Emergency #14 – Flashcard

18-years-old male:
* Rigid abdomen and generalised tenderness
* Pain lower abdomen
* CRP 250

What do you see? Perforated appendicitis? What is your diagnosis?

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

Musculoskeletal #3 – Long case

Axial CT abdomen bone window

Axial CT abdomen soft tissue window

Where is the lesion?

Left iliac bone

What are the radiological characteristics/findings?

Large lytic lesion with wide zone of transition, cortical destruction, and large soft tissue component.
No specific matrix.

What is the differential diagnosis of an aggressive iliac bone lesion?

* Metastasis
* Plasmacytoma: solitary plasma cell tumor expansile lytic lesion with bone destruction and soft tissue component. Usually shows low signal intensity on T2 with variable post contrast enhancement. 
* Chondrosarcoma: malignant cartilage tumor destructive lytic lesion with intralesional rings and arcs calcification (chondroid matrix). High signal intensity on T2. 

What is the most likely diagnosis?

Plasmacytoma

Cáceres’ Corner Case 208 – SOLVED!

Dear Friends,

Presenting today radiographs of a 65-year-old man with back pain.

What do you see?

Click here to see the images


Click here to see the answer

Findings: PA chest radiograph shows an ill-defined opacity in the right middle lung field (A, asterisk), located in the anterior clear space in the lateral view (B, arrows). The anterior arch of the 4th right rib is missing.

A cone down view demonstrates an expanding lytic lesion in the anterior arch of the 4th right rib (C, asterisk), confirmed with CT (D and E, red arrows).

I thought this was an easy case, but I am disappointed because some of you missed a collapsed vertebra (F, circle), not present three years earlier (G, circle). Sagittal CT confirms it as well as additional affectation of L1 and posterior elements of D10 (H, red arrows).

In a patient with a port-a-cath, the presence of multiple lytic lesion suggests metastatic disease as the first possibility.
 
Final diagnosis: Carcinoma of esophagus with bone metastases

Congratulations to Andy, who was the first and to Archana Reddy.t who discovered the collapsed vertebra.

Teaching point: this case is similar to the previous one and the teaching point is the same: look at the underlying rib. And, above all, don’t forget to examine the rest of the bones!