Chest and Thorax #1

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56-year-old male patient:
* After kidney transplantion presented with cough

What are the findings?

What are the findings?

Multiple intrapulmonary consolidations with peripheral ground-glass opacities.
No bronchial obstruction.
No pathologically enlarged lymph nodes

What is the most likely diagnosis?

What is the most likely diagnosis?

Fungal infection (Rhizopus infection)

Fungal infections in immunocompromised patients may manifest as intrapulmonary nodules or consolidations with peripheral ground glass opacities. May lead to cavitation, pseudoaneurysm formation and bleeding

Treatment in this case: Anti-fungal systemic therapy
Patient died 5 months thereafter from pulmonary artery aneurysmal bleeding

Abdominal #26

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17-year-old male patient:
* Cholestatic jaundice, otherwise healthy
* Ultrasound showed extensive biliary tree dilatation

What should be done next?

What should be done next?

*MRCP
*Non-contrast MR of the abdomen with MRCP was performed

MRCP Images

MRCP Image

T2 images, axial and coronal

T2 Axial Image
T2 Coronal Image

DWI (left) with ADC map (right)

DWI with ADC map
Describe the findings

Describe the findings

*Marked biliary tree dilatation, common bile duct almost 2 cm wide with abrupt caliber change at the level of the pancreatic head
*No gallstones seen in biliary ducts or the distended gallbladder
*Diffuse pancreatic enlargement with marked restricted diffusion, no peripancreatic fat stranding, free fluid or collections
*Main pancreatic duct narrowing, barely visible

Differential diagnosis includes…

Differential diagnosis includes…

*Pancreatic cancer (especially diffuse infiltrative)
*Pancreatic lymphoma
*Autoimmune pancreatitis

Pancreatic biopsy confirmed autoimmune pancreatitis

Autoimmune pancreatitis is:
– Rare type of chronic pancreatitis
– Associated with IgG4-related sclerosing disease and autoimmune diseases
– Bulky appearance of the pancreas on imaging (“sausage shaped”), main pancreatic duct narrowing and absence of peripancreatic inflammatory changes seen in the acute pancreatitis
– Stenosis of the common bile duct is typical

What is the best course in treatment?

What is the best course in treatment?

Corticosteroids

Follow-up MRCP three weeks later showed improvement after corticosteroid therapy
Cholecystectomy was also performed

Pre-tearment
Follow-up after treatment

Musculoskeletal #40

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85-year-old patient:
– with long-standing left hip pain
– X-rays requested

Showing images from an MRI

T2W Fat Sat
T1W

What is the most likely diagnosis?

What is the most likely diagnosis?

Marked collapse of the articular surface of the left femoral head, along with fragmentation, indicative of osteonecrosis
Secondary dvanced degenerative changes in the hip joint

Reference: Mont MA et al: Nontraumatic osteonecrosis of the femoral head: where do we stand today? A 5-year update. J Bone Joint Surg Am. 102(12):1084-99, 2020

Musculoskeletal #38

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15-year-old patient with left hip pain:
– X-rays requested

What is the next step?

What is the next step?

MRI

T1W
T2W Fat Sat
What is the most likely diagnosis?

What is the most likely diagnosis?

Femoral stress fracture

MRI findings linear low-signal pattern on the medial aspect of the femoral neck, accompanied by bone marrow oedema
Surrounding cortical thickening and solid periosteal reaction

Reference: Shelat NH et al: Pediatric stress fractures: a pictorial essay. Iowa Orthop J. 36:138-46, 2016

Musculoskeletal #36

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35-year-old patient:
– With persistent right hip pain
– Pain exacerbated by abduction/external rotation
– MRI arthrogram requested

Showing images from an MR-arthrography:

What are the findings?

What are the findings?

There is a complete tear in the anterosuperior labrum, located around the 2 o’clock position.

Reference: Schmaranzer F et al: Diagnostic performance of direct traction MR arthrography of the hip: detection of chondral and labral lesions with arthroscopic comparison. Eur Radiol. 25(6):1721-30, 2014

Musculoskeletal #37

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14-year-old patient:
– With left hip pain
– X-rays unremarkable
– MRI requested

Showing T2W Fat Sat images:

What is the next step?

What is the next step?

A CT

What is the diagnosis?

What is the diagnosis?

The MRI revealed a subchondral bone lesion in the superomedial region of the left femoral head, accompanied by noticeable and extensive bone edema in the surrounding area. There is also a minor effusion in the left hip joint.

Differential diagnosis includes either an osteochondral injury or, more likely, osteoid osteoma.

CT confirms the typical features of osteoid osteoma such as subchondral lucency within an internal sclerotic focus and the presence of sclerosis in the surrounding region

Reference: Bhure U et al: Osteoid osteoma: multimodality imaging with focus on hybrid imaging. Eur J Nucl Med Mol Imaging. 46(4):1019-36, 2019

Musculoskeletal #35

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52-year-old patient:
·With chronic right hip pain

MRI findings:

T1W
T1W
T2W Fat Sat
T2W Fat Sat
T2W Fat Sat
What is the underlying reason for the alterations observed in the bone marrow?

What is the underlying reason for the alterations observed in the bone marrow?

– A subchondral insufficiency fracture accompanied by bone marrow edema is noted
– The presence of additional bone marrow edema in the right femoral neck, particularly in the anterolateral region, is likely indicative of an insufficiency response
– Complete cartilage damage is observed

Pelvic insufficiency fractures

-Pelvic insufficiency fractures typically manifest in the lateral aspect of the femoral neck, while stress fractures tend to occur on the medial aspect

-Additionally, damage to the articular surface can result from cartilage loss, a condition distinct from osteonecrosis

Reference: Peh WC et al: Imaging of pelvic insufficiency fractures. Radiographics. 16(2):335-48, 1996

Musculoskeletal #34

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51-year-old patient:
* Present with a painful lump in right thigh
* No history of trauma
* MRI requested

T2W Fat Sat
T2W Fat Sat

What should be the subsequent action to be taken?

What should be the subsequent action to be taken?

– Perform an X-ray to exclude the presence of calcifications
– Confirm that there is no prior history of trauma

The patient had been involved in a car accident five months before the lump was detected

What further actions can we taken to assure an accurate diagnosis?

What further actions can we taken to assure an accurate diagnosis?

Perform a follow-up X-ray in three months

What is the most likely diagnosis?

What is the most likely diagnosis?

Myositis ossificans

It should be distinguished from parosteal osteosarcoma and soft tissue sarcoma

Key imaging characteristics to consider include:

-The zonal phenomenon: Mineralization typically initiates and progresses from the periphery towards the center. The absence of this phenomenon should raise concerns.
-Soft tissue edema is more common around myositis ossificans than around sarcomas. It may show marrow edema, periosteal reaction, and peripheral edema at any stage better expressed

Reference: McCarthy EF et al: Heterotopic ossification: a review. Skeletal Radiol. 34(10):609-19, 2005

Emergency #42

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66-year-old male:
– Presented with cough and dyspnea
– Known metastatic prostate cancer, under radiological surveillance

What do you see?

What do you see?

Progressive course with veiling basal lung opacities and right pleural effusion.
Widespread metastatic sclerosis of the examined chest wall and upper humeri, scapulae and clavicle.