo free and showing complete filling on colour Doppler, the possibility of thrombosis was ruled out. There was no evidence of any herniating fat, bowel loop or lymphadenopathy in the inguinal region. The aforementioned sonological imaging findings were compatible with the diagnosis of round ligament varicocele.
The patient was managed conservatively and was followed up with repeated ultrasound evaluations on a monthly basis till term to rule out complications as she continued to have swelling and mild pain which was not increasing in intensity. She did not develop any complications and had an uneventful vaginal delivery at 38 weeks. The symptoms resolved completely by 3rd week postpartum. |
pmc-6159189-1 | A 75-year-old female presented insidiously with right upper quadrant abdominal tightness and band-like pain. This was associated with a right flank swelling. She had been suffering with progressively worsening abdominal discomfort for many years. There was a 2.5 kg history of weight loss, but no other associated symptoms including ascites or jaundice. Her past medical history included a right partial nephrectomy undertaken in her early 20 s for a renal abscess. The patient also had a history of atrial fibrillation managed with Rivaroxaban.
On examination the patient had a large body habitus and a right-sided subcostal “hockey-stick” scar. Lateral to this scar was a reducible, soft and non-tender hernia with no cough impulse. No hepatomegaly could be felt. |
pmc-6159190-1 | A 35-year-old male patient, with persistent AF refractory to the pharmacologic treatment underwent RFA in our hospital. As a routine practice in our centre, the patient was assessed pre-procedurally by transesophageal echocardiography (TEE) on the day of procedure to delineate anatomy of pulmonary veins and left atrium (LA) and to exclude LA appendage thrombus. During RFA procedure all four PV were individually isolated under guidance of intracardiac echocardiography. RF energy was delivered using a conventional 4 mm and 8 mm tip ablation catheters and a power setting of 30 W, 50 °C around a circular decapolar catheter located at the pulmonary veins ostia. Application of the RF was immediately interrupted when microbubbles were detected by the intracardiac echocardiography (ICE). After a curative ablation therapy patient was kept on aspirin to prevent pulmonary venous or arterial thrombosis and recurrence of AF. Ambulatory follow-up cardiac computed tomography (CT) angiogram was done 3 months following RFA and showed approximately 60% left superior PVS but no intervention was performed because the patient was asymptomatic and he was kept on oral anticoagulation ().
Two months later, the patient developed cough associated with hemoptysis, mild intermittent fever, mild left-sided pleuritic chest pain and shortness of breath on exertion. He visited the primary health centre close to his residency where chest radiography was done and showed left upper lobe poorly marginated opacities and minimal left pleural effusion. Further laboratory studies were done to rule out pulmonary tuberculosis (TB) which were within normal limits. A definitive diagnosis was not made and the patient was given broad spectrum antibiotics and referred to pulmonology clinic in our hospital for further investigation.
Patient presented to our hospital 6 months after ablation without improvement in the symptoms. Non-enhanced CT was done and showed increased parenchymal attenuation and multiple peripheral patchy consolidations in the apico-posterior and anterior segments of left upper lobe associated with minimal left pleural effusion (). Cryptogenic organizing pneumonia (COP), chronic eosinophilic pneumonia (CEP), fungal infection (pulmonary aspergillosis), lung cancer and primary pulmonary lymphoma were suggested as differential diagnosis and ultrasound-guided aspiration of the left-sided pleural effusion was carried out and the obtained specimen was fluid of serous nature. Besides that, lung biopsy was also performed and the histopathologic examination revealed surprisingly intimal hyperplasia associated with multifocal haemorrhagic infarction due to PVO and hypertensive pulmonary arteriopathy. After that contrast-enhanced CT scan was performed with 3D reconstruction and manifested clearly an occluded left superior pulmonary vein (LSPV) (). Occlusion was confirmed by conventional angiography. Ventilation/perfusion scan demonstrated absent perfusion of the involved lung parenchyma and left upper lobectomy was warranted. |
pmc-6159191-1 | We present a 20-year-old female with athletic constitution in good health condition. She suffered trauma caused by an accident during skiing, where she jumped over a small hill border and landed in a small pit on the slope. The traumatic mechanism of the accident was a ventral-lateral (right side) collision with the solid iced slope in knee and hip flexion at intermediate speed.
According to the patient’s narrative, she was never unconscious, but immediately felt strong pain in her right upper and lower extremities after trauma. Clinical examination of the peripheral extremities showed no signs of neurological or vascular trauma.
The patient was hospitalized via flying ambulance to the closest surgical-trauma department shortly after. At admission to the hospital, clinical examination and conservative X-rays in two planes showed a posterior dislocation of the right hip (Thompson–Epstein Grade I), but no signs of fracture. Additionally, X-rays in two perpendicular planes of the right forearm were performed, showing a combined radial and ulnar fracture. The fracture was splinted with split plaster cast of the right arm. The dislocation was treated by joint reduction (Böhler’s technique) under general anaesthesia. The procedure took place around 2 hours after trauma and was performed by a trauma surgeon. A CT scan of the hip was performed afterwards (, ), indicating an acetabular fracture line without any dislocation and consequently needing no further surgical treatment. After one night of medical surveillance, our patient was discharged from hospital with treatment recommendations to use underarm crutches and to consult the nearest trauma department for surgical therapy of the forearm fracture after returning back home. Regarding pain management, the patient received a prescription for non-steroidal anti-inflammatory drugs as prn medication.
Since it was not possible for the patient to handle crutches with her fully casted right arm, she visited the nearest trauma ambulance 3 days after the accident. After denial of two orthopaedic surgeons to perform surgical stabilization of the radial and ulnar fracture, the patient was provided with an arm splint for better handling of the crutches. Owing to unsatisfying success of this option, our patient was advised to hobble. Additionally, she was referred to a physical therapist for remobilization of the injured arm. According to our patient, she was not aware of pain in the hip during this period, but stated that she might have been distracted by the subjectively more severely felt symptoms of her injured arm.
A few weeks later, our patient consulted her general practitioner and presented with continuing moderate pain in the right hip. The general practitioner decided to request MRI sequences of the patient’s hip, which showed several trauma-related injuries. On the images (), the articulation of the femoral head within the acetabulum was congruent. The posterior and inferior muscles around the joint were altered with severe tissue oedema, visible as hyperintensity on T2-weighted images. The origin of the superior gemellus muscle was not visible, the muscle belly being retracted and thickened (). The obturator internus muscle tendon was surrounded by moderate effusion in the subjacent bursa (). The tendons of the inferior gemellus, the quadratus femoris and the external obturator muscles were normal; there was however severe tissue oedema in the muscle bellies of the quadratus femoris () and the external obturator muscles (). Piriformis, gluteal and tensor fasciae latae muscles were normal. No abnormalities of vessels or adjacent nerves were observed.
After 19 months of conservative treatment post trauma, our patient was still complaining about mild hip pain. A second MRI was performed to exclude avascular necrosis of the femoral head. The follow-up MRI () showed an undulated shape of the tendon of the superior gemellus muscle (). Although the obturator muscle itself was without pathology in the first MRI, it now was partially ruptured (). There was some scarring around the quadratus femoris muscle (). Scarring of the femoral head was present (). Additionally, we detected hypertrophy of the piriformis muscle (), which was without pathological findings in the first MRI report. |
pmc-6159193-1 | A 17-year-old female presented to the physician with a 4 weeks history of fever, predominantly with evening rise of temperature. The temperature fluctuated between 37.7 and 38.8°C. She had no history of cough, haemoptysis or significant loss of weight. Neither a previous history of TB nor a recent exposure to TB was evident. Physical examination of the patient did not reveal any positive information as there was neither hepatosplenomegaly nor lymphadenopathy. Routine haematological investigations were found be largely within normal limits except for elevated C-reactive protein (39 mg l–1) and mildly elevated gamma-glutamyl transferase (56 Ul–1). Her haemoglobin was 11 g dl–1, with slightly reduced mean corpuscular volume, mean corpuscular haemoglobin and mean corpuscular haemoglobin concentration. The investigations for various types of fevers, including Widal test for typhoid/ paratyphoid, malarial parasite, leptospira immunoglobulin M antibodies, Weil Felix test for rickettsial infection, urine test and sputum and blood culture were non-contributing. She tested negative for retrovirus infection. No significant pathology was identified on her chest radiograph. Abdominal ultrasound scan was unremarkable (). Finally, an 18-fluorodeoxyglucose (FDG)-positron emission tomography (PET)-CT scan was performed, which demonstrated multiple focal areas of abnormally high FDG uptake within the spleen (, ), which were not identifiable on CT scan images (non-contrast CT and contrast-enhanced images) (). No other focal abnormalities were detected anywhere else. MRI of the abdomen was performed for further characterization of the splenic lesions. However, MRI abdomen, including diffusion-weighted images, did not show any nodules in the spleen (). To avoid splenectomy for histopathological diagnosis, biopsy of the splenic lesions was planned, after ensuring that the coagulation profile was normal. True–cut biopsy was done by placement of a coaxial needle into one of the lesions under CT scan guidance, after carefully analysing the PET images.
Necrotizing granulomatous lesions suggestive of TB were identified on histopathology, as described in . The patient was started on antitubercular therapy for 9 months. The fever resolved by 3 weeks after the beginning of the treatment. |
pmc-6159194-1 | A 63-year-old male presented with abdominal pain and was diagnosed with a 7.5 × 7.3 × 7.0 cm (AP × ML × CC) splenic mass on CT. It was predominantly hypo-attenuating with peripheral serpiginous enhancement. The lesion was very well defined and the imaging characteristics were interpreted as being consistent with a benign mass such as haemangioma or hamartoma; however, malignancy could not be excluded (). A three-phase 99mTc-RBC scan was performed to further characterize the splenic mass. It showed a normal blood flow and on delayed images showed a photopenic defect at the location of the mass with mild peripheral blood pooling ( and ), which was interpreted as possibly representing a haemangioma with central thrombosis, or an atypical haemangioma, however malignancy could not be excluded and further imaging was recommended.
Since the patient was well clinically, the splenic mass was followed conservatively with serial ultrasounds. An initial ultrasound showed a heterogeneous, mostly hypoechoic mass with no internal vascularity and no focal lesions in the liver. The findings on the ultrasound study were interpreted as being in keeping with haemangioma (). A follow-up ultrasound performed 10 months later showed that the splenic mass was stable in size and was still likely a haemangioma. Sixteen months after the initial CT, however, the patient presented with a 2-month history of 35 lb weight loss, failure to thrive, 1 month of daily diarrhea, fever and drenching night sweats, bloating, distension and decreased appetite. His haemoglobin was 75 g l–1 (normal 120–160 g l–1), and platelets 9 (normal 140–450 109 l–1). A follow-up ultrasound showed an increase in the size of the splenic mass and new liver lesions.
A core biopsy of the liver showed polymorphic atypical proliferation of poorly differentiated cells associated with coagulated necrosis and a sprinkling of small lymphocytes with eosinophils. These pleomorphic cells included large multinucleated forms with open vesicular chromatin and prominent eosinophilic nucleoli. Immunohistochemistry was positive for EBER and Fascin and negative for CD21, CD35, CAM 5.2, CD31, ERG, S100, pan-keratin, CD45, CD43, CD34, ALK-1, PAX 5, CD30, CD68, CD23, HMB-45, lysozyme, myeloperoxidase, podoplanin, CD20 and muscle specific A (). These findings were consistent with pleomorphic spindle cell sarcoma (PSCS, previously known as malignant fibrous histiocytoma, MFH). A bone marrow biopsy was negative.
The patient was referred for an 18F-FDG PET/CT for staging. Maximum intensity projection (MIP) images showed innumerable intensely 18F-FDG avid lesions in the liver and spleen (). The largest splenic mass measured 9.6 × 7.5 cm with maximum standardized uptake value (SUVmax) 15.8 (). The lesions were almost entirely necrotic, with a thin rim of intense 18F-FDG uptake. The patient passed away a few days later, before any treatment plan could be initiated. |
pmc-6159196-1 | A 65-year-old female non-smoker of Indian origin living in the UK for 42 years was referred to rheumatology outpatients with a 5-year history of mild arthralgia affecting the shoulders, hands and elbows. A 6-month history of productive cough without haemoptysis and concurrent weight loss was also reported. No fever, night sweats, chest pain or shortness of breath on exertion was present. Examination of the chest, cardiovascular system and abdomen was unremarkable. The only finding was nodal osteoarthritis in the hands with evidence of Heberden’s and Bouchard’s nodes, but no evidence of active synovitis. |
pmc-6159197-1 | A 20-year-old female with history of primary amenorrhoea referred to our radiology department for further evaluation. On physical examination, all the secondary sexual features were well made out. In view of primary amenorrhoea, an abdominal sonography was performed which showed upper abdominal organs in normal anatomical location. On pelvic sonography, there was complete non- visualization of uterus, cervix and vagina (). Both the ovaries were not seen in their normal anatomical location and on extensive search, they were localized in bilateral inguinal canals (). On Doppler study there was no significant vascular compromise in both the ovaries. In addition to above findings bilateral ureteroceles were also noticed ().
CT urogaphy and screening MRI pelvis were advised for detailed evaluation of urogenital anomalies which confirmed complete agenesis of the uterus, cervix and vagina (). Both the ovaries were visualized in bilateral inguinal canals (). In abdomen the kidneys were normal in size, morphology and located in normal anatomical location without any developmental anomalies (). Delayed CT KUB scan showed bilateral ballooning of vesicoureteric junction confirming the bilateral ureteroceles (). Genetic karyotyping showed 46XX chromosome pattern.
The diagnosis of Type I MRKH syndrome with bilateral ovarian hernias was established. |
pmc-6159200-1 | A 62-year-old lady with past medical history of lupus anticoagulant on warfarin, and grade II obesity (body mass index of 38.5) status post laparoscopic gastric banding in 2003, presented with a 3-day history of bright red blood with clots per rectum. She presented with left-lower quadrant abdominal pain, nausea, emesis, lightheadedness, weakness and exertional dyspnea. On evaluation in the emergency department, patient was afebrile and vital signs were within normal limits. Physical examination was unremarkable. Haemoglobin was 9.4 and INR was 2.1 on admission. |
pmc-6159202-1 | A 79-year-old male, with positive history of ischaemic heart disease and dyslipidemia, was referred to our centre for further management of an incidental finding of an abdominal aortic aneurysm (AAA). Initial CT angiography of the aorta revealed an infrarenal AAA measuring 6.3 cm × 7.0 cm × 20.0 cm, which extended to the level of the right common iliac artery. There were scattered wall calcifications. The thoracic aorta was normal. After discussing with the patient and family members, a decision was made to repair the AAA via an endovascular approach. A bifurcated endovascular stent graft was deployed via a percutaneous femoral route. The procedure was successful. However, 3 months post procedure, the patient came back with complaints of fever of 39°C, associated with chills, loss of appetite and back pain. He reported no vomiting or diarrhoea. Full blood count revealed a total white cell count of 15 × 109 l–1 with predominant neutrophilia. In view of the underlying AAA, a repeat CT was pursued. This revealed the presence of air surrounding the endovascular graft, with associated inflammatory changes and aortic wall thickening. The air was seen extending to the proximal common iliac artery (). Medical therapy and appropriate antibiotics were initiated, with a plan to embark on surgery once the patient was more stable. Blood cultures grew Staphylococcus aureus. Unfortunately, the patient succumbed to sepsis after 1 week of medical therapy. |
pmc-6159202-2 | A 54-year-old male who was a chronic smoker and had long-standing heart failure was referred to our centre for investigation of abdominal pain with elevated liver enzymes. He reported with fever with recorded temperature of 38°C, with nausea, vomiting and diarrhoea. There were no chills and rigors. Full blood count showed a total white cell count of 20 × 109 l–1 with predominant neutrophilia. A multiphasic CT hepatobiliary system was initially planned, with a provisional diagnosis of hepatobiliary pathology. During the image acquisition, incidental finding of an infrarenal AAA was noted. The AAA measured 3.4 cm × 3.4 cm × 2.7 cm with protruding mural thrombus. No clear fat plane was identified, and multiple air pockets were seen. Retroperitoneal and para-aortic collections were present, with no bony destruction (). In view of the findings, blood cultures were taken and medical therapy instituted. The blood cultures came back positive for Salmonella; thus antibiotic therapy was commenced according to the sensitivity. However, after 14 days of hospitalization, the patient unfortunately succumbed to complications of exacerbated heart failure. |
pmc-6159203-1 | In August 2008, a 43-year-old female underwent a partial mastectomy with axillary lymph node dissection for right-sided breast cancer. Pathological diagnosis confirmed an infiltrating canalicular carcinoma (1.0 × 1.2 cm in diameter) as the primary tumour. Lymph node metastasis was observed in 6/34 harvested nodes. The disease was classified as stage IIIA according to the Union for International Cancer Control Tumour Node Metastasis classification for breast cancer(T1C N2 M0). A subsequent immunohistochemical examination revealed positive expression of hormone receptors in the primary tumour as well as the HER2 status as negative.
After surgery, the patient received four cycles of 5-fluorouracil, adriamycin and cyclophosphamide, followed by radiotherapy (60 Gy) and 12 cycles of paclitaxel. Once adjuvant chemotherapy was completed, the patient received goserelin and tamoxifen during 2 and 5 years, respectively.
Six years after surgery, in response to a complaint of respiratory symptoms, the patient underwent a CT. The CT revealed a mediastinal nodal conglomerate, multiple lung nodules and right pleural effusion. Then, the patient was subjected to a PET/CT with 2-deoxy-2-[fluorine-18] fluoro-D-glucose (18F-FDG) PET/CT to evaluate the extent of the metastatic lesions. The PET/CT revealed increased 18F-FDG uptake in the lungs, bones and axillary lymph nodes (). The largest pulmonary nodule (17 mm), localized at the posterior basal segment of the left lower lobe, showed an SUVmax value of 10.7, whereas a mediastinal lymph node had an SUVmax of 3.9.
Owing to the aggressiveness of the disease, a phenotypic conversion at metastatic sites was suspected, including modification of the hormone receptor status (ER, PR). Thus, a parallel study using 68Ga-DTPA anti-HER2 and 18F-16α-17β-fluoroestradiol (18F-FES) was subsequently conducted ().
Metastatic tumours of the lungs and lymph nodes were visualized with both radiotracers, and the SUVmax values from the largest lesions were presented as follows: 3.3 for the lung lesion and 3.4 for lymph node using 68Ga-DTPA anti-HER2, and 3.2 and 3.3 for the lung and lymph node with 18F-FES. Thus, the resulting biopsy specimens were obtained from both metastatic lesions exhibiting the highest uptake to confirm the HER2 overexpression.
Lastly, immunohistochemical examination revealed positive staining for hormone receptors in the breast (), lymph node () and lung (), whereas HER2 was negative in the breast () and indeterminate (2+) in both metastatic sites (). However, using fluorescence microscopy and in situ hybridization (FISH), HER2 overexpression was confirmed in the lymph node (4.18) as well as in the lung (3.19) (), whereas the primary tumour remained negative (). |
pmc-6159205-1 | A 27 year-old female came to the hospital for routine second trimester antenatal ultrasound. Clinical history did not reveal any predisposition to increased risk for genetic or familial disorder. Initial first trimester ultrasound scan was done at 6 weeks which did not show any significant abnormality. Then she reported directly at 24 weeks of gestation for follow-up second trimester foetal anomaly scan. Apart from second trimester ultrasound, other routine antenatal investigations did not reveal any significant abnormality. The foetal karyotype was normal.
The classical ultrasound signs of “CHAOS” are as follows:
Dilated airways below the level of obstruction ().
Hyperexpanded and hyperechoic lungs ().
Flattened diaphragm ().
These signs were classically depicted in the foetal ultrasound scan images –. |
pmc-6159206-1 | A 55-year-old female presented to gastroenterology outpatients clinic with a 2-month history of dysphagia for solids. Her medical history included learning difficulties, but she was otherwise fit and well.
At upper gastrointestinal endoscopy there was an impassable stenosis 30 cm from the incisors. Biopsies were obtained and revealed a moderately differentiated oesophageal adenocarcinoma. Oesophageal stenting was performed for symptomatic relief. There were no demonstrable metastases on her initial staging CT chest and abdomen, but before proceeding with surgical management a PET scan was arranged.
This detected FDG avid uptake in the left submandibular gland (). An ultrasound scan confirmed a poorly defined mass within the left submandibular gland suspicious for malignancy ().
Two cream-coloured cores were obtained with an 18-gauge needle under ultrasound guidance. Microscopic appearances ( and ) were compatible with metastatic infiltration of the left submandibular gland from the known moderately differentiated oesophageal adenocarcinoma (CK7 and CDX-2 positive/CK-20 negative on immunohistochemistry). The patient was subsequently referred for palliative chemotherapy. |
pmc-6159208-1 | A 66-year-old Chinese lady presented with a retracted nipple and generalised thickening over the lateral aspect of her right breast. She had a medical history of metastatic adenocarcinoma of the lung which was initially diagnosed approximately one and a half years prior to the development of her breast symptoms.
On clinical examination, no palpable mass was found in both breasts, but there was mild skin thickening in right lateral breast. Mammography showed bilateral dense breasts with no dominant mass, suspicious micro-calcification or architectural distortion.
Ultrasonography, however, revealed diffuse stromal thickening in the background of heterogeneous parenchyma corresponding to the area of palpable thickening in the right lateral breast with no focal mass or nodule (). Ultrasound-guided 14G core needle biopsy was performed, and histology confirmed a metastatic adenocarcinoma with an immune-profile favouring a lung primary ().
Further imaging with a CT scan showed a lingula lobe primary tumour with extensive skeletal metastasis ( and ). Shortly thereafter, she progressed on to develop metastases to the cerebrospinal fluid (CSF) and succumbed within a month from diagnosis. |
pmc-6159208-2 | A 59-year-old Chinese lady initially presented to her family physician for a routine check-up. Routine blood screening showed raised levels of tumour markers with abnormally raised levels CEA, CA125, CA153 and CA19.9. She had a previous total hysterectomy and bilateral salpingo-oophorectomy 15 years ago, for adenomyosis. Apart from that, she had no history of malignancy.
During her consultation with the oncologist, she was found to have a mobile breast lump in the left breast. Subsequent mammography revealed a nodule in the lower inner quadrant of left breast with no associated micro-calcification or architectural distortion ().
Ultrasonography revealed a 0.6 × 0.6-cm iso-echoic nodule corresponding to the nodule in mammogram (). Ultrasound-guided 14G core needle biopsy was performed, and histology with immunostaining revealed a metastatic adenocarcinoma from a lung primary ().
A CT scan was done as part of her metastatic workup and it revealed a mass in right lower lobe, associated precarinal lymphadenopathy and bony metastases. The patient died approximately 2 months after diagnosis. |
pmc-6159208-3 | A 40-year-old Chinese lady presented to our institution with a left breast mass. Mammography and ultrasonography of the left breast. Imaging revealed a lobulated mass in the upper quadrant at 12 o’clock position with associated ipsilateral axillary lymphadenopathy. Several large cysts were also noted in both breasts ().
MR of the breasts was performed to evaluate the size and number of lesions which were difficult to separate from the adjacent cysts. This showed a predominant 25 × 23 × 27-mm mass in the left breast, and several other smaller rim-enhancing lesions that demonstrated rapid enhancement with a plateau and washout on delayed phase. The smaller enhancing foci were thought to also represent metastatic lesions. The MR also further demonstrated a left lower lobe lung mass and associated atelectasis (–). On further questioning, the patient admitted to having had a cough for 1 month.
Ultrasound-guided 14G core biopsy of the left breast mass revealed a poorly differentiated adenocarcinoma, likely of lung origin (). Fine-needle aspiration (FNA) of the left axillary nodes were also positive for malignant cells.
A staging CT scan confirmed the presence of a mass in the apical segment of the left lower lobe. There was also evidence of widespread sclerotic bony metastasis involving the axial skeleton. She was treated with chemotherapy but progressed to develop a solitary brain metastases in the left parietal lobe, approximately 13 months after diagnosis. Currently 7 years after diagnosis her disease remains fairly well controlled allowing her a good quality of life. |
pmc-6159210-1 | A 15-year-old female presented to the emergency department of a level 1 trauma centre after being involved in a high-speed motor vehicle accident. After the initial survey was performed in the emergency department, the patient was found to be haemodynamically stable. She underwent a routine whole body scan as part of our institution’s polytrauma protocol. This includes a CT scan of the head and cervical spine followed by contrast-enhanced CT scan of the chest, abdomen and pelvis with reconstructions of the thoracic and lumbar spine. The contrast-enhanced examinations are obtained at the standard 60–70 s delay.
The CT of the abdomen and pelvis demonstrated Grade 5 (AAST liver injury scoring scale) liver lacerations in the right lobe extending to the right and middle hepatic veins (), a centrally located hypodense filling defect in the suprahepatic inferior vena cava (IVC) () extending to the base of the right atrium (), a right adrenal gland haematoma, a moderate haemoperitoneum and a grade 4 right kidney injury. Additional findings noted on CT scan of the chest included multiple rib fractures, lung contusions and bilateral small pneumothorax.
During the first days of admission, initial goals were to monitor and manage the early complications of severe polytrauma including respiratory or haemodynamic decompensation, bleeding and coagulopathy. Following admission, the patient required multiple transfusions including packed red blood cells, fresh frozen plasma and platelets. The haemoglobin trended down from 12.3 g dl−1 on day 1 to 6.5 g dl−1 on day 3 (normal: 12–15 g dl−1). She developed consumption thrombocytopenia and the platelet count decreased from 222 000 ul−1 on day 1 to 87 000 ul−1 on day 3 (normal: 150 000–450 000 ul−1). She maintained a mildly elevated INR 1.2–1.7 (normal: 0.8–1.1), a normal partial thromboplastin time 24–30.9 (normal: 23.3–38.6) and mildly elevated fibrinogen levels of 432–720 (normal: 234–500). The severity of the concomitant injuries and the patient’s haemodynamic status precluded considering therapeutic anticoagulation or more invasive interventional or surgical thrombectomy procedures at this time.
A repeat contrast-enhanced CT of the abdomen and pelvis on day 3 of admission demonstrated increased haemoperitoneum, stable solid organ injuries and IVC thrombus without active bleeding. The patient’s haemodynamic status and haemoglobin levels stabilized by day 5 and prophylactic low molecular weight heparin were started. An abdominal ultrasound was performed on day 6 to evaluate the IVC and did not demonstrate an intraluminal thrombus. The patient was noted to have intermittent macroscopic haematuria, and in the absence of clinical or laboratory signs of IVC thrombus progression (back pain, chest pain, oxygen desaturation on room air, lower extremity oedema, rising liver function tests) a decision was made to hold on starting therapeutic anticoagulation. The patient remained stable and was discharged home on day 10. She had no signs or symptoms to suggest progression of thrombosis on a scheduled 4-week outpatient follow-up. |
pmc-6159232-1 | A 79-year-old male presented with locally advanced transitional cell carcinoma (TCC) of the bladder. This was staged as T2 N1 M0 radiologically. Transurethral resection of the bladder tumour was performed and he was then treated with three cycles of gemcitabine and cisplatin chemotherapy. Post chemotherapy cystoscopy revealed normal appearances of the urothelium and bladder capacity of 400 ml. Post chemotherapy CT imaging showed almost total resolution of the pelvic lymphadenopathy.
The patient was treated with 64 Gy in 32 fractions over 6.5 weeks to his bladder together with 53 Gy in 32 fractions to his pelvic nodes at the same time. He received synchronous 5-flurouracil (5-FU) and mitomycin-C (MMC) in weeks 1 and 4 of treatment.
Treatment was tolerated well with only mild, occasional diarrhoea. Full blood counts were largely normal despite the large volume irradiated. Platelet count was reduced with a minimum value of 82 × 109 l–1 in week 3 of treatment.
This patient has been followed up for 17 months and at that time remained disease and symptom free. A cystoscopy showed mild radiation changes throughout the bladder only. |
pmc-6159232-2 | A 77-year-old male presented with a background of metastatic prostate cancer. At the time of diagnosis with a TCC of the bladder his prostate cancer was well controlled with androgen deprivation therapy. He presented with haematuria, and cystoscopy identified muscle invasive disease. A single involved obturator node was identified on imaging that had developed alongside the bladder cancer while the prostate disease had been well controlled. He was therefore staged at T3 N1 M0.
The patient received three cycles of neoadjuvant gemcitabine and cisplatin chemotherapy following transurethral resection of the bladder tumour. Post treatment cystoscopy showed only scarring where the tumour had been excised. His CT imaging showed that the obturator node had regressed significantly.
The patient subsequently received concurrent chemoradiotherapy. 64 Gy was delivered in 32 fractions with concurrent 5-FU and MMC. The patient tolerated therapy well. No significant toxicities were reported. He did however, experience thrombocytopenia, with the lowest recorded result 92 × 109 l–1.
Nineteen months after completion of his treatment, the patient remains well. No long-term consequences of his therapy have been reported and he has had no relapse of his bladder cancer as monitored by CT imaging and cystoscopy. |
pmc-6159232-3 | A 74-year-old male with T3 bladder TCC with left internal iliac and obturator lymph node positivity presented with hydronephrosis. This was treated with the insertion of a nephrostomy before neoadjuvant gemcitabine and cisplatin chemotherapy was started.
Following three cycles of chemotherapy a CT scan showed excellent response with complete resolution of the previously identified pelvic lymphadenopathy.
The patient then received radical radiotherapy, 64 Gy in 32 fractions to the bladder with 53 Gy in 32 fractions to pelvic lymph nodes. Treatment was delivered concurrently with 5-FU and MMC chemotherapy in week 1 only. Week 4 chemotherapy was cancelled owing to thrombocytopenia (platelets of 86 × 109 l−1). The patient otherwise tolerated therapy well with no other side effects reported.
A follow-up scan 6 months after treatment showed no evidence of metastatic disease or local relapse. No permanent sequelae of his therapy are reported. |
pmc-6159232-4 | A 67-year-old female presented with a high-grade transitional cell carcinoma after presenting with cystitis. Initial staging was T2 N0 and the patient underwent three cycles of neoadjuvant gemcitabine and cisplatin chemotherapy before a restaging scan showed two enlarged iliac lymph nodes despite an otherwise good response to treatment. The multidisciplinary meeting at the treating hospital agreed that these lymph nodes were likely to be malignant and therefore the patient went on to have radiotherapy where the treatment volume included the pelvic nodes also. 64 Gy in 32 fractions was delivered to the bladder, the suspicious pelvic node received 52 Gy in 27 fractions and the bilateral nodal volume received 48 Gy in 27 fractions. MMC and 5-FU chemotherapy was given concurrently.
The patient tolerated the therapy extremely well. No detrimental fall in the full blood count was observed and all chemotherapy was delivered as planned. She complained of no acute radiation toxicity other than mild lethargy and diarrhoea.
Unfortunately, while her post treatment restaging scan showed that the pelvic lymphadenopathy had regressed, there was significant lymphadenopathy outside the radiotherapy volume in the retroperitoneum, mediastinum and both sides of the neck. A biopsy confirmed this to be metastatic TCC.
The patient went on to receive vinflunine chemotherapy as the standard treatment arm in a clinical trial. Despite an initial good response, chemotherapy had to be discontinued owing to neutropenia. The patient developed metastaic liver lesions and was started on weekly paclitaxel, which continues for 9 months after completing radical treatment. |
pmc-6159232-5 | A 70-year-old male of previous excellent health presented with haematuria and was found to have T2 N1 TCC of the bladder. He underwent four cycles of neoadjuvant chemotherapy with gemcitabine and cisplatin without complication and was shown to have had a good response. He was felt to be inoperable owing to the node-positive state and was therefore considered for radiotherapy.
The patient received 64 Gy in 32 fractions to the bladder and positive nodes. A prophylactic dose of 53 Gy in 32 fractions was delivered to the bilateral pelvic nodes. No concurrent chemotherapy was given.
The patient tolerated therapy without significant problems although he reported mild diarrhoea for which he did not require medication.
This patient’s follow-up CT scan unfortunately showed retroperitoneal lymphadenopathy. A CT PET scan was performed to see if this was solitary metastatic disease and therefore to assess his suitability for salvage therapy. Unfortunately, the CT PET scan, performed 5 months after treatment, showed extensive retrocrural and supraclavicular lymphadenopathy. Eight months after completing radical treatment he continues on palliative carboplatin and gemcitabine therapy.
provides a summary of patient characteristics, treatment parameters and outcomes for ease of comparison. |
pmc-6159233-1 | A 74-year-old female was referred to the respiratory clinic with incidental finding of a pulmonary nodule on chest X-ray. She did not have any other respiratory symptoms. She was a non-smoker throughout her life and had no exposure to asbestos or tuberculosis. Her past medical history was significant only for chronic lymphoedema and recent hip replacement. |
pmc-6159235-1 | A 46-year-old male was referred to the Department of Oral and Maxillofacial Surgery, Aarhus University Hospital, Denmark, with a 3-week history of infection after tooth extraction in the left side of the mandible. He was diagnosed with gout in 2004, and was on regular medication with allopurinol, prednisolone and alendronate for the last 14 months. He was a non-smoker with moderate use of alcohol (two to three units daily).
The patient presented with a large swelling in the left side of the face with pus from the extraction sockets of the lower left first and second molars. Despite medical advice he refused admission for treatment with intravenous antibiotics and drainage, but accepted a prescription for oral antibiotics (penicillin one MIU four times daily and metronidazol 500 mg three times daily) to use at home. One month later, he went to his general dentist with persistent infection and worsening of the swelling. The infection had escalated dramatically and he was immediately admitted to the hospital for treatment. Subjective symptoms were trismus, moderate pain and the feeling of impending rupture. He felt no impairment of breathing or pain when swallowing, but he had been sleeping in a sitting position and only had liquid food for several days. Objectively, a large swelling on the left side of the face extended from the zygomatic arch to the submandibular region and with a focus of the size of a tennis-ball around the mandibular angle. The swelling was warm, red and had several non-ruptured pus-filled foci (). His body temperature was 37.7 °C, C-reactive protein was 125 mg l–1, white cell count was 13800 µl and blood pressure 108/68 mmHg with a pulse rate of 97. Intraorally, there were signs after extraction of two molars of the left side of the mandible, no spontaneous pus from the alveolus and only a slight swelling of the floor of the mouth on the left side. The patient proceeded to venous phase contrast-enhanced CT imaging, which was performed using a dual-source 128-multiple detector CT scanner (Somatom Definition Flash, Siemens Healthcare). CT imaging demonstrated a transspatial, multilocular abscess with extension from the zygomatic arch to the level of C4/C5 and posterior from the sternocleidomastoid muscle along the base of the left mandible to the midline involving the buccinator space, the masticator space, the submandibular space, the lateral pharyngeal space and the retropharyngeal space (). Bone resorption at the lingual aspect of the molar region in the left mandible indicated the origin of infection from a molar tooth. The extension of the infection both on the lateral and the medial aspects of the left condyle led to bone destruction and fracture with some displacement of the left mandibular condyle (). Diffuse stranding, reduced space in oropharynx, compression of the internal jugular vein and several enlarged lymphatic glands of the left side of the neck were observed. |
pmc-6159236-1 | An 83-year-old male with chronic hepatitis was noted to have a hepatic mass with early enhancement in the right lobe of the liver. A PV shunt was also noted close to the tumour on dynamic abdominal CT. The hepatic tumour was diagnosed as hepatocellular carcinoma by ultrasound-guided biopsy, and transcatheter arterial chemoembolisation was performed. This patient had mild encephalopathy, and the serum ammonia level was already increased to 104 μg dl−1 before the chemoembolisation. Hyperammonaemia worsened to 144 μg dl−1 and mild hepatic encephalopathy continued after treatment of the hepatocellular carcinoma. Amino acid solution (Aminoleban; Otsuka Pharmaceutical, Tokyo, Japan) and lactulose did not alleviate the hyperammonaemia. Therefore, transcatheter embolisation of the PV shunt was planned.
Procedure: The right femoral vein was punctured using ultrasound guidance, and a 6 Fr 11 cm sheath introducer was inserted. The right hepatic vein was catheterized using a 6 Fr 20 mm balloon catheter (SELECON, Terumo, Tokyo, Japan). Two pathways from the portal vein to the hepatic vein were seen on the preoperative dynamic CT. Since the right hepatic vein was dilated and because flow at the PV shunt was rapid, occlusion of the right hepatic vein was deemed impossible using the 20 mm balloon catheter. Therefore, only one pathway could be catheterized and balloon-occluded. After the balloon occlusion, the location of the PV shunt was confirmed using retrograde venography. One of the pathways of the PV shunt was embolized using 10 Interlock detachable coils (six 14 mm × 30 cm, two 14 mm × 20 cm and two 12 mm × 30 cm) (Striker, Tokyo, Japan) under flow control using the balloon catheter. Next, an attempt was made to catheterize the other pathway, but it was unsuccessful despite the use of several different preshaped catheters. Meanwhile, the patient was not able to remain still on the bed because of hepatic encephalopathy. Thus, embolisation of the right hepatic vein using an AVP II was planned.
After the right jugular vein was punctured using ultrasound guidance, a 9 Fr 11 cm sheath was inserted. A 9 Fr multipurpose-type catheter (Bright tip, Cordis Corporation, Miami, FL) was led into the right hepatic vein, and the AVP II (22 mm) was deployed at the right hepatic vein. The procedural time was 135 min. The next morning, the serum ammonia level decreased to 34 mg dl–1, and hepatic encephalopathy had improved. Successful embolisation of the PV shunt was confirmed on abdominal dynamic CT that was performed 2 months after the embolisation (). |
pmc-6159236-2 | A 75-year-old female presented to the emergency room of our hospital after sudden onset of confusion and incontinence. She had no medical history of trauma, liver disease or loss of consciousness. Her serum ammonia level was elevated to 330 mg dl–1. Head CT showed no obvious cause for her confusion. Consequently, she was diagnosed with hepatic encephalopathy. Based on our experience with the case described above, an embolisation of the PV shunt using the AVP II was planned.
Procedure: The right jugular vein was punctured under ultrasound guidance, and a 9 Fr 11 cm sheath was inserted. Then, a 9 Fr multipurpose type catheter (Bright tip, Cordis Corporation) was advanced to the left hepatic vein. Digital subtraction venography showed the location of the PV shunt. Then, a 14 mm AVP II was deployed at the left hepatic vein through the catheter. Retrograde venography of the left hepatic vein indicated obstruction of the PV shunt. The procedural time was 45 min. The next morning, the serum ammonia level had decreased to 30 mg dl–1, and the hepatic encephalopathy had improved markedly. The success of embolisation of the PV shunt was confirmed on abdominal dynamic CT performed 1 month after the embolisation (). The hepatic encephalopathy did not reappear, and the ammonia level did not increase to more than 80 μg dl–1 up to 5 months later in both cases. |
pmc-6159238-1 | A 79-year-old male was referred to the surgical outpatient department with a 2-month history of altered bowel habit. Abdominal examination and digital rectal examination in the outpatient clinic were unremarkable.
The laboratory studies, full blood count and biochemistry were normal. A colonoscopy study identified four abnormal lesions, two of which were colonic subcentimetre polyps. More distally in the mid-rectum, at 15 cm from the anal verge, there was a sizeable, villous polypoidal lesion, which was proved on biopsy to be a tubulovillous adenoma (TVA) showing low-grade dysplasia. More proximally in the distal sigmoid colon at 25 cm there was a segment of a malignant-looking lesion associated with a stricture (). However, biopsy samples from this region showed hyperplastic colonic mucosa showing lamina propria fibrosis and mild chronic active inflammation with separate pieces of granulation tissue and ulcer slough but no evidence of malignancy.
As per local protocol for malignant-appearing lesions on endoscopy, a staging CT scan was arranged on the basis of the colonoscopy appearances to facilitate the cancer pathway. This demonstrated, at the site of the presumed malignancy in the distal sigmoid colon, a 7 cm segment of circumferential thickening on a background of diverticulosis (). This was associated with a few subcentimetre locoregional and inferior mesenteric lymph nodes. There was no suggestion of malignancy elsewhere; so the proposed CT staging was T2/3 N1 M0.
Although the 5 cm rectal TVA could explain the patient’s symptoms it was felt at the multidisciplinary team discussion that either lesion could be responsible for the patient’s symptoms. Despite the lack of malignant cells from the biopsy samples the surgical team were still concerned about a potential sigmoid colon malignancy from the endoscopy and CT appearances. It was felt that the colonoscopy sampling was not truly representative of the malignant appearing sigmoid colon lesion seen at colonoscopy and CT. An anterior resection was planned for the patient to remove both the TVA and presumed sigmoid colon malignancy. An MRI scan of the rectum was performed in order to preoperatively assess the rectal polyp further. The sigmoid tumour was incidentally included in the MRI scan field owing to proximity to the rectal lesion (); however, this did not add any diagnostic value preoperatively.
The patient underwent an uncomplicated laparoscopic-assisted anterior resection with defunctioning loop colostomy. Post-surgical histology confirmed that the rectal polyp was a low-grade TVA. However, histological assessment of the presumed distal sigmoid cancer at 25 cm demonstrated mucosal ulceration with underlying fibrosis and diverticulosis. The ulceration was associated with a 5 cm jagged edged intraluminal dental plate containing a single front upper incisor prosthetic tooth found impacted at this site, with no metallic components (). The dental prosthesis was so impacted that endoscopic retrieval would be unlikely to have been successful. No malignancy was demonstrated in the post-surgical specimen. There were a few enlarged local lymph nodes present in the specimen, which were all benign. The patient had a good post-surgical recovery and went on to have an uncomplicated reversal of defunctioning colostomy several months later.
Retrospective review of the patient’s previous imaging revealed that the patient had attended the accident and emergency department 2 years earlier, having accidentally swallowed “false teeth” during a meal. An abdominal plain radiograph had been taken at the time, which did not demonstrate any radiopaque foreign body. The CT scout view also demonstrates no radiopaque foreign body (). The patient denied any symptoms and had been discharged with no further follow-up. Interestingly, the patient claims he has always known that he had not passed the swallowed dental prosthesis. |
pmc-6159239-1 | We present a case of a 51-year-old male who presented with atypical chest pain. As part of his workup and coronary artery disease (CAD) risk stratification, he underwent a Coronary CT angiography (CCTA) scan at our institution. The “short” LAD was not short since it branched out of the LMCA and coursed along the epicardial surface of the left ventricular anterior wall all the way to the apex of the heart. A long LAD branches out of the RCA and courses along the epicardial surface of the right ventricular and into and along the distal AIVG. In our patient, the long LAD joined the AIVG at its mid part. Both LAD arteries were similar in length ( and ).
With the patient positioned supine and arms placed above his head, electrocardiogram-gated cardiac/coronary CTA was performed using a 256-MDCT scanner (Philips iCT, Philips Healthcare, Amsterdam, The Netherlands). Anteroposterior and lateral scout scans were performed, with a scan range from the apex of the chest to the costophrenic angle. Scan parameters were as follows: detector width of 256 × 0.625 mm, pitch of 0.2:1 ratio, rotation time of 0.27 s, 100 kVp, 200 mA, with z-axis modulation, and scanning time of 2.1 s. A caudocranial scan direction was employed.
Via a 22 gauge venous catheter, placed in the right brachiocephalic vein, contrast media (CM) was injected with an automated dual-barrel power injector (Optivantage, Mallinckrodt, Cincinnati). Right-sided venous access was used in this study because it provides a uniform opacification incontrast to the heart; with the least possible dilution. Hence, this approach promotes optimal image quality coupled with reduced contrast volumes. Both the contrast media and saline injection rates were 4.5 ml s−1.
Bolus geometry is an opacification pattern measured in the region of interest. and plotted on a time (s)/attenuation Hounsfield units curve; after an intravascular injection of contrast material. This technique was employed where the region of interest was plotted inside the abdominal aorta; at the level of the aortic hiatus. The procedure comprised of a small amount of contrast material (5 mL); injected at the same rate as that of the main bolus. region of interest assessed the time to peak and determined the arteriovenous circulation time for the thoracic vasculature at the level of the aortic hiatus ().
To synchronize data acquisition with optimal arterial opacification, it has been recommended that scan direction during CTA should be in the opposite direction of CM flow during CTA. During CTA, it is feasible to scan at a faster rate than that of CM traversing the vessel. A drawback to faster scan acquisitions is poor arterial opacification, particularly when antegrade blood flow from the brachiocephalic trunk to the coronary arteries exists. Such pathological processes cause turbulence of blood flow before, within and after the origin of the ascending aorta, resulting in a slowing down of the passage of contrast associated with the antegrade blood flow from the origin of the ascending aorta to the distal segments of the coronary arteries. Even though there are clear limitations in the literature regarding the impact of fast scan times and associated contrast/blood flow dynamics, a practical solution to overcome such limitation is to measure the opacification peak of the descending thoracic aorta at the distal segment. Once these data are available, the exact contrast/blood flow dynamics can be predicted irrespective of blood flow dynamics. Therefore, optimal synchronisation between blood/contrast media flow with a caudocranial CT scan direction, achieves peak opacification throughout the entire hypoplastic ascending aorta and coronary arteries ().
The following parameters were set: standard reconstruction of axial images at 0.625 mm slice width, reconstruction interval of 0.5 mm, field of view of 180 × 180 mm and an iterative reconstruction technique software (iDose4; Philips Healthcare, Cleveland, OH, USA) with a window width and level of 420 and 65, respectively. The electrocardiogram-gated scan reconstruction interval, with the least motion artefacts, was determined by reconstructing a slice at the mid segment of the ascending aorta in 2% steps from 35% to 75% of the R–R interval. For diagnostic interpretation, reconstruction of the CTA images was used; where a time point with the least motion artefact was located at the mid segment of the ascending aorta (48%). |
pmc-6159240-1 | A 45-year-old Caucasian male presented with right arm pain and a palpable mass below the right mandibular angle, 2 years after resection of a cutaneous melanoma in the right jaw. The initial resection 2 years prior was followed by a repeat local excision and level I–V lymph node dissection, with none of the 48 lymph nodes showing metastatic involvement. Ultrasound-guided biopsy of the recently developed mass confirmed recurrence of melanoma.
18F-fludeoxyglucose (FDG) positron emission tomography (PET)/CT was performed for restaging of disease, demonstrating an intensely metabolically active tumour mass in the resection bed, with perineural spread along the right C3 and C4 nerves and contiguous invasion into the spinal cord ().
MRI was subsequently performed for more detailed morphological characterization of local tumour recurrence and regional spread. This showed an irregularly enhancing soft tissue mass in the right side of the neck, with contiguous abnormal thickening and enhancement of the C3 and C4 nerve roots extending through enlarged intervertebral foramina into the right side of the spinal cord. Post- gadolinium T1 fat-suppressed images were particularly helpful in demonstrating the solid mass-like pattern of perineural nodular enhancement progressing retrogradely into the cervical cord substance ().
Owing to the rapid growth of the recurrent mass in the submandibular region leading to ulceration of the overlying skin and significant discomfort, it was surgically resected for local control, and the patient was started on combined immunomodulatory treatment with ipilimumab and targeted radiation therapy.
Histopathologically, the resected mass contained desmoplastic stroma infiltrated by malignant cells with spindle and epithelioid morphology and enlarged nuclei containing prominent nucleoli. On immunohistochemical analysis, the cells were positive for S100 protein (). The architecture of some nerves included in the resection specimen was disrupted and replaced by tumour. |
pmc-6159242-1 | A 2 year old male child with a history of recurrent projectile non-bilious vomiting, since 4 weeks after birth, was referred for a barium meal study to rule out pyloric stenosis or gastro-oesophageal reflux disease. The patient experienced persistent hunger and was always underweight. The results of a full blood count test were within normal limits. A barium examination localised the stomach in the right upper quadrant of the abdomen, on the same side as the liver ().
Subsequent images revealed a distended stomach with indented gastric antrum, narrowed pylorus and delayed emptying suggestive of partial pyloric stenosis ().
Complementary ultrasound examination localised the spleen (which showed no abnormality) and two other structures with the same appearance as the spleen in the right upper quadrant adjacent to the right kidney (). The suspicion of other abnormalities and congenital transpositions of other organs lead to suggestions for other radiological procedures. Although MRI scan is the standard reference for definitive diagnosis of organ transposition, the procedure was, however, not performed owing to breakdown of the MRI equipment at that time. Hence a CT abdominal scan was undertaken with parental consent.
The CT scan confirmed the normal position of the internal viscera of the thorax and the abdomen, except the stomach and the spleen. The CT scan showed a dilated stomach on the right posterior to the liver and partial pyloric stenosis. The pyloric canal appeared elongated, and the whole pylorus was thickened. In addition, the spleen and the other structures with similar appearance as the spleen (suggesting multiple spleens) were found at the right side of the patient adjacent to the right kidney (). A surgical correction of the partial pyloric stenosis further confirmed the anomaly.
A post-operative MRI scan performed 5 months later confirmed the anomaly as described above (–). The procedure was a free-breathing MRI scan as parental consent was without sedation. It also showed a thickened pyloric wall at the site of the repair and revealed the patient had multiple spleens (3) on the right ( and ). The child has had a normal life since the correction of the partial pyloric stenosis 2 years ago. |
pmc-6159243-1 | A 45-year-old male with history of blunt abdominal trauma was brought to casualty with abdominal distension and drop in haemoglobin levels. Initial ultrasound imaging revealed free fluid in the abdomen. Exploratory laprotomy was done that show hemoperitoneum, and liver laceration in the right lobe. Perihepatic packing was done to achieve hemostasis.
CT imaging done on day two revealed replaced right hepatic artery arising from superior mesenteric artery (SMA) with hepatic laceration involving segment VI and VII. Arterial phase CT images showed a prominent segmental branch of the right hepatic artery with a fistulous track communicating with the right hepatic vein (–). Two days later in view of the further drop in hemoglobin and rising SGPT/SGOT levels, it was decided to intervene.
From a transfemoral approach, the superior mesenteric artery was catheterized with 6F catheter (Chuang-William Cook Europe APS). Selective angiogram showed two prominent hepatic artery segmental branches leading to the lacerated liver parenchyma with early filling of the right hepatic vein suggesting post-traumatic arteriovenous fistulae (). The replaced right hepatic artery was catheterized coaxially with a progreat microcatheter (Terumo Corporation, Tokyo, Japan) and then navigated into the segmental arterial branches leading to the arteriovenous fistulae. The segmental branches leading to the arteriovenous fistulae were embolized with multiple 018 micro coils (Tornado Embolisation Coils Cook, Bloomington, IL). Post-embolization angiography showed completely occluded arteriovenous fistulae (). The patient was followed up for 2 weeks and he made an uneventful recovery. |
pmc-6159245-1 | Case1: Reported here is a 41-year-old male patient who had previously undergone pyeloplasty for right pelviureteric junction obstruction. The patient was diabetic since 10 years and had developed chronic kidney disease 5 years ago. The patient presented with fever with chills, burning micturition and right flank pain.
On examination the patient was febrile. Urine examination done just before the MR urogram showed 32 white blood cells/hpf and 1 bacteria/hpf. The creatinine level of the patient was 3.9 mg dl–1, which prevented the administration of contrast.
CT imaging was performed, which showed perinephric fat stranding and hydronephrosis with sudden tapering of the right ureter at the pelviureteric junction ().
MRI was performed to image the ureter and to diagnose the cause of obstruction. Clinical suspicion was of a post-pyeloplasty stricture. The patient’s high creatinine level prevented the administration of iodinated contrast.
MRI showed hydronephrosis of the right kidney with sudden tapering at the level of the pelviureteric junction with diffusion restriction at the tip of the renal pyramid, with widening of the fornices, clubbing of the calyces and filling defects in the lower pole and interpolar calyx. Additionally, cleft was noted at the lower pole. These imaging findings were suggestive of a right pelviureteric junction stricture with papillary necrosis ().
However,there was no growth of bacteria on urine culture for this patient. There was growth of Candida species other than Candida albicans on fungal culture. Nevertheless, the patient was started on broad-spectrum antibiotics with systemic antifungals with resultant resolution of fever and flank pain with the urinary white blood cell count returning to normal. Post treatment urine culture was normal. |
pmc-6159245-2 | Case 2: Reported here is a 48-year-old female patient who is a known case of diabetes with chronic kidney disease. She previously had bilateral emphysematous pyelonephritis, which resolved with treatment. Stenting was done for the patient at that time, which was removed with resolution of patient symptoms and normalization of routine urine analysis and culture. In the current episode the patient presented with right flank pain and fever. Serum creatinine level of the patient was 6.1 mg dl–1.
MRI was requested in view of bilateral hydronephrosis on ultrasound imaging with the clinical differential diagnosis of pyelonephritis and ureteric calculus.
MRI showed mild bilateral hydronepehrosis and bilateral perinephric fat stranding, which was more on the right side. Multiple filling defects were noted within the pelvicalyceal system on both sides, with diffusion restriction noted at the tips of two of the renal pyramids on the right side. A ring sign was seen in the calyces on the right side (). Complimentary non-contrast CT was performed following the MRI, to definitively rule out a ureteric calculus. This CT showed papillary calcifications on both sides ().
Urine examination of the patient showed 10 white blood cells/hpf and culture showed growth of Klebsiella. Right-sided ureteric stenting was performed. The patient was treated with antibiotics following which her symptoms reduced and urine routine and culture returned to normal. |
pmc-6159245-3 | Case 3: Reported here is a 66-year-old non-hypertensive, non-diabetic female patient, known to have chronic renal failure who presented with progressively increasing flank pain. Initial evaluation by ultrasound imaging showed left-sided hydronephrosis (). The creatinine level of this patient was 4.5 mg dl–1.
MRI was requested to rule out pyelonephritis. MRI showed filling defect in the proximal ureter causing hydroureteronephrosis. Further, coronal slice of the 3D MR cholangiopancreatography image showed filling defect in the upper polar calyx and diffusion-weighted images showed diffusion restriction in the calyx and renal pyramid ().
The patient underwent ureteric stenting under antibiotic coverage, where a brownish black irregular slough was removed. This was followed by relief of symptoms. The stent was removed after 3 months and the patient had an uneventful course at 6 month follow-up. |
pmc-6159245-4 | Case 4: Reported here is a 47-year-old male who underwent radical cystoprostatectomy with bilateral ureteric reimplantation into the ileum for bladder carcinoma. The patient subsequently developed increased creatinine and acute renal failure with a creatinine level of 6.6 mg dl–1. Laboratory evaluation showed increased white blood cell count and the presence of bacteria in urine routine examination. MRI was requested to establish the diagnosis of pyelonephritis and to rule out the recurrence of bladder carcinoma.
Evaluation by MRI showed a medially deviated left ureter with a filling defect in the left lower pole calyx. Further, a bulky right kidney with areas of parenchymal diffusion restriction surrounded by free fluid with filling defects in the right ureter, calyces and the renal pelvis suggested a diagnosis of right-sided pyelonephritis with bilateral papillary necrosis (). Further evidence of diffusion restriction was seen at the calyces and the tips of the renal pyramids ().
The medially deviated left ureter probably represents its post surgical course, ultimately terminating in its ureteric implantation. The filling defect in the left lower pole represents old papillary necrosis, either secondary to obstruction or due to an older event of pyelonephritis. This slough poses a risk of causing obstructive uropathy and hence left-sided percutaneous nephrostomy was done as a preventive measure.
In view of ureteric reimplantation into the ileum, a right percutaneous nephrostomy was done with removal of slough. After the procedure, a nephrostogram showed free flow of contrast through the right pelvicalyceal system into the ileum ().
The urine culture of the patient showed growth of Proteus vulgaris. The patient improved with antibiotics and was put on twice weekly follow-up. This was followed up by a percutaneous nephrostomy on the left side. |
pmc-6159245-5 | Case 5: Reported here is a 64-year-old male patient, a known case of diabetes since 18 years, who presented with fever and burning micturition. The patient had an elevated creatinine level of 3.5 mg dl–1 and presented with back pain and fever raising a suspicion of pyelonephritis. Ultrasound imaging showed bilateral hydroureteronephrosis. Laboratory investigation revealed increased white blood cell count.
MRI was requested to elucidate the cause of the bilateral hydronephrosis. Evaluation by MRI additionally showed filling defects in the calyces of both kidneys (). Further, the right kidney showed a thin rim of parenchymal diffusion restriction with diffusion restriction of the calyces and the tip of the medullary pyramids in both kidneys (). This suggested a possibility of early right-sided pyelonephritis with a diagnosis of bilateral papillary necrosis. Other features of papillary necrosis such as filling defects, clefts and phantom calyces were seen. Urine culture demonstrated the growth of Escherichia coli ().
The patient underwent bilateral ureteric stenting, followed by a course of antibiotics. This resulted in improvement of patient symptoms with return of routine urine examination and urine culture to normal.
Thus diffusion restriction at the calyx and tip of the renal pyramid with filling defects within the pelvicalyceal system was seen in all five cases of papillary necrosis. A cleft in the region of the tip of the renal pyramid was seen in two of the five patients. This led us to conclude that diffusion restriction at the calyx and tip of the renal pyramid with filling defects within the pelvicalyceal system is an important finding in papillary necrosis.
Also to be noted in this series is that all patients had elevated creatinine levels, which prevented the use of intravenous urography (conventional) or contrast-enhanced CT or MR urography. MRI can provide valuable information by imaging the urine-filled ureter. Thus, at our institution, in this subset of patients, imaging with MRI is preferred. Further, in contrast to CT, MRI does not deliver any radiation dose to the patient. This becomes important since many patients with diabetes and patients with renal failure undergo multiple imaging examinations. |
pmc-6159246-1 | A 31-year-old male patient first presented to our clinic (time point A, ) with daily vertigo, aggravated by sudden movements of the head and complicated by nausea and vomiting, as well as difficulties sustaining his balance in confined spaces. His medical history was blank except for meningitis at 2 years of age; his family history showed no vertigo, epilepsy or hearing loss and no familial cancer syndromes (such as Gorlin-, Li-Fraumeni-, Turcot-, Gardner- or Cowden syndrome). He had not experienced headaches, and neurologic and audiometric examination only revealed perceptive high tone loss in his right ear with unknown cause; a subsequent MRI examination focused on the cerebellum and cerebellopontine angle half a year later (time point B) was normal. A diagnosis of probable benign paroxysmal positional vertigo (BPPV) was made, and the patient was given home exercises to alleviate his symptoms ().
Three years later (time point C), the patient sought medical attention again because of a persistent balance disorder (his initial symptoms of vertigo had disappeared), present throughout the day with no predilection to one side. Concomitant with these symptoms, he had noticed decreased vision in his lateral visual fields for fast-approaching objects, such as tennis balls. Neurological examination showed a new bilateral horizontal nystagmus when looking laterally, the tandem gait was performed below normal for his age, he had difficulties standing still with closed eyes, and the Dix-Hallpike test (classical test for diagnosing BPPV clinically) was positive with a predilection to the right. Audiometric evaluation showed persistent perceptive high tone loss in his right ear. However, a follow-up MRI examination, including thin slices through the cerebellum and cerebellopontine angle and series after contrast administration, again showed no pathology. The initial diagnosis of BPPV was maintained, and the patient was again given home exercises for symptom alleviation. One-half year later, the patient presented for the third time (time point D), and was seen in our dizziness clinic with a balance disorder, difficulties in processing information and in typing (wrong characters), which had been present since 3–4 months after the second MRI examination. Symptoms progressed to dysarthria, decreased vision with diplopia and optokinetic photophobia within the next few months. A full overview of the timeline can be found in . |
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