What do you see?
Ivory osteoma of the skull
Sclerotic lesion arising from the outer layer of the left parietal bone with narrow zone of transition. No cortical break through or soft tissue component. The medullary cavity is intact
53-year-old male:
– Hemodialysis patient
– Presents with a very large scrotum, size of a football
– Patient is not sick, no fever
– Laboratory results are normal
– US: Incarcerated inguinal hernia? Hydrocele? Malignancy?
Diagnosis: Extensive scrotal lymphoedema
– Extensive scrotal wall thickening associated with diffuse lymphoedema extending to the base of penis not involving the penile corpora
– No extension into the deep subcutaneous tissue planes, inguinal canal, or muscles
– No extension to the groin or lower abdomen
– No inguinal adenopathy
– Both testicles are morphologically normal with no associated hydroceles
– There is no associated soft-tissue mass
A 6-year-old boy presenting to emergency department with headache, nausea, and vomiting
Intra-axial cystic lesion with mass effect shows CSF signal intensity on all sequences, without enhancement and perilesional edema
Differential diagnosis include
* Parasitic diseases (hydatid cyst) spheric
* Neuroglial cyst may have surrounding gliosis
* Porencephalic cyst surrounding gliosis, communicates with ventricle
Same cystic lesion in superior lobe of left lung
Hydatid cyst disease
Both lesions were treated by surgery
A 55-year-old male. Pain left flank and macroscopic hematuria.
Diagnosis: Left hydronephrosis and hydroureter with proximal obstructing ureter stone. Fat stranding surrounding left kidney, “blow out” of urine
A 6-year-old child. Cough since months. DD, allergy, asthma
What do you see?
Diagnosis: Pneumonia lingula (consolidation obscuring left heart border but not left hemidiaphragm)
Mycoplasma (bacterial) pneumonia
72-year-old alcoholic patient with intractable dorsal pain and legs numbness and weakness.
What do you see?
Thoracic spine compression fracture with posterior displacement of the posterior wall of the vertebral body compromising the spinal canal, cord compression and associated myelopathy. T2W image shows fluid and hypointense bubble-like artifact consistent with vacuum cleft in the collapsed anterior vertebral body
Kümmel disease (osteonecrosis and collapse of the vertebral body)
Intravertebral vacuum cleft and fluid within the collapsed vertebral body is a characteristic feature
Differential diagnosis includes a pathologic (tumoral) fracture, and the presence of air strongly favors osteonecrosis
Would you like to see a complementary case?
MR T2-weighted and CT images to highlight the characteristic features of Kümmel disease
Intravertebral fluid seen on T2 image and air on CT image
A 20-year-old male.
Fell off motor. Pain and swelling on the right wrist/hand.
What do you see?
Scaphoid fracture with perilunate dislocation. Also oblique non-displaced fracture of 3rd metacarpal
Dear Friends,
welcome to the second trimester of 2021! Showing today PA chest radiograph of a 66-year-old man with chest pain without any other symptoms.
What do you see?
More images will be shown on Tuesday and Wednesday.
Dear friends, showing today the lateral chest view.
Does it help?
Today I am showing an enhanced axial CT.
What would be your diagnosis?
Findings: PA chest radiograph shows an increase in size and opacity of the left hilum
(A, arrow), due to superimposition of a well-defined posterior mass visible in the lateral view (B, arrow). At first glance, the appearance of the mass is compatible with an extrapulmonary lesion. However, there is retrocardiac nodule in the PA view (A, red arrow), suggesting a metastasis from an intrapulmonary mass.
Enhanced axial CT confirms an irregular pulmonary mass (C, arrow), which is invading the chest wall, as confirmed by the displaced intercostal artery (C, yellow arrow) and erosion of the underlying rib (D, circle).
Caudal slices confirm the retrocardiac nodule (E, white arrow) and additional nodules (E-F, red arrows) representing pleural implants.
Biopsy of the main mass returned as lung carcinoma.
Final diagnosis: Carcinoma of the lung simulating an enlarged hilum in the PA view.
Congratulations to Dr LeLam and thaf1212, who detected the retrocardiac nodule, which is the clue to determine that the main mass is intrapulmonary.
Teaching point: Remember that one of the three causes of unilateral enlarged hilum is superposition of a pulmonary opacity either in front or behind the hilum (the other two are enlarged hilar lymph nodes and increase in size of the pulmonary artery)
Dear Friends,
This week’s case follows the pattern of a “Meet the Examiner” presentation, with questions and answers similar to a real examination. Take your time before scrolling down for the answer.
There will be no new blog posts over the Easter period. The next case will be published on Monday, April 5, 2021.
The images belong to a 65-year-old woman with cough and low-grade fever. The referred physician demanded a chest CT.
What would be your diagnosis?
1. Pneumonia
2. Pulmonary infarction
3. Peripheral adenocarcinoma
4. Any of the above
Findings: unenhanced axial and sagittal CTs show LLL airspace disease with a surrounding halo (B-C arrows). In my opinion, the sensible answer is 4. Any of the above, although I liked adenocarcinoma because of the peripheral halo and air bubbles within the infiltrate (A, circle).
Patient was diagnosed of pneumonia and treated with antibiotics, without improvement. Chest radiographs taken 13 days later shows progression of the LLL opacity (A and B, arrows).
A CT was recommended.
Two axial and one sagittal views are selected. What would your diagnosis be:
1. Peripheral adenocarcinoma
2. Tuberculosis
3. Covid pneumonia
4. None of the above
In comparison with the previous CT, the LLL infiltrate has increased markedly in less than two weeks. An upper halo persists (A and C, arrows). A small infiltrate has appeared at the right lung base (B, arrow) In my opinion, this rapid progression rules out carcinoma and TB. A PCR was negative. Blood tests were not remarkable. It was considered that the patient had an unusual pneumonia, and the antibiotic was changed.
The fever disappeared with the new antibiotic and the patient improved moderately. A new CT was taken three weeks later. What would your diagnosis be?
1. Löffler syndrome
2. Goodpasture syndrome
3. Cryptogenic organizing pneumonia
4. Any of the above
Findings: The most striking finding is the disappearance of the LLL infiltrate and the apparition of two new areas of airspace disease in RLL and LLL (A, arrows). There is a halo sign in the LUL infiltrate (B, arrows) and a negative halo in the RLL infiltrate (B and C, arrows).
This change of location of the opacities falls in the category of migratory infiltrates which are caused by several diseases, some of them listed in the previous questions.
The patient had no risk factors for parasitic infection and no peripheral eosinophilia, ruling out Löffler syndrome. Renal function was not altered, excluding Goodpasture’s syndrome
The combination of migratory infiltrates and a negative halo sign was very suggestive of a cryptogenetic organizing pneumonia, that was confirmed with BAL and an excellent response to corticosteroid treatment.
Final diagnosis: cryptogenic organizing pneumonia
Organizing pneumonia (OP) is a clinical, radiological and histological entity usually associated to other pathologies. The idiopathic form of OP is called cryptogenic organizing pneumonia (COP).
Clinical manifestations of COP begin with a mild flu-like illness with fever, cough and malaise.
In chest imaging it may appear as localized airspace opacity that may be confused with ordinary pneumonia, adenocarcinoma or aspiration, among others. The lack of response to antibiotic treatment and the peripheral location may help in suggesting the diagnosis.
I am presenting this case because it shows two features the help in the diagnosis: migratory infiltrates and the reverse halo sign.
Migratory infiltrates are not unique to COP, but they occur in a limited number of diseases (Loeffler syndrome, vasculitis, etc.) and their presence in the adequate clinical setting should suggest COP.
The reverse halo was originally described as specific of COP, but since then it has been seen in many other entities. It is defined as a central ground-glass opacity surrounded by denser consolidation of crescentic shape or a complete ring. It is visible in about 20% of cases.
In this patient the combination of both signs strongly pointed towards COP, that was confirmed and responded brilliantly to corticoid treatment.
To complete the presentation, I am showing two more examples of reversed halo and migratory infiltrates (CASES 1 and 2, below).
CASE 1. 61-year-old woman with COP and basilar infiltrates (A, arrows). During treatment, coronal and axial CTs show bilateral and symmetrical reversed halo signs (B and C, arrows)
CASE 2. 51-year-old woman with COP and migratory pulmonary infiltrates (A and B). The second CT shows nice examples of reversed halo sign (B, circle), better seen in the cone down axial view (C, arrows).
Follow Dr. Pepe’s advice:
1. Localized cryptogenic organizing pneumonia may mimic other pulmonary processes
2. Migrating infiltrates and reverse halo sign (or both) are helpful in suspecting COP
Elbow pain after a fall. What do you see?
Large joint effusion with the displacement of the anterior fat pad. Mild posterior soft tissue swelling over the olecranon. Fracture line along the lateral aspect of the radial neck. Radial head and articular surface are normal
Nondisplaced radial head fracture
– Check not only the bones and joints but also the soft tissues
– Search and interpret the findings in two different positions
– Pain always withholds a story behind
