6 years old boy presented with pain in the left hip and limping. Plain radiographs of the pelvis, AP and frog lateral views, were performed. Follow-up films were performed after 3 months. Follow-up films showed good healing of the left femoral epiphysis with a mild coxa magna deformity of the femoral neck.
|Pelvic X-ray - frog lateral view|
|follow up Pelvic Xray AP view|
The initial radiographs showed fragmentation of the left femoral epiphysis, which appears dense as compared with the right.
The aetiology of Perthes disease is idiopathic. It represents multiple vascular occlusive episodes that involve the femoral head, causing changes of avascular necrosis. It is a long ongoing process of vascular change and repair and is different from avascular necrosis secondary to trauma. It usually affects Caucasian boys (4-5 times more often than females), in the age group of 3-12 years, occurring bilaterally in 15% of cases and when bilateral is usually asymmetrical. When symmetric involvement is seen, hyporthyroidism and epiphyseal dysplasia should be excluded. The onset is earlier in females and the prognosis worse. There is increased incidence of associated congenital anomalies, congenital heart disease, pyloric stenosis and undescended testes.
|CT AXIAL PELVIS|
|CT AXIAL CLAVICLE|
|CT CORONAL LOWER LUMBAR|
|Tc-99m methylene diphosphonate bone scintigraphy|
The main findings in the CT study were sclerosis, irregularities, and hyperostosis of the manubrium and medial ends of both clavicles; asymmetric sacroiliitis (Fig. 2) and sclerosis and erosion of the superior-lateral corner of L4 vertebral body .
Bone scintingraphy revealed intense radiotracer uptake in both clavicle medial ends and sternoclavicular joints. There was also radiotracer uptake in the sacroiliac joints (more pronounced on the right).
SAPHO is an acronym that refers to an uncommon syndrome, composed of the combination of synovitis, acne, pustulosis, hyperostosis and osteitis. It affects more often young adults, with a female preponderance.
The causes are unknown, although some authors support its integration in seronegative spondyloarthtropaties which is supported by the increasead prevalence of the HLA B27 allele, occasional presence of sacroiliitis, inflammatory bowel disease and psoriasis.The most common dermatologic manifestations are palmoplantar pustulosis, severe acne, and psoriasis.
Characteristic radiographic findings include hyperostosis, which includes endosteal and periosteal proliferation and enthesopatic ossification. In association there are mixed areas of osteolysis. Adjacent joints show manifestations of arthritis, namely erosions and joint space narrowing. CT can depict these alterations in greater detail.
An 11-year-old boy was referred with acute paraplegia and local tenderness over the left costovertebral angle. He had also history of left side insidious back pain, low grade fever and malaise. Chest X-ray also showed a calcified focus probably a calcified lymph node at the left hilar region however no evidence of parenchymal infiltration was found.Helical abdominal CT was performed after taking the Plain radiograph of the thoracolumbar region.
Image of Helical abdominal CT was given here.
Identify the lesion and what is the most likely diagnosis?
Transverse T2-weighted image. Tube thickening (arrow) is detected as an amorphous solid masslike structure. A small amount of fluid (long arrow) in the Douglas space is seen.
Sagittal T2-weighted image depicts a few small cystic structures (small arrows) in the periphery of the enlarged adnexa, probably related to transudation of fluid into the ovarian follicles due to ovarian congestion.
Imaging findings were strongly suggestive of hemorrhagic necrosis of the adnexa following torsion and were confirmed surgically.
Adnexal torsion is a rare cause of lower abdominal pain, often presenting as a diagnostic problem due to the nonspecific clinical, laboratory and sonographic findings, as it was seen also in this patient.It is associated with an ipsilateral ovarian tumour or cyst in 50-81% of cases, which is almost always benign.
The sonographic findings of adnexal torsion are usually nonspecific and include the presence of a cystic, solid or complex adnexal mass, as it was seen in this patient.Free intraperitoneal fluid is found in one to two thirds of patients. CT and MR imaging is usually recommended in subacute or chronic cases to confirm the diagnosis of adnexal torsion and to differentiate haemorrhagic from nonhaemorrhagic infarction.Common CT and MR imaging findings of adnexal torsion include fallopian tube thickening, ascites and uterus deviation to the twisted side.Imaging findings suggestive of haemorrhagic infarction include eccentric smooth wall thickening exceeding 10 mm in a cystic ovarian mass, lack of contrast enhancement of the internal solid component or the thickened wall of a twisted adnexal mass, haemorrhage within the tube or adnexal mass, or haemoperitoneum.
|axial T1-weighted post-Gadolinium image|
|sagittal image T1-weighted post-Gadolinium|
|sagittal T2-weighted image|
|sagittal PD-weighted image|
What Is the diagnosis?
Xray showed a large fluid level from the midline at the upper mediastinum above the aortic arch and there was no evidence of a lower mediastinum widening.After swallowing barium, there appeared a large esophageal outpouching arising from the midline of the posterior wall of the pharyngoesophageal junction. The radiological diagnosis suggested that the patient had a pharyngoesophageal diverticulum (Zenker´s diverticulum).
Zenker's diverticulum is a pseudodiverticulum consisting of mucosa and submucosa that arise from the posterior portion of the inferior pharyngeal constrictor muscle. The Zenker diverticulum occurs at an area of potential weakness in the inferior pharyngeal constrictor muscle referred to as the Killian dehiscence.
The most common presenting feature is upper esophageal dysphagia, which occurs in as many as 98% of patients. Other common symptoms include halitosis, regurgitation of undigested food, noisy swallowing, and aspiration. Some patients also report excessive salivation and the sensation of a mass within the throat. Weight loss and recurrent pulmonary infections occur in approximately one-third of the patients.
hysical examination findings are rare, although some extremely large diverticula are occasionally palpable on examination. These are usually present to the left of the midline.
Fluoroscopic barium esophagography is the mainstay of the diagnosis of the Zenker diverticulum.
Patients with minimal symptomatology who do not desire surgical therapy may be followed up on a routine outpatient basis by monitoring their symptoms.
Several surgical options exist; however, the approach most frequently cited is myotomy of the cricopharyngeus muscle with or without diverticulopexy. Endoscopic treatment of Zenker's diverticulum, including endoscopic stapling, holds promise and is currently being investigated in clinical trials.
|Axial T1wFS image post IV gadolinium|
|coronal STIR image|
Axial and coronal STIR and T2w images showed a focal lesion with surrounding high signal in the right sacral alum and less well-defined high signal in the right iliac bone also. The sacral lesion was associated with cortical loss at the inferior aspect of the right sacroiliac joint and a low signal central bony sequestrum. The adjacent iliacus, pectineus, obturator internus, psoas and gluteus maximus muscles were thickened and of high signal. There was marked enhancement post-gadolinium of the bony sacral lesion and the anterior soft tissue collection.
Sacral osteomyelitis is rare and diagnosis is often delayed due to a variable clinical presentation, low suspicion of examining clinician, lack of awareness of diagnostic procedure, and rare findings on plain radiographs. The rate of complications increases with delay in diagnosis, and includes abscess or sequestrum formation, prolonged period of sepsis, long-term joint deformity, disability or even death .
Presentation is often a triad of fever, low back pain and difficulty weight-bearing, associated with an elevated C-reactive protein. The most common causative agent is Staphlococcus aureus.Brucellosis and other atypical organisms are associated with sacral osteomyelitis.
The plain radiograph is rarely helpful. An ultrasound examination is useful to exclude a hip joint effusion. Tc99-MDP bone scan is a sensitive test, but lacks specificity. CT clearly shows bone and soft tissue involvement, and may have a role in aspiration or biopsy. MRI has emerged as the imaging modality of choice due to its increased sensitivity and specificity.
What is the diagnosis?
|Axial CECT abdomen|
|Coronal CECT abdomen|
Giant aortic pseudoaneurysm
Pseudoaneurysm formation is a recognised but relatively uncommon complication associated with pancreatitis. The most common artery affected is the splenic artery, followed by gastroduodenal, pancreaticodudenal, left gastric, hepatic and small intrapancreatic arteries in decreasing order of frequency. The probable aetiopathogenesis suggests that the release of proteolytic pancreatic enzymes (especially trypsin and elastase) into the perivascular space results in enzymatic digestion and weakening of the arterial wall. The damaged vessel wall under the influence of sustained arterial pressure leads to dissection of blood into the perivascular tissues forming a perfused sac that communicates with the arterial lumen.
A 21-year-old man was admitted with bilateral lower extremity weakness and low-back pain.Plain radiograph was performed prior to MRI.
Multifocal spinal tuberculosis
|portal vein axial section|
|portal vein - sagittal section|
Idetify the abnormalities in these images and what is the most likely diagnosis?
Angiography of right lower extremity showed increased little tortuous arterial branches and absent deep venous system
What is the most likely diagnosis?