Case of the Week

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This Week’s Case of the week From 12/30/18

History: Abdominal pain.

What are the findings? Multiple left renal cysts, diffuse colonic low-density wall thickening with thickened folds and mild adjacent stranding from the proximal transverse colon to the proximal rectum/distal sigmoid, dominant left-sided renal cyst and multiple parapelvic cysts, moderately enlarged prostate gland

What is the differential diagnosis for the findings most likely to cause the patient’s symptoms? C. Dificile, Inflammatory colitis, Ischemia

What is the most likely of these diagnoses and why? C. dificile colitis because of a low-density boggy colon with diffuse segmental inflammatory change not extending to the distal rectum.

This Week’s Case of the Week From 12/23/18:

History: Status post injury. Wrist pain.

What is the diagnosis? Non displaced transverse distal pole scaphoid fracture

How is it typically treated? Either casting or pinning due to the risk of non-union (10% of cases)

This Week’s Case of the Week From 12/16/18:

History: Status post-injury. Right hip pain.

What are the most likely diagnoses? Multiple fractures- Inferior pubic ramus, superior pubic ramus, and right sacral ala.

What do you need to tell the emergency physician? Potentially an unstable fracture- immobilization recommended.

This Week’s Case of the Week From 12/9/18:

History: Status post thyroidectomy for thyroid cancer.

What is the most likely diagnosis? Residual tissue in the right thyroid bed.

Answers To Case of the Week From 12/2/18

History: Right hip mass.

What is the most likely diagnosis? Pseudoanuerysm of the right common femoral artery.

Answers To Case of the Week From 11/25/18

History: Leg Pain

What are the most likely diagnoses? Enchondroma or bone infarct

What do you do next? Leave alone. Correlate with metabolic/drug use.

Answers To Case of the Week From 11/18/18

History: Urinary Frequency/Lung cancer

What is the exam? FDG PET-CT Scan

What are the findings? Diffusely increased uptake at the prostate gland. Left external iliac hypermetabolic nodes. Probable left ureteral uptake.

What is the most likely diagnosis? Prostatitis. Left external iliac adenopathy-? neoplastic.

Answers To Case of the Week From 11/11/18

History: None provided.

What are the findings? Abnormal segmentation and deformity of the sacrum

What is the most likely diagnosis? Partial sacral agenesis.

Answers To Case of the Week From 11/4/18

History: Abdominal pain.

What are the findings? Distal ileal bowel loops with wall thickening, adjacent collection anterior to the thickened loops and superior to bladder containing air and fluid, adjacent stranding and separation of small bowel loops, mild thickening of the appendix, multiple borderline nodes,

What is the most likely diagnosis? Inflammatory bowel disease of the small bowel (Crohn’s) with adjacent abscess and/or fistula formation, appendiceal inflammation likely reactive.

Answers To Case of the Week From 10/27/18

History: Status post surgery

What are the findings? Right sided hydronephrosis on initial CTA of the chest. Increased density adjacent to the proximal ureter on delayed imaging, likely contrast material.

What is the most likely diagnosis to tie all the findings together? Active right sided urine leak, post traumatic injury to the right ureter.

12 hours ago

Now

Answers To Case of the Week From 10/20/18

History: Chest pain.

What are all the relevant findings? Lung nodules, mediastinal and hilar adenopathy, right sided plueral effusion, periportal/peripancreatic adenopathy, paraaortic retroperitoneal adenopathy, bulky heterogeneous uterine bed mass,

What is the most likely diagnosis to tie all the findings together? Uterine/endometrial cancer with hematogenously spread metastatic disease

Answers To Case of the Week From 10/13/18

History: Fatigue

What are the most likely diagnoses? Left atrial myxoma- most likely. Hypervascular metastasis also within the differential diagnosis.

Answers To Case of the Week From 10/6/18

History: Fever

What kind of study is this? Indium-labeled White Blood Cell Scan

What question about this study do you need to ask in order to come up with a diagnosis? What is the timing of the images- immediate, 4 hours or 24 hours

What are the most likely diagnoses? If immediate or 4-hour imaging increased lung uptake may be related to normal variant margination. If at 24 hours, it is suspicious for pulmonary infection/inflammation.

Answers To Case of the Week From 9/30/18:

History: Abdominal pain that recently went away and came back again.

What are the findings? Free air, peritoneal thickening and enhancement, dilated small bowel loops with transition point, fluid collections in Morrison’s pouch and pelvis

What are the most likely diagnoses? Peritonitis. Abscesses. Small Bowel Obstruction related to inflammation. Consider most likely ruptured appendicitis. Other etiologies- rip-roaring inflammatory bowel disease with perforation.

What do you need to tell the clinician? Recommend emergently starting antibiotics. Follow with surgery.

Answers To Case of the Week From 9/23/18:

History: Small Bowel Mass

What kind of study is this? Netspot/ Dotatate Gallium 68

What is the recommendation for the adrenal glands in this case? Normal adrenal uptake. Normal finding. No further workup needed.

Answers To Case of the Week From 9/16/18

History: Atrial fibrillation

What are the findings/most likely diagnoses?

Hyperdense liver- consider changes related to amiodorone use given the history

Left adrenal nodules with coarse calcifications

What is the differential?

Hyperdense liver- also consider hemochromatosis, transfusions, Wilson’s disease

Left adrenal nodules with coarse calcifications- granulomatous disease, adrenal adenomas with prior hemorrhage, less likely mets, etc.

Answers To Case of the Week From 9/9/18

History: Status post-injury.

What are the findings/diagnoses? Osseous fragment posterior to C5. ? Cortication.

What is the differential? C5 spinous process fracture vs. secondary ossification center/ligamentous calcification

What should you do next? Confirm with a physical examination. And, if unsure, recommend MRI of the cervical spine.

Answers To Case of the Week From 9/2/18

History: Status post fall three weeks ago.

What are the findings/diagnoses? Avulsion type fractures at the dorsal navicular and the lateral calcaneus

Answers To Case of the Week From 8/26/18

History: Abdominal pain.

What are the findings? Inflammation changes centered adjacent to the mid sigmoid colon with thickened walls, diverticuli, and adjacent extraluminal air. There is a pocket posterior to the sigmoid colon containing oral contrast, probably an enlarged and inflammed diverticulum. There is no free air. Also, there is mild thickening and adjacent inflammatory change at the tip of the appendix

What is the most likely cause for the main diagnosis? Acute diverticulitis with contained perforation.

What else is also within the differential diagnosis, but is less likely? Inflammed appendix/appendicitis. (less likely and not the center of inflammation), more likely reactive change.

How would you manage this case? Admit to the hospital under the care of surgery. Close follow up.

Answers To Case of the Week From 8/19/18

History: Abdominal pain.

What are the findings? Gastric sleeve/post-bariatric surgery. Right anterior abdominal wall collection with adjacent stranding and inflammatory change.

What is the most likely cause for the main diagnosis? Collection- most likely postoperative hematoma or infected hematoma/abscess. Likely related to prior bariatric surgery.

How would you manage this case? Consult with surgery- likely ultrasound guided abscess drainage

Answers To Case of the Week From 8/12/18

History: Shin pain.

What are the findings? Edema in the bone and subcutaneous edema on STIR sequence with adjacent anterior tibial cortical thickening. On T1, enhancement of the subcutaneous soft tissues and enhancement of the tibial marrow adjacent to the swelling.

Give the most likely diagnosis: Anterior shin cellulitis with adjacent tibial osteomyelitis

Answers To Case of the Week From 8/5/18:

History: Pelvic pain.

What are the findings? Gallium scan and SPECT shows increased activity at the right sacroiliac joint. MRI STIR sequence shows marrow edema at the right sacroiliac joint.

Give the most likely diagnosis? sacroiliitis at the right sacroiliac joint. Differential also includes septic joint (less likely)

Answers To Case of the Week From 7/29/18:

History: Abdominal Pain.

Please give the most important finding: Portal venous gas

What is the most likely source? Proximal large bowel wall thickening/ischemia

How would you manage this case? Surgical emergency- Call surgery

Answers To Case of the Week From 7/22/18:

History: Abdominal Pain

Findings: Uncinate process cystic density lesion, hyperdense renal mass, right-sided pleural effusion

Most appropriate management: MRI of the abdomen with and without contrast

Answers To Case of the Week From 7/15/18:

History: None provided.

Type of Study: Cystogram

Diagnoses: Cystogram showing left-sided vesicoureteral reflux and a vesicoenteric fistula to the sigmoid colon.

Answers To Case of the Week From 7/8/18:

History: Paroxysmal Atrial Fibrillation

Findings: Right coronary artery with take off from the left aortic cusp and coursing between the aorta and pulmonary artery, probable hepatic cysts

Most likely diagnosis: Anomalous right coronary artery, possibly cause for symptoms

Answers To Case of the Week From 7/1/18:

History: Chest pain.

Findings: Moderate apical, anterior and septal apical, and anterior and anteroseptal mid ventricular reversibility with normal gated wall motion

Diagnosis with vascular territories: Moderate to large ischemia in the mid LAD territory

Answers To Case Of The Week From 6/24/18

History: R/O sinus disease

Findings: Lucency within the midline maxillary bone adjacent to a residual left maxillary incisor

Diagnosis: Maxillary dental abscess.

Answers To Case of the Week From 6/17/18

History: Colon Cancer. Post-hepatic intra-arterial injection for pre-embolization mapping.

What are the findings? Uptake in the right hepatic lobe. Uptake in the stomach, salivary gland, and thyroid gland with sparing of the brain. Minimal lung uptake.

What are the diagnoses? Right hepatic arterial injection without obstruction. Tc99m-pertechnetate contamination. Minimal shunting to the lungs.

Answers To Case of the Week From 6/9/18

History: Cough

What are the findings? Mass like lesion filling the anterior clear space and not conforming to the typical segmental anatomy. Consider most likely an anterior mediastinal mass

Differential diagnosis: Germ cell tumor, lymphoma, thymic mass

Answers To Case of the Week From 6/2/18

History: Sinus disease
What are the findings? Round circumscribed nodule just lateral to the left optic nerve within the intraconal space.

What is the differential diagnosis? Most common etiologies are a hemangioma or neural sheath tumor. Other less likely possibilities can include lymphoma or metastatic disease.

Answers To Case of the Week From 5/26/18

History: Foot pain.

Please give diagnosis: Homolateral Lisfranc fracture dislocation.

Answers To Case of the Week From 5/19/18

History: Blurry vision

What are the findings? Thickening of medial and superior rectus muscles

What is the most likely diagnosis? Thyroid opthalmopathy

Answers To Case of the Week From 5/12/18

History: Foot pain.

Please give all the findings: A bit of an eye test- Multiple fractures including a 1st proximal phalanx intraarticular corner fracture, 2nd through 4th proximal metaphyseal metatarsal fractures, and a 5th distal metatarsal metaphyseal fracture

Answers To Case of the Week From 5/5/18

History: Ankle pain.
What are the findings and the diagnosis? Large gap in distal Achilles tendon, Achilles Tendon Rupture
What are the most important findings to tell the clinician? The size of the gap and the location of the tendon with respect to the calcaneal insertion

Answers To Case of the Week From 4/29/18

History: None.

What are the findings? Diaphragm defect at the posterior medical left diagphram containing stomach

What is the diagnosis? Diaphragm hernia- Bochdalek type

Answers To Case of the Week From 4/22/18:

History: Decubitus Ulceration. Tagged White Blood Cell SPECT-CT scan.

What are the findings? Fused tagged white blood cell scan with fragmentation of the left ischial tuberosity with decreased uptake.

What is the most likely diagnosis? Necrosis of the left ischial tuberosity

Answers To Case of the Week From 4/15/18:
History: Status post trauma. Neck Pain.

What are the findings and likely diagnosis? Dorsally displaced dens fracture/ Type II dens fracture

Answers to Case of the Week From 4/8/18

History: Hip pain

What are the findings and likely diagnosis? Right femoral head double line sign with adjacent marrow edema, subacute avascular necrosis of the hip

History: Abdominal pain.

What are the findings and likely diagnoses? Dilated left renal collecting system and ureter, likely related to herniation into inguinal scale. (More Challenging Diagnosis) Abrupt caliber change at the distal common bile duct. ? etiology

Answers to Case of the Week From 3/25/18

History: Arm pain.

What is the differential diagnosis? Fibrous dysplasia, Aneurysmal bone cyst, Giant cell tumor

Answers to Case of the Week From 3/18/18

History: Neck pain. History of prior surgery.

What is the most likely diagnosis? Interval loosening of the hardware at the C3 pedicle.

1st video – 2 years ago,

2nd video- today

Answers to Case of the Week From 3/11/18

History: Back pain.

What is the most likely diagnosis? Interval Development of Pagetoid changes at L4 with picture frame vertebral body and suggestion of trabecular thickening.

today 2 years ago

Answers to Case of the Week From 3/4/18

History: Bleeding

What is the most likely diagnosis? Early embryonic demise

What else do you need to do? Confirm with realtime ultrasound and/or video because of potential errors with M-mode. Call the doctor.

Answers to Case of the Week From 2/25/18

History: Head swelling/lump.

What is the diagnosis? Pott’s Puffy Tumor

Answers to Case of the Week From 2/18/18

History: Jaw pain.

What is the diagnosis? Sialoadenitis

Answers to Case of the Week From 2/11/18:

History: Right Lower Quadrant Pain

What are the diagnoses? Right-sided delayed nephrogram with findings suggestive of a distal ureteral stone. Multiple appendicoliths within a borderline sized appendix.

What would you tell the referring doctor? Symptoms are most likely related to a distal urinary tract stone with obstruction. Appendicoliths and borderline sized appendix are likely chronic, possibly related to prior inflammation. Recommend clinical follow-up with a surgeon.

Answers to Case of the Week From 2/4/18

History: Dysarthria

What is the diagnosis? ALS

Answers to Case of the Week From 1/28/18

History: Prostate Cancer

What do you want to do next? Bone SPECT

What is the differential diagnosis? Degenerative disease, lumbar compression fracture, metastatic disease, and overlying contamination (the ultimate diagnosis)

Answers to Case of the Week From 1/21/18

History: Chest Pain. Shortness of Breath.

What are the diagnoses? Calcific pericarditis and right-sided pleural effusion with adjacent atelectasis or pneumonia.

Answers to Case of the Week From 1/14/18

History: No history.

What kind of scan is this? Tc-99m MDP Bone SPECT

What is the most likely diagnosis? Left rib fractures. Left costovertebral angle post-traumatic vs. degenerative change.

Answers to Case of the Week From 1/7/18

History: Reflux. Difficulty eating solids.

What is the most likely diagnosis? Distal esophageal cancer

What is the differential? Distal esophageal cancer, Achalasia

What would you recommend to do next? Endoscopy

Answers to Case of the Week From 12/31/17

History: Right-sided facial pain.

What is the most likely diagnosis? Fibrous dysplasia of the right skull base with expansile ground glass lesion causing narrowing of several right-sided skull base neural foramina

What is the differential? Fibrous dysplasia, less likely metastatic disease given lack of erosive changes.

What would you recommend to do next? Neurosurgical consult

Answers to Case of the Week From 12/24/17

History: Call back for asymmetric density.

What is the diagnosis? Overlapping normal breast parenchyma

What techniques are used? Standard CC view, Digital Tomography CC view, Spot Compression Digital Tomography CC view

What is the point of showing this case? Spot compression imaging can be important even when a patient has had a prior mammographic tomogram. Sometimes additional compression can spread out and isolate the normal tissue that may be equivocal on standard digital tomography. In this instance, we performed a spot compression of a tomogram.

Answers to Case of the Week From 12/17/17

History: Hydronephrosis.

What is the diagnosis? Tc99m Mag-3 study showing right-sided mechanical urinary tract obstruction with slightly increased right renal cortical retention/mild component of renal tubular dysfunction.

Answers to Case of the Week From 12/10/17

History: Wrist pain. Recent injury.

What is the diagnosis? Tear of the dorsal radioulnar ligament of the TFCC.

Answers to Case of the Week From 12/3/17

History: Abdominal pain. R/O Abscess

What are the three imaging modalities? Contrast enhanced CT scan, Contrast enhanced T1 Weighted MR, Tc99m Tagged Red Blood Cell Scan

How would you manage this case? Given that there is a mildly enhancing mass inferior to the spleen without uptake on red blood cell imaging (not splenosis), next step would be biopsy to determine if it is neoplasm, infectious, or inflammatory.

Answers to Case of the Week From 11/26/17

History: Shortness of breath

What are the two imaging modalities? V/Q SPECT and CT scan

What is your final diagnosis? No findings to suggest PE/low probability with nonsegmental defect corresponding to a right upper lobe mass

Answers to Case of the Week From 11/19/17

History: Toe Pain

What is the most likely diagnosis? Osteomyelitis of the 1st digit

What is the best test for confirming the diagnosis and why? Tagged white blood cell scan because the resolution of the toes tends to be poor on MRI.

1 year ago Today

Answers to Case of the Week From 11/12/17

History: Rectal Cancer

What is the MRI sequence? High Res T2 weighted image perpendicular to the rectal axis.

What is most important to tell the surgeon based on the MRI findings? Ill definition of the rectal wall consistent with a T3 tumor.

Answers to Case of the Week From 11/5/17

History: Breast cancer. Left pubic symphysis lesion.

What is the most likely diagnosis? How would you manage this patient?

Probably a benign pubic symphyseal subchondral cyst related to degenerative change with slight growth over 6 years.

How would you manage this patient?

Followup CT scan or MRI to check for continued stability.

6 years ago

Present Time

Answers to Case of the Week From 10/29/17

History: Difficulty Swallowing.

What are the studies?

CT scans, Ultrasound, Iodine-123 scan

What is the most likely diagnosis?

Ectopic thyroid tissue.

Answers to Case of the Week From 10/22/17

What are the studies?

Tagged Tc99m-RBC scan and CT scan

What is the most likely diagnosis

Hyperemia likely related infectious or inflammatory colitis (Activity in the right upper quadrant is stationary)

Answer to Case of the Week From 10/15/17

1. What are the studies?

Pyp scans 2. CT scan without contrast

2. What is the diagnosis?

transthyretin-related cardiac amyloidosis

Answer to Case of the Week From 10/8/17

1. What are the studies?

Gallium Scan 2. Oral Sulfur Colloid 3. CT scan of the chest at the level of the shoulders. 4. Right shoulder plain film

2. What is the presumptive diagnosis? What is the management?

Given a positive gallium scan at the right shoulder with negative right shoulder CT scan and negative right shoulder series with a history of shoulder pain consider early septic joint/osteomyelitis of the right shoulder.

3. What is the management?

Recommend MRI for confirmation of diagnosis if lower clinical suspicion. Alternatively, can tap the joint if there is continued high clinical suspicion.

Answer to Case of the Week From 10/1/17

Findings: Edema within the hamstring musculature consistent with a muscle strain/partial muscle tear

Answer to Case of the Week From 9/24/17

Scan type: Indium 111 labeled octreotide scan

Findings: Left hepatic lobe lesion on first two images (6 months ago) is more intense on the next two images (today) and corresponds to a hepatic lesion on CT scan

Final Diagnosis: Interval progression of carcinoid liver metastasis.

Answer to Case of the Week From 9/17/17

First two images on the left- 3 months ago, round oil cyst with almost imperceptible walls at the lower inner quadrant

Two images on the right- New thickening and irregularity of the walls of the oil cyst- likely an infected oil cyst.

Management- Can followup in 3 months to check for interval resolution. BIRADS-3

Answer to Case of the Week From 9/10/17

Findings: Bright T2 dark signal instead of the normal T2 dark signal near the plantar fasica insertion site at the plantar calcaneus with thickening. Abnormal thickening on T1 weighted imaging.

Diagnosis: Full thickness plantar fascia tear

Answer to Case of the Week From 9/3/17

Findings: Meniscal chondrocalcinosis with relatively increased osteophytosis and joint space narrowing at the patellofemoral joint.

Diagnosis: Most likely CPPD (Calcium Pyrophosphate Deposition Disease). Also, consider atypical osteoarthritis.

Answer to Case of the Week From 8/27/17

Radiopharmaceutical: Gallium-68 Dotatate (Similar mechanism of action to octreotide)

Diagnosis: Normal variant uptake in the pituitary. Unremarkable Ga-68 Dotatate PET-CT Scan

Answer to Case of the Week From 8/20/17

Enhancing infiltrative hepatocellular carcinoma (HCC). In this case, there was abnormal arterial enhancement at the periphery of the liver.

Gallium is often warm or hot at the site of HCC. In this case, it was of similar uptake compared to the remainder of the liver.

Answer to Case of the Week From 8/13/17

(Right Image) New Right Iliacus Retroperitoneal Hemorrhage

Answer to Case of the Week From 8/6/17

Findings:

Leftmost study: CT scan with subtle sclerotic lesion at the left ischial tuberosity

2nd to left study: Bone scan showing a cortically active left ischial tuberosity lesion likely corresponding to the CT scan findings

Three right most studies: Axumin PET-CT showing left inguinal adenopathy and no Axumin active lesion corresponding to the sclerotic lesion on PET

Diagnosis/Management:

Even though the lesion on Axumin lesion is not active, it is still highly suspicious for a bone metastasis give the positivity on bone scan. Axumin is not reliable as a predictor of bone metastases and sclerotic bone lesions if negative (less active than blood pool). These lesions on if not active on Axumin and seen on CT scan should be treated with caution and worked up further!!!