Cáceres’ Corner Case 240

Dear Friends,

Today’s case has been provided by my good friend Victor Pineda. Radiographs belong to a 36-year-old man with cough and fever. For comparison, I am including radiographs taken nine years earlier.

Diagnosis:

1. Chronic TB changes
2. Endobronchial lesion
3. Congenital lesion
4. None of the above

What do you see? Come back on Friday to see the answer.

Head and Neck – Flashcard #2

What do you see on the following images?

Click here to see the answer

Dehiscent jugular bulb

The jugular bulb bulges into the left middle ear cavity with absence of the sigmoid plate separating the jugular bulb from the middle ear in keeping with dehiscent jugular bulb.

It is one of the causes of pulsatile tinnitus, patients can also present with conductive hearing loss if the jugular vein contacts the tympanic membrane.

Cáceres Corner Case – Vignette 237

Dear Friends,

If you are Sci-Fi fans I recommend this week the novel “The windup girl” and the short stories collection “Pump six” by Paolo Bacigalupi.

Today’s radiographs belong to a 57-year-old woman with cough and fever. She had an osteosarcoma of the lower limb removed eight years earlier.

Diagnosis:

1. Carcinoma
2. Pneumonia
3. Tuberculosis
4. Any of the above

Click here to see the answer

Findings: PA chest shows haziness of left hemithorax, elevation of the left hilum (A, arrow) and luftsichel (A, red arrow), typical signs of LUL collapse. The collapse is confirmed by the marked displacement of the major fissure on the lateral view (B, arrows). At this point, the best diagnosis is an endobronchial lesion, most likely carcinoma

Click here to see more images

CT with and without contrast enhancement was done. What would be your diagnosis?

1. Carcinoid
2. Carcinoma
3. Endobronchial TB
4. Endobronchial metastasis

Click here to see the answer

Findings: unenhanced CT demonstrates LUL collapse with coarse calcification that seems to follow the path of the bronchus (C, arrows). Enhanced CT shows a non-enhancing endobronchial lesion at the origin of the LUL (D, arrow).

Of the diagnosis offered, the coarse calcification makes carcinoma very unlikely and suggests a carcinoid tumor, although I would expect some enhancement after contrast injection. Given the previous history of osteogenic sarcoma, endobronchial metastases should be considered. I would vote against TB.

Bronchoscopy found a mass occluding the LUL bronchus. Biopsy returned the diagnosis of osteosarcoma.

Final diagnosis: endobronchial metastases from osteogenic sarcoma.

I am showing this unusual case because it is my first and probably my last case of endobronchial metastasis from osteogenic sarcoma. It is also unusual the prolonged span of time (eight years) between the removal of the primary and the appearance of the metastasis.
 
Remember that the most common cause of LUL collapse is first and foremost a carcinoma of the lung. Endobronchial metastases can give a similar appearance and are more common in tumors of breast, kidney and melanoma although they may occur in any type of tumor, as in the present case.

Emergency #21 – Long case

A 21-year-old male:
* Collapse twice
* Loss of strength of right arm
* Trouble finding words
* Headache

What are the CT Findings?

CT Findings

* No abnormalities were seen.
* No bleeding.
* No signs of recent ischemia.

Patient develops fever. Cannot bend his neck properly. When asked, he has been traveling recently to Thailand

What further imaging could help us?

What are the MRI findings?

MRI findings

* Two areas left frontal and left parietal with T2/FLAIR hyperintense swelling/edema of cortex and subcortical white matter, with diffusion restriction and patchy, gyriform cortical enhancement
* Diffusely leptomeningeal enhancement
* No ring-enhancing lesions. No white matter vasogenic or cytotoxic edema

What is the most likely diagnosis?

Diganosis

Cerebritis (precursor of abscess) and meningitis. Not yet an abscess

Note: Encephalitis means inflammation of PARENCHYMA

Differential diagnosis of meningitis:
* Leptomeningeal carcinomatosis
* Sarcoidosis and other granulomatous diseases
* Vasculitis
* Connective tissue diseases

Viral inflammatory cause for symptoms was confirmed with lumbar puncture and patient was treated with IV anti-viral treatment.

Musculoskeletal #10 – Flashcard

29-year-old long-distance athlete presenting with 3 weeks of sciatica associated with an increase of running training loads

What do you see?

Click here to see the answer

IMAGING FINDINGS:

Unilateral sacral bone edema T2W, STIR hyperintensity associated with hypointense fracture line

DIAGNOSIS:

Fatigue stress fracture

TEACHING POINTS:

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”

Abdominal #9 – Flashcard

31-year-old male with:

* Right upper quadrant & epigastric pain
* History of gastric bypass surgery

What aquatic sign is used for the finding in the red circle?

Whirlpool sign

What is shown at the blue arrow?

The transition point from dilated small bowel (with the “small bowel feces sign”) to non-dilated small bowel at the site of internal herniation through a mesenteric defect.