Long Case Set 02. Dr Raviraj Uppoor. Dr Sameer Shamshuddin. Consultant Radiologist Cumberland Infirmary, Carlisle, UK

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1 Long Case Set 02 Dr Raviraj Uppoor MBBS, DMRD, DNB, FRCR Consultant Radiologist Cumberland Infirmary, Carlisle, UK Dr Sameer Shamshuddin MBBS, DMRD, FRCR Consultant Radiologist Royal Lancaster Infirmary, UK

2 Packet 2: Case 1 55 year old male Abdominal distension

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6 Packet 2: Case 2 20 year old male with right shoulder pain

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9 Post contrast T 1 Coronal & Axial

10 Packet 2: Case 3 20 year old female Recent onset of convulsions

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13 Packet 2: Case 4 50 year old female Dyspnea

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16 Packet 2: Case 5 1.5year old girl Failure to thrive

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19 Packet 2: Case 6 65 year old male Backache of 2 month duration

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24 Case 1 Observations & interpretation: AXR & CXR: Show grossly dilated inverted 'U' shaped ahaustral large bowel loop. Limbs of this loop are pointing to pelvis and the dome is in left hypochondrium & overlapping T10 vertebra. - 2 No air fluid level seen. Rests of the bowel loops are dilated. No signs of free peritoneal air nd AXR shows flatus tube in situ with deflated large bowel loop- indicating that the dilated inverted 'U' shaped loop is consistent with sigmoid colon. - 1

25 Diagnosis & DD: Sigmoid volvulus. - 1 DD: pseudo-obstruction- can be differentiated by limited contrast enema. -1 Further work up & management: Inform the surgeon. - 1 Contrast enema (can be therapeutic) - 1 To work-up further for underlying cause by CT

26 Case 2: Observations & interpretation: Radiographs of both shoulder: frontal & axial: Patchy sclerotic areas in visualized bones. - 1 Snow cap appearance of left humeral head- indicating likely AVN.- 1/2 Rt humeral head & glenoid fossa articular margins are showing erosions. 1/2 Decreased right shoulder joint space. No dislocation. CE MRI Enhancing periarticular soft tissue & synovium.- 1 Joint effusion & fluid around long head of biceps. Marrow edema & articular margin erosions.- 1

27 Diagnosis & differential diagnosis: Septic arthritis right shoulder with signs of Sickle cell disease - 1 DD: Tubercular arthritis. - 1 Management & Further work up: Aspiration of joint effusion under USG guidance and send for C/S - 1 Screen for SCD- patient & family members - 1

28 Case 3 Observations & interpretation: Radiograph of LS spine: B/L SI joint arthritis (sclerosis); Rt > Lt. Articular margin erosions (ilial aspect) on right side. - 1 Otherwise unremarkable LSS. Normal appearing psoas shadow on left side; Rt psoas not well made out. - 1 CT brain (NCCT & CECT): Ring enhancing lesions in right cerebellum & left high parietal lobe with mild to moderate perifocal edema. - 1 No midline shift or herniation, No hydrocephalus. No basal enhancing exudates. - 1 No intra cranial hemorrhage.

29 Diagnosis & differential diagnosis: Bilateral SI arthritis & ring enhancing granulomas in brain- likely tubercular etiology. -1 DD- Other bacterial or fungal cause - 1 Metastasis- unlikely as SI joints are involved. Management & Further work up: Image guided aspiration or biopsy from SI joint-1 Cross sectional imaging of abdomen to look for psoas abscess and possible bowel involvement. CXR to search for chest focus. - 1

30 Case 4 Observations & interpretations: CXR: Predominantly coarse reticular shadowing with honey combing evenly distributed in all the zones. - 1 Lung volume restricted. Possible dilated esophagus (tubular lucency in right para cardiac area) - 1 No pleural effusions or pneumothorax. Normal mediastinal shadow. Normal size cardia. Chest wall soft tissue & bony thorax- normal. CT Chest (HRCT): Predominantly peripheral 2/3rd lung involvement with coarse interstitial septal thickening. - 1 Traction bronchiectasis and honey combing seen in lower regions of both lungs. 1/2 No pleural plaques/ calcifications seen, - 1/2 No mass lesions in both lungs. Dilated lower esophagus.

31 Diagnosis & DD: Systemic sclerosis with interstitial fibrosis. - 1 DD- Idiopathic interstitial fibrosis less likely as esophagus involvement is not known. Asbestosis related lung disease- less likely no pleural plaques. - 1 Sarcoidosis: less likely as no nodal enlargement. Management & further work up: UGI endoscopy & contrast studies- to know the extent of esophageal & small bowel involvement. - 1 Vascular studies of extremities to know the vascular involvement. - 1

32 Case 5 Observations & interpretation: USG abdomen: shows numerous hypoechoic lesions in liver. - 1 Left supra renal mass lesion. - 1 Spleen and kidneys are normal CECT Abdomen: USG findings are confirmed. - 1 No obvious any other retro peritoneal or peritoneal mass, Normal appearing kidneys. - 1 No free intra peritoneal fluid.

33 Diagnosis & differentials Left supra renal neuroblastoma with liver mets, - 1 DD- Lymphoma- less likely as there is adrenal involvement. - 1 Management & Further work up: Image guided liver mets biopsy. - 1 MIBG scan to look for skeletal mets. - 1

34 Case 6 Observations & Interpretation: LS radiographs: Partial erosion / destruction of L4 & L5 vertebral bodies and its posterior elements. - 1 Disc space (L4/5 & L5/S1) narrowed.- 1/2 No significant soft tissue components in pre/ para vertebral regions. -1/2 Degenerative changes seen in lumbar spine, otherwise unremarkable rest of the LSS. MRI: LSS x-ray findings are confirmed. L4 & 5 vertebrae & in between disc involvement with posterior element involvement are confirmed. - 1 Soft tissue components seen with spinal canal extension. - 1 CXR: Left upper zone opacity appears like fibrotic band. 1/2 Otherwise unremarkable lungs & heart. No pleural effusion. Bony thorax appears normal. CT Thorax: Left upper zone opacity on CXR corresponds to a spiculated mass in apical segment of left upper lobe. 1/2 Rest NAD.

35 Diagnosis & DD: Ca lung with spinal mets. - 1 DD: Infective or TB spondylo-discitis with left upper lobe fibrosis - 1 Other infective cause. Further work up & management: Image guided biopsy or aspiration of L4/5 soft tissue. - 1

36 Thank You Dr Sameer Shamshuddin