Newborn with dysmorphic signs, small palpebral fissure, abnormal implantation of the thumb of her left hand, respiratory distress syndrome, tachypnoea, and cyanosis.
This is the second pregnancy of healthy 27 year old mother. The pregnancy was uneventful until the third trimester, when polyhydramnios and intrauterine growth retardation were detected by antenatal ultrasound. The child was born by uncomplicated delivery at 37 weeks of gestation. Apgar scores were 6 and 8. Birth weight: 1730 g. Ambu-bag resuscitation was necessary. Physical examination showed dysmorphic signs, including: small palpebral fissure and abnormal implantation of the thumb of her left hand, along with respiratory distress syndrome, tachypnoea, cyanosis, copious secretions, and a scaphoid abdomen.
Chest radiography was performed soon after birth.


What is the possible diagnosis in this patient?


ANSWER

Xray shows Nasogastric tube projected onto the proximal oesophagus and absence of gastrointestinal air. There is a widespread pattern of granular increased density in the lungs, with effacement of the cardiac borders, consistent with respiratory distress.

Oesophageal atresia and tracheo-oesophageal fistula is a complex of congenital anomalies characterised by incomplete formation of the tubular oesophagus.
Different types of oesophageal atresia are identified on the basis of the presence (and location) or absence of a tracheo-oesophageal fistula.
- Type A: atresia without fistula (8%)
- Type B: atresia with proximal fistula (1%)
- Type C: atresia with distal fistula (80%)
- Type D: atresia with proximal and distal fistulae (1%)
- Type E: fistula without atresia (4%)
About half the children have other associated malformations and the VACTERL complex (Vertebral disorders, Ano-rectal malformations, Cardiovascular anomalies, Tracheo-oesophageal fistula, Radial/Renal dysplasia, Limb defects) is the best known group of anomalies associated with oesophageal atresia.
Typical clinical findings are failure to successfully pass a catheter into the stomach, regurgitation, inability to swallow saliva or milk, aspiration, respiratory distress, aspiration pneumonia.
Radiologic diagnosis is based on findings at anteroposterior and lateral chest radiography wich reveals a blind pouch of the proximal oesophagus, distended with air. adiographic evaluation should always include the abdomen to asses the presence of air in the gastrointestinal tract (distal fistula). In types A and B there is complete absence of gas in the stomach and intestinal tract; in types C and D, the gastrointestinal tract usually appears distended with air.
The type of oesophageal atresia is confirmed by advancing a radiopaque feeding tube from the nose to the level of the atresia. The tube will curl when it approaches the blind end. Rigid bronchoscopy is performed to confirm the anatomy, to evaluate for a proximal fistula and to control the distal fistula.
During pregnancy, oesophageal atresia may be suggested by the presence of a combination of polyhydramnios.

Answer - Type A Oesophageal atresia : atresia without fistula

A 52 year old woman, affected by the anti-phospholipid syndrome (APS), and subjected to dialysis because of right shrunken kidney and left nephrectomy, came to our attention for complaints of generalized abdominal pain and frequent episodes of diarrhoea.
Her medical history included coagulation disorders, thromboembolic events, and positioning of aorto-superior mesenteric, left aorto-renal and aorto-bi-iliac prostheses.
Two months earlier, the patient developed an obstruction of aorto-superior mesenteric bypass with distal revascularization by collateral vessels stemming from gastroduodenal artery and severe subocclusive stenosis of left aorto-renal bypass. After left renal revascularization, nephrectomy was carried out owing to acute intraparenchymal bleeding.
Following the onset of abdominal symptoms erect Xray of the abdomen and CT scan were done.



One week later Abdominal CT scan and thoracic CT were done.



What is the most likely diagnosis in this patient?

ANSWER

Plain abdominal X-ray showed gastric distension, with evident gas-fluid levels in the small bowel area, while the colonic frame was empty.CT scan confirmed the above findings, showing diffuse fluid distension of small bowel loops, with multiple gas-fluid levels.
CT scans taken after One week later showed: an inhomogeneous hypodense area located just below the diaphragm and characterized by indistinct margins and dilatation of intrahepatic bile-ducts, suggestive of hepatic abscess. Moreover, a thoracic CT scan revealed a consolidation area within the lower lobe of right lung in association with scissural thickening.

Ischemic small bowel infarction in APS.

APS is an autoimmune disorder, characterized by association of arterial/venous thrombosis or recurrent pregnancy loss with positivity in at least one of the laboratory tests employed to detect anti-phospholipid (aPL) antibodies, including lupus anticoagulant (LA), anti-cardiolipin (aCL) and anti-B2-glycoprotein I (aB-2GPI) antibodies.
Clinical spectrum of APS range from an increased risk of thromboembolic events, including peripheral thrombophlebitis, pulmonary thromboembolism, stroke, retinal artery occlusion, Devic’s syndrome, myocardial infarction, placental thrombosis, Budd syndrome, skin and gastrointestinal disturbances.

A 69-year-old asymptomatic woman with prior nephrectomy came for routine follow-up to a nephrology clinic. The patient had undergone a radical nephrectomy in 1992 for stage I right renal cell carcinoma (RCC). On her examination, she was found to have a small non-tender palpable lump in the epigastric region. Computed Tomography (CT) of the abdomen was performed.
What are the abnormalities in this Contrast enhanced axial CT and what is your diagnosis?

ANSWER

Renal cell carcinoma with pancreatic metastases

The right kidney is removed. Multiple avidly enhancing nodular lesions in the pancreas can be noted.

About one third of patients with RCC have metastases at presentation and another third develop widespread metastatic disease following nephrectomy. Late metastases after months to years following resection of the primary tumour have been documented. Lungs, bones, and contralateral kidney are common sites for distant metastases from RCC.
Metastases to pancreas are relatively rare and account for 2% of malignant masses of the pancreas.The primary malignancies metastasising to the pancreas originate most commonly from lung, colon, breast and kidney.

65 years old male presented with confusion and irregular small pupils that react to near objects, but not to light.Further neurological examination revealed ataxic wide-based gait and foot slap, areflexia and loss of position.



What is the probable diagnosis?

ANSWER

Tertiary Syphilis,Gumma in Bone and Symptoms suggestive of Argyll-Robertson pupil and Tabes dorsalis, also known as locomotor ataxia
There is an irregular lytic area in the left frontal bone, which variably involves the whole thickness of the vault. The process seems to have extended down the coronal suture into the anterior part of sphenoid. Compare with normal diploic vessels. Otherwise vault markings are normal without any increase in vascular markings. The dorsum sellae appears intact.

Young adult male motorcyclist with haematuria after recent accident.


Identify these two IVUs?



ANSWER

The top IVU  shows a distorted pelvicalyceal system with a gap in the nephrogram of enhanced renal tissue in the mid-part of the left kidney. There is a recent fracture of the transverse process on the right side of L1 vertebra. In one view, the possibility an an apophysis cannot be excluded. The rounded tip of the left transverse process of the second lumbar vertebra, L2, has been lost. It lies immediately below as a triangular density in this view (and as a crescent over the left renal artery in the angiogram).
The left renal angiogram shows normal renal perfusion, but with a laceration of the kidney giving a gap in the perfusion and immediate enhancement of the renal cortex.

Man with Cerebellar Signs

Saturday, October 9, 2010 12 comments

33 years old male with a a long history of unsteadiness, since childhood. Mentation was below average. Clinicians elicited 'past-pointing' and ataxia.

Identify this CT scan???


ANSWER

There are visible cerebellar folia. The 4th ventricle is large. The foramina of Magendie and Lushka are shown in one cut. The posterior fossa cisterns are visible. The pons and brain stem are grossly normal size. All of the diagnostic changes lie below the tentorium cerebelli.

Man With Renal Cell Carcinoma

Thursday, July 29, 2010 1 comments

This is a single cut from  CT series after intravenous contrast,of a 68 year old man who admitted to the surgery ward complaining of  Haematuria and Loin pain.He was hypertensive and pale.Renal cell carcinoma was confirmed in this patient.


What is the abnormality seen in this Contrast CT image?

ANSWER

The Correct Answer is Invasion of the IVC by Renal Cell Carcinoma
This single cut from a CT series after intravenous contrast (given into a lower limb vein) shows opacification of spinal and pre-vertebral veins (immediately behind the aorta). The density of a renogram shows the site of the left kidney. The inferior vena cava opacification is incomplete, outlining a soft tissue mass in the vein and decreasing the effective lumen by at least 75%.

Male with Diabetes Mellitus

Monday, July 19, 2010 0 comments

This is the Pelvic Xray of a 56 year old patent who has been having poorly controlled Diabetes Mellitus about for 8 years.


Identify this X- ray?


ANSWER

The Correct Answer is CALCIFIED VAS DEFERENS in the left side

Diabetes and TB are the two common causes of calcification of the vas deferens. Diabetes tends to cause bilateral, symmetrical, non-obstructing calcifications in the muscle part of the vas, while TB tends to cause unilateral, irregular calcifications.

Other causes include infections like gonorrhea and syphilis as well as chronic urinary tract infections.

This is an intravenous urogram of a 27 years old white male with a 3 month history of dysuria and bilateral loin pain.He did not have either haematuria or obstructive lowerurinary tract symptoms.On examination of this patient he had bilateral renal angle tenderness and tenderness over the suprapubic area. 

Identify the abnormality in this IVU?

ANSWER

Correct Answer is Bilateral Ureterocoeles
Clinical history is suggestive of pyelonephritis.
The kidneys pelvicalyceal systems and proximal ureters appear grossly normal, renal pelvis and calyces are dialted indicating bilateral mild hydronephrosis, implying the possibility of obstruction.(mild left sided hydronephrosis).Both ureters are normal calibre.The lower ends of the ureters cross the bladder wall towards the trigone, but are dilated at their lower end.(cobra head sign) The contrast in the lower end of the ureter is surrounded by a zone of contrast free space within the density of the bladder.

This is a micturating cystogram of a 8 months old male infant who was brought to the paediatric ward by the mother complaining of high fever which was lasting about 1week associated with excessive crying when micturates,freaquency,vomiting and decreased oral intake.On physical examination, tenderness in the costovertebral angle and suprapubic tenderness was elicited.Full blood count and Urine full report revealed UTI.


What would be the possible diagnosis in this infant?

ANSWER

The Correct Answer - This 8 months old male infant is having urinary tract infection secondary to posterior urethral valve

Micturating cystogram shows that visible bladder base tapers towards the prostatic urethra which abruptly dilates. The dilatation is non-uniform and shows the dual crescentic shadows from the contrast held back by the folds of the valves. These overlap the membranous urethra. Beyond the external sphincter, the calibre is normal.

This is a double-contrast barium enema of a 31 year old unmarried woman with lower abdominal pain that seemed to occur monthly.And she also complains of passing altered  colored stools associated with lower abdominal pain.


What would be the possible diagnosis?

ANSWER

In this double-contrast enema, barium has coated the caecum and a soft-tissue mass that involves the ileo-caecal junction. The caecal mucosa coats irregularly immediately adjacent to the lesion.
Correct Answer is the Endometriosis of the Caecum
Endometriosis

These are two chest X-rays (AP View and Lateral View) of 50 year old man who was complaining of Exercise related chest pain.He also has had one episode of unconsciousness recently.
On physical examination, there was a harsh Ejection systolic murmur heard loudest at the base of the heart is often but not always prominent.The murmur also radiated toward the cardiac apex, but harsh component is lost.His Carotid pulses are slowly rising and low in volume.

Identify these X-RAYS?


ANSWER

Correct Answer is Calcified Aortic Stenosis

This is the Xray showing the hands and the wrists of a two and half year old child who was initially diagnosed patient with fanconi syndrome now presented with Bow legs(Genu Vulgus) and Short Stature.


Identify this Xray?


This is a CT Brain Of a 8 years old  boy  who was admitted to the neurology unit because of complaining of Headache and having dizziness lasting from several seconds to one minute in duration for about 5 months duration.They occurred quite infrequently and he was able to resume activity immediately following the episodes. The spell became more frequent and prolonged, and by the time of initial evaluation were occurring 2-3 times per day and lasting 2-3 minutes in duration.


And since last two months he had experienced three episodes of seizure attacks which are more suggestive of  partial seizure according to the given Hx by the patient.
His neurological examination was unremarkable.

What would be the most llikely diagnosis in this patient? 

EXPLANATIONS



ANSWER

Arachnoid cyst


Arachnoid cysts are benign cystic lesions localized within the arachnoid membrane that usually contain clear, colorless fluid that is most likely normal cerebrospinal fluid; rarely, they contain xanthochromic fluid.Most are developmental anomalies.But it can also be associated with neoplasms,trauma,surgery and neonatal infections.They are most commonly found in the suprasellar region, sylvian fissure, over the convexity of the hemisphere, and more rarely in the cisterna magna of the posterior fossa.Arachnoid cysts also occur within the spinal canal.
Arachnoid cyst expansion most likely occurs when intracranial pulsation pushes CSF through defects and CSF then becomes entrapped in arachnoid locations.
Arachnoid cysts often are an incidental finding on imaging. Usually, arachnoid cysts are asymptomatic; this is true even of cysts that are quite large. The most commonly associated clinical features are headache, calvarial bulging, and seizures; focal neurologic signs occur less frequently.


Investigations
  • MRI is the diagnostic procedure of choice because of its ability to demonstrate the exact location, extent, and relationship of the arachnoid cyst to adjacent brain or spinal cord
  • On CT scans, arachnoid cysts are characterized by sharp, nonenhancing borders; they are isodense to CSF
  • Plain radiographic findings are nonspecific and have little to offer in the diagnosis of arachnoid cysts

This is the Xray showing both knee joints of  a 4 1/2 year old  female who was brought to the orthopedic clinic by her mother complaining of  a 1 1/2 year history of episodic left knee pain, worsening over the past 6 months, especially when walking.
On examiantion there was Bilateral varus deformity of lower extremities which was more prominent in the left side than the right side.





Identify this Xray ?



ANSWER

Blount's disease
Xray Findings
  • Bilateral depression and deformity of medial aspect of proximal tibial epiphysis and metaphysis
  • Beaking of proximal tibial metaphysis bilaterally


Differential Diagnosis:
1) Mild rickets
2) A physiological bow legs


Blount disease is a growth disorder of the tibia characterized by disordered ossification of the medial aspect of the proximal tibial physis, epiphysis, and metaphysis. This progressive deformity is manifested by varus angulation and internal rotation of the tibia in the proximal metaphyseal region immediately below the knee.


Blount disease most likely is caused by a combination of excessive compressive forces on the proximal medial metaphysis of the tibia and altered endochondral bone formation


Two main types
Infantile Blount disease - tends to be bilateral and occurs in children less than 3 years.The infantile form is generally more common in females and children generally start to walk early, usually when aged 9-10 months.
Juvenile Blount disease - usually unilateral seen in children aged 4-10 years


Diagnosis
Xray Features
  • The medial epiphyseal line demonstrates irregularity
  • Abnormal sloping of the medial tibial epiphysis
  • The metaphyseal portion of the plate demonstrates irregular beaking


Treatment: Children can be treated by bracing, epiphyseal stapling, osteotomies, or in extreme cases, by intra-epiphyseal corrective realignment.

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