Transcript ABCDES of Arthritis

Long Island Radiological Society
Interesting Case Panel
Tuesday, March 12th, 2013
Nassau University Medical Center
East Meadow, NY
Case 1
40 year-old Hispanic female with left upper
quadrant pain and weight loss; left upper
quadrant mass palpable on exam
Submitted by Judy Atallah, DO PGY4
STOP Proceed to next slide for diagnosis
Leiomyosarcoma
• Uncommon malignancy of smooth muscle origin arising
from alimentary tract, retroperitoneum, urogenital tract,
or soft tissues
• Most commonly metastasizes to liver, lung, peritoneal
surfaces; may also spread to soft tissues, bone, spleen,
or cause ascites
• Represent 11% of retroperitoneal malignancies
• 16% 2 year survival when in retroperitoneum
Leiomyosarcoma
• Imaging features are nonspecific
• Usually large and necrotic mass, without
calcification
• When large, primary tumor and metastases may
demonstrate moderate peripheral enhancement
• Otherwise, contrast enhancement is not a
prominent feature
RadioGraphics,
Reference
Primary Retroperitoneal Neoplasms: CT and MR Imaging
Findings with Anatomic and Pathologic Diagnostic Clues. M.
Nishino, K.Hayakawa, M. Minami, A. Yamamoto, H. Ueda, K.
Takasu. January 2003 RadioGraphics, 23, 45-57.
Leiomyosarcoma: computed tomographic findings. A J
McLeod, J Zornoza, A Shirkhoda. July 1984 Radiology, 152,
133-136.
Case 2
72 year-old male with cough productive for
blood tinged sputum for one month as well
as weight loss and decreased appetite
Submitted by Sofiya Greenberg, MD PGY3
STOP Proceed to next slides for diagnosis
Clinical Findings
• AFB culture positive for mycobacterium
tuberculosis
• Patient and department of health were notified
• Patient was placed on respiratory isolation
• Treatment for TB was administered, patient was
instructed to follow up with ID for long term
treatment
Empyema Necessitans
• Extension of a pleural infection out of the
thoracic cavity and into neighboring structures.
• Most commonly due to TB or fungal infections
• Can occur following necrotizing pneumonia or
lung abscess
• Treatment is with antibiotics plus closed or open
drainage of the pleural space
References
Heffner JE, Klein JS, Hampson C. Diagnostic utility and
clinical application of imaging for pleural space infections.
Chest. 2010;137 (2): 467-79.
Glicklich M, Mendelson DS, Gendal ES et-al. Tuberculous
empyema necessitatis. Computed tomography findings.
Clin Imaging. 1990;14 (1): 23-5.
Haddad CJ, Sim WK. Empyema necessitatis. Am Fam
Physician. 1989;40 (4): 149-52
Case 3
19 year-old male presents after MVA with
blunt abdominal trauma and diffuse nonspecific abdominal pain
Submitted by Brian Goodman, MD PGY2
Do you see any vascular abnormality?
STOP Proceed to next slide for diagnosis
Celiac Artery Injury after Blunt
Abdominal Trauma
• Approximately 90-95% of
injuries to abdominal visceral
vasculature are caused by
penetrating trauma, only 5-10%
are attributed to blunt trauma
• Injury to the celiac axis is
extremely rare, only case
reports in the literature
• Mortality can be as high as 75%
Celiac Artery Injury after Blunt
Abdominal Trauma
• Initial evaluation is usually with arterial phase CT
angiography
• If suspicious, confirm with conventional angiography
• MR angiography less commonly used
• Imaging findings:
• Luminal disruption/filling defect
• Intimal flap suggestive of dissection
• Superimposed thrombosis
• Look for evidence of abdominal visceral ischemia
References
Gorra AS, Mittleider D, Clark DE, Gibbs M. Arch Surg. Asymptomatic
isolated celiac artery dissection after a fall. 2009 Mar;144(3):279-81.
doi: 10.1001/archsurg.2009.22.
Kirchhoff C, Stegmaier J, Krotz M, Muetzel Rauch E, Mutschler W,
Kanz KG, Heindl B. Celiac dissection after blunt abdominal trauma
complicated by acute hepatic failure: case report and review of
literature. J Vasc Surg. 2007 Sep;46(3):576-80.
Suchak AA, Reich D, Ritchie W. Traumatic isolated dissection of the
celiac artery. AJR Am J Roentgenol. 2007 Dec;189(6):W373-4.
Case 4
54 year-old female with hypertension and
palpitations; clinical concern for
pheochromocytoma
Submitted by Allison Rubin, MD PGY2
Axial T2W images of the abdomen at the level of the adrenal glands
Indium-111 labeled octreotide scan of abdomen and pelvis
Axial T2W, T1W, and T1W FS post gadolinium administration
images of the pelvis
Sagittal T2W image of the pelvis
STOP Proceed to next slide for diagnosis
Extra-adrenal Paraganglioma:
Organ of Zuckerkandl
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Rare catecholamine secreting tumor that arises from
the neural crest chromaffin cells
May occur at any site where sympathetic nervous
tissue is located
– Adrenal pheochromocytomas  90%
– Extra-adrenal paragangliomas  10%
The most common site for extra-adrenal
paragangliomas is the Organ of Zuckerkandl
(Chromaffin tissue near the origin of the IMA)
Signs and Symptoms: episodic headache, sweating,
hypertension, palpitations
Paragangliomas are associated with a number of
inherited syndromes, e.g. MEN 2A/B, NF1, VHL,
Carney’s Triad, and Familial Paragangliomas
Imaging Findings
• CT Findings
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Para-aortic soft tissue mass with homogenous enhancement
May have central areas of low attenuation
Punctate calcifications
Acute hemorrhage may cause areas of high attenuation
• Nuclear Imaging
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121I-
or 131I-MIBG imaging used in the evaluation of pheochromoctyoma,
however, it is less sensitive in the diagnosis of extra-adrenal paraganglioma
– 99mTc- labeled hydrazinonicotinyl-Tyr3-octreotide scintigraphy was shown to have
96% sensitivity as compared to 72% sensitivity for 131I-MIBG imaging in the
diagnosis of extra-adrenal paragangliomas (Chen et al., 2009)
• MR Imaging
– T1: isointense or hypointense to liver
– T2: hyperintense
– Enhances with gadolinium administration
References
Chen L et al. 99mTc-HYNIC-TOC Scintigraphy Is Superior to 131I-MIBG
Imaging in the Evaluation of Extraadrenal Pheochromocytoma. J Nuc Med
2009; 50:397-400
Kahraman D et al. Extra-adrenal Pheochromocytoma in the Organ of
Zuckerkandl: Diagnosis and treatment strategies. Exp Clin Endocrinol
Diabetes 2011; 119: 436-9
Lee KY et al. Imaging Extraadrenal Paragangliomas of the Body: Imaging
features. AJR 2006; 187: 492-504
Sahdev et al. CT and MR Imaging of Unusual Locations of Extra-adrenal
Paragangliomas (Pheochromocytomas). Eur Radiol 2005; 15: 85-92
van Gils APG et al. MR Imaging and MIBG Scintigraphy of
Pheochromocytomas and Extraadrenal Functioning Paragangliomas.
Radiographics 1991; 11: 37-57
Case 5
45 year-old female with shortness of breath
Submitted by Toshimasa Clark, MD PGY5
STOP Proceed to next slide for diagnosis
Partial Anomalous
Pulmonary Venous Return
• Congenital right to left shunt wherein one or more
pulmonary veins return anomalously to the superior
or the inferior vena cava, the right atrium, or the
coronary sinus.
• Upper lobe PAPVR may drain to the
brachiocephalic vein via a vertical vein, while in this
case a lower lobe PAPVR drains to the IVC
• Mechanism is thought to be involution of a portion
of the common pulmonary vein on the affected side
at an embryological stage when there remain
connections between the pulmonary veins,
omphalomesenteric veins, and primitive IVC
References
Kalke B, Carlson R, Ferrlici R, et al. Partial pulmonary
anomalous venous connection. Am J Cardiol 1967; 20:91101.
Zwetsch B, et al. Three-Dimensional Image
Reconstruction of Partial Anomalous Pulmonary Venous
Return to the Superior Vena Cava. Chest 1995;
108(6):1743-1745.
Kaiser LR, et al. Mastery of Cardiothoracic Surgery.
Philadelphia: Lippincott and Williams, 2007. Print.
Case 6
48 year-old female with chronic left ankle pain
Submitted by Kory Byrns, MD PGY3
STOP Proceed to next slide for diagnosis
Fibrous Talocalcaneal Coalition
• Abnormal bridging, usually related to failure
of embryological segmentation
• May be asymptomatic or present as
progressive ankle pain/stiffness, lateral leg
pain, or, uncommonly, with tarsal sinus or
tarsal tunnel symptoms
• 25% bilateral, though may present with only
unilateral symptoms
• May be osseous, cartilaginous, or fibrous
• Radiographs are relatively insensitive and
nonspecific, but may note “C sign” of
calcaneal sclerosis along the medial
subtalar joint
Fibrous Talocalcaneal Coalition
• In fibrous coalition, CT reveals sclerosis
and irregularity at the articulation with
narrowing and broadening of the joint
space
• Subchondral cysts may develop
• MR reveals sclerosis as low signal on all
pulse sequences
• With motion, marrow edema develops,
demonstrating diminished T1 and
elevated T2 signal, as in this case
• If present, marrow and trabecular
continuity indicate osseous rather than
fibrous coalition
Reference
Crim J: Imaging of tarsal coalition. Radiol Clin North Am.
46(6):1017-26, vi, 2008