Right upper abdominal pain, nausea and low-grade fever in a 79-year-old man with history of coronary heart disease and lung emphysema. Positive Murphy’s sign and mild jaundice at physical examination. Slightly raised laboratory inflammation markers, leukocyte count and serum bilirubin.
Urgent abdominal MRI with MR cholangiopancreatography (MRCP), requested to investigate clinical suspicion of acute cholecystitis with coexistent choledocholithiasis, was performed after the routine USS abdomen.

Unenhanced T1 MRI,T2 weighted MRI,coronal section of MRCP are given here.Identify the abnormalities?

A 25-year-old healthy young woman twisted her neck while being turned over by a big wave on a summer holiday in Spain. Returning home, she went to see a doctor for diffuse right-sided neck pain and dizziness, that had started with the accident. She was referred for an MRI of the cervical spine.
Routine sagittal and transverse, T1-weighted MRI were done.Contrast-enhanced MR-angiography of the supra-aortic arteries performed afterwards.

What is the diagnosis?


Traumatic vertebral artery dissection

Sagittal and transverse, T1-weighted MR images showed a bright hyperintense rim around a small eccentric flow void in the right vertebral artery (VA), which extended along all segments.Contrast-enhanced MR-angiography of the supra-aortic arteries performed afterwards showed an irregular stenosis of the right VA.There were no intracranial aneurysms.

The typical manifestation of vertebral artery dissection (VAD) is posterior headache or neck pain followed by posterior circulation transient ischaemic attack or stroke. Less frequent features include isolated neck pain, cervical spinal cord ischaemia, or radicular symptoms. Asymptomatic VADs have also been reported. The most dreaded and often lethal complication from intracranial extension of VAD is subarachnoid haemorrhage.

60 year old male patient hospitalised due to recurrent febrile episodes each lasting 6-8 days (body temperature up to 39-40°C) during the past three months.His previous medical history recorded acute myocardial infarction 5 years earlier, aorto-coronary bypass plus aortic valve replacement with biological prosthesis two years earlier.At admission, conventional chest radiographs were unremarkable. Laboratory tests disclosed mild leukocytosis (11.000/mmc WBC with 73% neutrophils), raised C-reactive protein levels (64). Initially, haemocultures were persistently negative due to previous empiric antibiotic therapies.

Axial T1-weighted  and Axial T2-weighted MRI were requested after the routine abdominal ultrasound.Identify the lesion and what is the most likely cause for that lesion?

Low back pain in a young athlete

Thursday, April 21, 2011 5 comments

An athletic office worker presented with acute onset low back pain after lifting some office furniture. The pain was non-radiating and localised to the lower lumbar spine. Clinical examination was unremarkable. plain radiography taken. The pain improved after a period of immobilisation in a corset. 

The patient continued his sporting activities. He re-presented 18 months later with persistent low back pain similar to the initial presentation.Repeated the plain radiography.
Identify the abnormalities in these X rays.


Lumbosacral plain radiography shows a left L5 pars defect and repeated plain radiography shows bilateral L5 pars defects

Answer - Lumbar Spondylolysis

A 48-year-old male patient with history of long exposure to dusts (especially plaster) and previous pulmonary tuberculosis (TB) presented with dyspnea on exertion, cough and hemorrhagic sputum. Smoking habit was not reported.
Physical examination revealed decreased intensity of vesicular breathing in right side and diffuse crackles at pulmonary auscultation.

Chest radio-graph and high resolution CT (HRCT) of the chest were performed.Identify the abnormality?


Chest radiograph demonstrated two cavitary lesions presenting with the "air-crescent sign" in medial and upper zones of the lungs, bilaterally.
In high resolution CT (HRCT) of the chest, diffuse fibrotic changes with areas of disruption of normal lung anatomy were present, associated with cavitations, most likely secondary to the previous TB infection. More specifically there were two thick-walled lung cavities containing radiodense "material". One of them presented with the classic "sponge like" appearance.he findings were consistent with the presence of fungus balls within the preexisted cavities.

Answer - Bilateral aspergillomas

Aspergilloma (also known as mycetoma or fungus ball) is a collection of hyphae of fungus, almost with the morphology of a ball, also accumulating cellular debris, which usually colonizes already existing cavities, generally as a result of previous pulmonary diseases, such as sarcoidosis or pulmonary tuberculosis.This colonization usually begins as a nodular thickening of the cavity, formed by the conglomeration of hyphae. When not supportable within the inner wall, the fungus ball falls in the cavity, mixing with cellular debris and having a “sponge like” appearance due to presence of air pockets within the lesion. As there is no attachment to the wall of the cavity, the aspergilloma changes its position with the mobility of the patient.
Aspergillomas are more common in middle-aged patients, being asymptomatic and discovered accidentally. However, sometimes aspergillomas can be found following an episode of haemoptysis, which is a relatively frequent presentation.
The other types of Aspergillus infection allergic bronchopulmonary aspergillosis, semi-invasive aspergillosis, airway-invasive aspergillosis and angioinvasive aspergillosis .
A minority of aspergillomas can resolve spontaneously.In cases of severe haemoptysis surgical resection is indicated.

An 81-year-old man was presenting with mild neck stiffness, headache and fever. Blood tests showed leukocytosis and high C-reactive protein. Low glucose levels and elevated granulocytes and proteins were found in cerebrospinal fluid (CSF). Gram stain and culture of CSF were negative. 
The patient did not have relevant previous medical history. Serologies for HIV-1 and HIV-2 were negative.

Contrast-enhanced brain CT and T1-weighted MRI taken after gadolinium injection.
What are the abnormalities seen in these image?


Contrast-enhanced brain CT showed a low density mass in the frontal lobe with peripheral oedema and a thin enhancing capsule after contrast injection. Hyperdense material on the right occipital horn was also seen, with no significant ependymal enhancement.
T1-weighted images after gadolinium injection showed ring-enhancement related to the capsule and ruptured into lateral ventricle associated to a mild ependymal enhancement.

Answer - Ventriculitis as a complication of a brain abscess


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