17-year-old patient with leg pain, worsening at night and improving with acetylsalicylic acid intake.
Cortical bone reaction of the tibia mainly characterized by thickening with small lytic zone with central punctate calcification in the epicenter (nidus)
Osteoid osteoma. Characteristic location, imaging and clinical presentation
29-year-old long-distance athlete presenting with 3 weeks of sciatica associated with an increase of running training loads
What do you see?
Unilateral sacral bone edema T2W, STIR hyperintensity associated with hypointense fracture line
Fatigue stress fracture
The sacrum is a frequent site for stress fractures
They can be related to overload occurring in a healthy bone as in this case, or related to osteoporosis (insufficiency stress fractures) in which cases they tend to be bilateral and “h- shaped”
Regarding the following X-Ray:
Metaphysis of the base of the fourth middle phalanx.
Expansile lytic lesion (bubbly appearance) with narrow zone of transition, no cortical break through, and no soft-tissue component.
Enchondroma: Enchondromas have variable imaging appearances but are typically lytic lesions with non-aggressive features. They could show chondroid calcifications (rings and arcs calcification). But in the hands and feet they are typically purely lytic with no matrix.
Eosinophilic granuloma: It mainly involves the diaphysis and does not cross the growth plates. It appears as punched out lytic lesions without sclerotic rim. Imaging appearance in the long bones depends on the phase of the disease which is imaged. It can look aggressive in the initial phase. In the healing phase it can show solid benign periosteal reaction.
Fibrous dysplasia.Usually shows ground-glass matrix but may be completely lucent or sclerotic. Well-circumscribed lesions with no periosteal reaction may lead to premature fusion of growth plates leading to short stature in the lower limbs and bowing deformities (Shepherd’s Crook deformity of the femoral neck)
Diagnosis: Enchondroma
What are the associated syndromes with multiple enchondromas?
Ollier disease: multiple enchondromas are usually confined to one side of the body and limited to the limbs. There is increased risk of chondrosarcoma
Maffucci syndrome: multiple enchondromas with soft-tissue haemangiomas
18-years-old male:
* Rigid abdomen and generalised tenderness
* Pain lower abdomen
* CRP 250
Diagnosis Perforated sigmoid diverticulitis (Hinchey 3 or 4, peritonitis)
> Mesenterial fatty infiltration, free air bubbled outside bowel lumen.
> Also subdiaphragmal free air and free fluid.
> Notice enlarged reactive lymph nodes and peritoneal thickening and enhancement, indicative of peritonitis.
> Patient was operated, free faeces was found in the abdomen.
Hinchey classification of acute diverticulitis:
* Stage 1a: phlegmon
* Stage 1b: diverticulitis with pericolic or mesenteric abscess
* Stage 2: diverticulitis with walled off pelvic abscess
* Stage 3: diverticulitis with generalised purulent peritonitis
* Stage 4: diverticulitis with generalised faecal peritonitis
A 48-year-old male patient:
* HIV (+)
* Presented to emergency with headache, confusion, N/V
What do you see?
Dear Friends,
Today I am showing chest radiographs of a 39-year-old man with high fever and malaise.
What do you see?
Come back on Friday to see the solution!
Continue reading “Dr. Pepe’s Diploma Casebook: CASE 135 – SOLVED!”
16-year-old patient with dystonia, mask-like face, rigidity, dysartria.
What do you see?
What do you see on the following images?
* Right frontal lesion with characteristic high T2 popcorn appearance with dark signal rim.
* T1 high signal areas indicating hemorrhage.
* Significant blooming on SWI.
Dear Friends,
Today I am showing chest radiographs of a 81-years-old man with chest pain five years after left pneumonectomy for lung carcinoma
Diagnosis:
1. Broncho-pleural fistula
2. Intestinal hernia
3. Empyema
4. None of the above
What do you see?
Check the images below, leave your thoughts in the comments section, and come back on Friday for the answer.
Continue reading “Dr. Pepe’s Diploma Casebook: CASE 131 – SOLVED”
45-year-old male with acute chest pain radiating to the back and hypertension
Type A or type B dissection?
Type B, entry zone/intimal tear after left subclavian artery.
False lumen often of lower contrast density due to delayed opacification, as in this case. Origin of coeliac trunk, SMA and right renal artery usually from true lumen and origin of left renal artery usually from false lumen.
Teaching point: Notice that dissection continues in the SMA with intramural thrombus. Usually no fear of bowel ischemia due to arc of Riolan with IMA
Notice in this case: Right renal artery comes off from false lumen and dissection continues in it. Right kidney parenchyma enhances less than left, due to hypoperfusion, high risk of ischemia.
What are possible complications of an aortic dissection?
* Dissection and occlusion of branch vessels
* Abdominal organ ischaemia
* Distal thromboembolism
* Aneurysmal dilatation: this is an indication for endovascular or surgical intervention
* Aortic rupture
What is the appropriate management?
Aggressive blood pressure control with beta blockers as they reduce both blood pressure and also heart rate hence reduce extra pressure on the aortic wall.
In this case: Complicated type B dissection and persistent hypertension led to Bentall thoracic surgery with stent, due to risk of proximal continuation in ascending aorta, coronaries and neck vessels.
