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
What is the most likely diagnosis?


ANSWER

Perthes disease


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.

A 41-year-old Caucasian female patient presented with diffuse pustulous skin lesions and polyarthralgias. The patient had no other relevant past medical history. The histological study of the skin lesions revealed a polymorphonuclear infiltrate in the dermis. Other laboratory tests were unremarkable. 

CT AXIAL PELVIS

CT AXIAL CLAVICLE

CT CORONAL LOWER LUMBAR

Tc-99m methylene diphosphonate bone scintigraphy
What is the likely diagnosis?

ANSWER


SAPHO syndrome

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?

Woman with Acute abdomen

Saturday, September 10, 2011 10 comments

A 22-year old woman was admitted for acute pain in the right lower abdominal quadrant. Laboratory analysis showed mild leukocytosis and slight elevation of C-reactive protein. Transvaginal sonography revealed a complex right adnexal mass and a moderate amount of fluid in the Douglas pouch. A pelvic MR study was indicated.





T2-weighted MR Images are shown here.What is the most likely diagnosis?

ANSWER

Adnexal torsion with haemorrhagic infarction

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.

28 year old femal patient. Hypostenia and hypoestesia localized at lower limbs and loss of sphincterial control. Sagittal T2, PD and T1 weighted images pre- and post- paramagnetic contrast medium i.v. administration, and axial T1 and T2 weighted images in the area of the suspected lesion were performed.These Images are given below.
axial T1-weighted post-Gadolinium image

sagittal image T1-weighted post-Gadolinium
sagittal T2-weighted image
sagittal PD-weighted image

Identify what  the lesion is  and where the lesion is?

A 50-year-old man, who was previously healthy, presented with symptoms that included progressive intermittent but severe dysphagia, halitosis, paroxysms of coughing and regurgitation of food and liquids. He also had an unintentional weight loss of 20 kg. These symptoms developed during a 15-month period. He had no history of tobacco or alcohol use. Results of the physical examination done were found to be normal. A radiographic image was obtained.




What Is the diagnosis?

ANSWER

Giant Zenker's diverticulum

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.


An 11-year-old boy who lived on a farm presented with a 2-week history of fever, vomiting and pain in the right hip that extended into the right buttock. The patient was non-weight bearing on the right leg, with restricted movement of the right hip. CRP was elevated. The pelvic radiograph at presentation was normal. Clinical examination had revealed tenderness on deep palpation of the right iliac fossa, and an abdominal ultrasound obtained to exclude appendicitis was negative. No hip joint effusion was seen on ultrasound.
MRI image study was requested.Axial T1wFS image post IV gadolinium and coronal STIR images at the level of Sacrum given below.

Axial T1wFS image post IV gadolinium

coronal STIR image

What is the Diagnosis?

ANSWER

Sacral osteomyelitis associated with pyogenic sacroiliitis

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.

A 76-year-old man, with a long story of hypertension, arrived at the emergency room with sudden severe tearing thoracic pain, tachycardia and progressive hypotension. Few minutes after his arrival he lost consciousness.

CT images taken.


What is the diagnosis?

ANSWER

Acute aortic dissection
CT imaging reveals a dissection involving the ascending aorta.

Acute aortic dissection is the most common emergency affecting the aorta; its prevalence exceeds that of ruptures of thoracic and abdominal aneurysms combined. Untreated, acute aortic dissection can rapidly be fatal.
Patients with hypertension or connective tissue disorders such as Marfan syndrome, cystic medial necrosis, Ehlers-Danlos syndrome and Turner syndrome are at risk for aortic dissection. Pregnancy, aortic stenosis, and coarctation of the aorta are other risk factors.

Stanford classification is the widely used. Regardless of the site of intimal tear or the distal extent of the dissection, dissections involving the ascending aorta (Stanford type A) usually require emergency surgical repair (because of the risk of acute aortic insufficiency, occlusion of the coronary vessels or rupture of the dissection into the pericardium), whereas dissections that are distal to the left subclavian artery (Stanford type B) usually can be controlled medically, unless there is aortic ropture or renal or visceral vascular compromise.

CT is a rapid, relatively noninvasive, and readily available method for evaluation of acute aortic dissection. It is 93.8% sensitive and 87.1% specific. The classic features of AAD on CT scans are an intimate flap and false lumen, which are found in approximately 70% of cases; demonstration of an intimate flap is usually conclusive.Secondary findings include increased attenuation of the acutely thrombosed false lumen on scans obtained before administration of contrast material, internal displacement of intimal calcification, mediastinal or pericardial haematoma, delayed enhancement of the false lumen, mural thickening with increased attenuation, and irregular compression of the true lumen by an expanding intramural haematoma or thrombus.

A 60-year-old male who was being treated for acute-on-chronic pancreatitis with a large pancreatic-pseudocyst presented with acute abdomen to the emergency department. On presentation he was hypotensive. Laboratory parameters confirmed low haemoglobin (8.6 gm/dl) and mildly elevated serum amylase levels (180IU). Serum electrolytes revealed a low sodium and pottasium.Contrast CT abdomen was performed and two images were given below.
Axial CECT abdomen

Coronal CECT abdomen
What is the diagnosis? 

ANSWER

Contrast CT abdomen revealed atrophic and papery-thin body-tail of pancreas with relatively spared pancreatic-head. Adjacent peripancreatic fat planes were dirty. No overt fluid collection was seen in its vicinity. Additionally, a giant aneurysmal sac from the right postero-lateral aspect of the abdominal aorta at L1-L2 vertebral level was seen.The sac was seen extending into the right paravertebral gutter with extension also seen into the right psoas sheath.

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.

T1 MRI
T2 MRI




































A 21-year-old man was admitted with bilateral lower extremity weakness and low-back pain.Plain radiograph was performed prior to MRI.
Sagittal T1-weighted and T2- weighted Magnetic resonance imaging (MRI) study was performed after taking plain radiograph.

What are the abnormalities in these images and what is the most likely diagnosis? 

ANSWER

Magnetic resonance imaging (MRI) study showed involvement of the Th 7, 8, 9, 12 and L3 vertebrae. Th7 and Th 8 vertebrae were destructed with collapse of the Th7-8 and Th 8-9 intervertebral disc spaces. Paravertebral and epidural abscesses were also detected at the same level. The spinal cord was compressed to the posterior by expanding epidural abscess. Postgadolinium images showed intense homogenous enhancement at epidural lesions and intense heterogeneous enhancement at paravertebral lesions. Involved vertebrae also enhanced.

Multifocal spinal tuberculosis

80 year old female, with history of cryptogenic cirrhosis, ischaemic heart disease and diabetes mellitus admitted with abdominal pain and bleeding through the colostomy of a Hartmann's procedure for a rectal carcinoma.
This patient presented with a short history of abdominal pain and bleeding from her colostomy. Relevant past medical history includes a palliative Hartmann's procedure for a rectal adenocarcinoma, cryptogenic cirrhosis with portal hypertension , Ischaemic heart disease and Diabetes Mellitus. A CT scan of the abdomen and pelvis showed no evidence of recurrent colonic malignancy or liver metastasis.
Contrast CT just proximal to bifurcation of portal vein is shown here.

















Then  duplex ultrasound scan was performed.
portal vein axial section
portal vein - sagittal section
















Idetify the abnormalities in these images and what is the most likely diagnosis?

A 9-month-old girl was brought by her parents because of swelling of the right leg since birth. On examination there was hemi-hypertrophy, venous varicosities and pinkish discoloration.

Plain radiographs showed marked soft tissue enlargement and mild bone enlargement.



Colour Doppler showed absent deep venous system and few varicose venous channels.















Angiography of right lower extremity showed increased little tortuous arterial branches and absent deep venous system

















What is the most likely diagnosis?


ANSWER

Klippel-Trénaunay Syndrome

Klippel-TrĂ©naunay Syndrome  is a rare congenital malformation characterised by the triad of capillary malformations, atypical varicosities or venous malformations, and bony or soft tissue hypertrophy usually affecting one extremity.The most frequent clinical aspect of Klippel-Trenaunay Syndrome is a dermal capillary stain associated with dilated marginal vein of Servelle often identified in the subcutaneous fat of the lateral calf and thigh. It should be distinguished from Parkes-Weber syndrome by absence of underlying arteriovenous malformation.Prominent superficial varicose veins are present in majority of the patients.Extremity pain, spontaneous haemorrhages, venous insufficiency or thrombophlebitis are commonly encountered. Treatment is usually conservative and includes application of graded compressive stockings or pneumatic compression devices. Percutaneous sclerosis of varicosities and surgical treatment by epiphysiodesis to control leg length discrepancy, excision of hypertrophied soft tissue or less commonly reconstructive surgery of deep venous obstruction has been reported in some patients.

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