Delayed Metastatic Cholangiocarcinoma to the Stomach With Imaging Characteristics Resembling Gastrointestinal Stromal Tumor: A Case Report and Review of the Literature.

Intrahepatic cholangiocarcinoma (ICC) is a relatively rare subtype of cholangiocarcinoma, and there has been an increasing incidence of ICC in Western countries in recent years. Surgical resection is the most effective treatment for ICC. However, overall outcomes are extremely poor given that most patients are diagnosed at an advanced stage, and postoperative ICC recurrence is still very high despite hepatic resection. We report a case of metastatic ICC to the stomach presenting after resection of the original tumor, with imaging characteristics highly resembling gastrointestinal stromal tumor (GIST) on imaging. Reported cases of metastatic ICC to the liver are sparse. Given that there is a significant difference in the survival rate between metastatic cholangiocarcinoma and other tumors arising from the gastrointestinal tract, including GISTs, it is important to delineate the differences via imaging features. We further discuss the imaging characteristics of intrahepatic ICC, comparing and contrasting it to other gastric tumors.

Candida dubliniensis Fungemia Leading to Infective Endocarditis and Septic Pulmonary Emboli.

Illicit drugs, especially those injected intravenously, are becoming increasingly more common worldwide. Individuals who use intravenous drugs often reuse or share needles which predisposes them to life-threatening infections. We present the case of a patient who was injecting intravenous drugs into her internal jugular vein, which eventually led to acutely worsening sepsis secondary to fungal infective endocarditis and bilateral septic pulmonary emboli. Transthoracic echocardiogram demonstrated multilobulated and spherical vegetations on the tricuspid and mitral valves, respectively. On computed tomography of the thorax, numerous cavitary lesions and ground-glass opacities were present in both lungs. Multiple hyperdense, linear structures consistent with broken needles were seen on chest radiography. It is important for radiologists to recognize the possibility of broken needles in patients with a history of intravenous drug use as astute recognition of broken needles may lead to better source control and improved outcomes.

Dural lymphoma misdiagnosed as subdural hematoma following head trauma after an episode of syncope.

Primary dural lymphoma is a rare subtype of primary central nervous system lymphoma. Primary dural lymphoma may be radiologically misdiagnosed as it shares similar imaging characteristics with several pathologies, including meningiomas and subdural or epidural hematomas. We present a patient who was originally diagnosed with a subdural hematoma following a syncopal episode on computed tomography. Follow-up magnetic resonance imaging of the brain demonstrated heterogeneously enhancing dural-based mass overlying the left frontoparietal convexity associated with bidirectional dural tails, suggestive of a malignant meningioma. Neurosurgical histopathology revealed marginal zone B-cell lymphoma. This case represents the potential difficulty in diagnosing primary dural lymphoma, especially in the setting of uncertain clinical history and obscured imaging features.

Enlarging Liver Mass: Inflammatory Pseudotumor in a Patient With Polymyalgia Rheumatica.

Inflammatory pseudotumors of the liver are rare, non-neoplastic liver tumors. Due to the nonspecific clinical presentation, imaging features, and histopathological findings, they can mimic malignant tumors requiring invasive diagnostics. We present a case of a 61-year-old female patient with a history of type 2 diabetes mellitus, hypothyroidism, hyperlipidemia, and polymyalgia rheumatica who had initially presented with abdominal pain for 3 weeks. Further workup showed normal liver chemistries and tumor markers: AFP and CA 19-9. Magnetic resonance imaging (MRI) of the abdomen showed a segment 6 lesion measuring 4.1 × 4.0 × 3.7 cm. A liver biopsy then confirmed the diagnosis of an inflammatory pseudotumor of the liver with negative IgG4. On follow-up imaging, a rapid growth of this liver lesion was noted. Laparoscopy was done but did not show any distinct liver lesion. Follow-up imaging confirmed a decrease in the size of the mass. Interestingly, the patient had been on a higher dose of steroids for her polymyalgia rheumatic leading up to the follow-up imaging. This is the first case of an inflammatory pseudotumor of the liver in a patient with polymyalgia rheumatica. With this case, we would like to increase the awareness for inflammatory pseudotumors of the liver as a differential diagnosis of liver lesions in patients with underlying autoimmune disorders.

Tracheal and main bronchial diverticula simulating pneumomediastinum following a motor vehicle collision.

Tracheal and bronchial diverticula are outpouchings arising from the trachea or bronchus. We present a case of a 35-year-old female who presented to the emergency department following a motor vehicle accident and was found to have multiple round, air-filled structures within the mediastinum on computed tomography of the thorax, concerning for pneumomediastinum. The patient had a negative fluoroscopic esophagography and subsequent imaging indicated tracheal and bronchial diverticula. While they are often asymptomatic and incidentally found, tracheal and bronchial diverticula may be misdiagnosed as pneumomediastinum, especially in the setting of blunt or penetrating trauma to the thorax.

Hypervascular vestibular schwannoma: A case report and review of the literature.

Vestibular schwannomas, also known as acoustic neuromas, are benign tumors that arise from Schwann cells near the transition from glial cells to Schwann cells. While most vestibular schwannomas are hypovascular tumors, a small percentage constitute the hemorrhagic and/or hypervascular vestibular schwannomas (HVS) subtype. We describe a case of a 36-year-old female who presented with nausea, vomiting, and an acute decrease in vision in her right eye. Computed tomography of the head demonstrated a hemorrhagic lesion in the right hemisphere with evidence of ventricular effacement. Follow-up magnetic resonance imaging revealed a mass in the right cerebellopontine angle that was hypointense on T1-weighted imaging and mild hyperintense heterogeneous signal on T2-weighted imaging, suggestive of a hemorrhagic vestibular schwannoma. It is important for radiologists to recognize the unique clinical and radiological features of HVS in the initial diagnostic assessment of cerebellopontine angle tumors and to distinguish it from common (hypovascular) vestibular schwannomas and other related pathologies. A preoperative diagnosis of HVS allows clinicians to become familiar with the unique characteristics of the tumor and to devise a feasible operative strategy prior to surgical resection.

A case report of an adolescent with ligase-4 deficiency and the potential dangers of ionizing radiation in this rare patient population.

DNA ligase IV deficiency is a rare disorder characterized by mutations in the LIG4 gene. Mutations in this gene cause a wide array of phenotypes, many of which are fatal early in life. We present an adolescent patient with heterozygous LIG4 mutations and the T-B-NK+ DNA ligase IV phenotype. Pelvic ultrasound and magnetic resonance imaging was completed to assess the patient's amenorrhea and delayed puberty, which demonstrated an atrophic cervix, distal vagina, and uterus without direct visualization of the ovaries. Early diagnosis of DNA ligase IV deficiency is important to minimize exposure to ionizing radiation from radiologic studies and preferentially utilize imaging studies that do not require ionizing radiation, such as ultrasonography and magnetic resonance imaging.

Subcutaneous Soft Tissue Metastases in Lung Adenocarcinoma: A Surprising Initial Presentation on Bone Scintigraphy.

ABSTRACT: Initial disease presentations are often surprising compared with expected clinical trajectories. We present a case of metastatic lung adenocarcinoma where the initial presentation was masquerading as a musculoskeletal soft tissue mass. Initial concern was for a hematoma after light trauma, but due to a pacemaker, MRI was contraindicated. Workup included a 99mTc-MDP bone scan where the lesion demonstrated activity. Further workup imaging was serendipitous, revealing a left upper lobe mass. Biopsy demonstrated poorly differentiated adenocarcinoma of lung origin. Soft tissue metastasis can occur with lung adenocarcinoma, and although it constitutes a less frequent metastatic route, it is nevertheless clinically important.

Relapsed Wilms' Tumor Presenting as Metastasis to the Zygoma.

Wilms' tumor accounts for the majority of renal tumors in children. Rarely, Wilms' tumor may metastasize to the bone. We present a case of a 15-month-old female who presented with severe abdominal distension and signs of cachexia. Abdominal ultrasonography and radiography of the abdomen both demonstrated a large abdominal mass. Follow-up computed tomography of the abdomen revealed a heterogeneous intra-abdominal mass arising from the left kidney which was surrounded by a thin rim of renal parenchyma. Biopsy of the mass revealed findings consistent with Wilms' tumor. The patient was 14 months status-post nephrectomy and chemoradiation but returned to the clinic with left facial swelling. Magnetic resonance imaging of the face demonstrated a multilobulated, heterogeneously enhancing solitary mass lesion in the left temple centered in the left zygoma with signs of bone breakdown. Despite its rarity, metastatic Wilms' tumor to bone should be considered in a child presenting with a new focal mass overlying bony-structures.

Mucoepidermoid carcinoma of the thymus incidentally diagnosed following two-years of non-productive cough.

Mucoepidermoid carcinoma of the thymus is a rare primary thymic carcinoma. Radiologic imaging of this malignancy is rarely reported in literature. We present a patient who complained of a chronic cough for two years who was later found to have mucoepidermoid carcinoma of the thymus. Chest radiograph revealed a large anterior mediastinal mass. Follow-up computed tomography of the thorax demonstrated a large, heterogeneous anterior mediastinal mass with traversing vessels. F-18 fluorodeoxyglucose positron emission tomography-computed tomography demonstrated high avidity in the lesion with areas of diminished activity thought to represent necrosis. Following surgical resection, pathology revealed high-grade mucoepidermoid carcinoma of the thymus extending into the skeletal muscle and pericardium with evidence of lymphovascular invasion. The patient received external beam radiation therapy and has remained disease-free for three years.

Chronic lymphoid leukemia metastasis to the gallbladder as a focal mass: A case report.

Chronic lymphocytic leukemia (CLL) is the second most common hematologic malignancy, and it is characterized by lymphocytic leukocytosis and secondary hematologic deficiencies. While it most commonly presents as a systemic disease, extramedullary involvement may rarely occur. The literature surrounding CLL metastatic disease to the gallbladder is particularly sparse. Interestingly, we describe a case of a 67-year-old female who presented with painless jaundice and was found to have a rapidly growing gallbladder wall mass which was determined to be CLL metastatic disease after extensive surgical resection. It is important for radiologists to recognize the possibility of CLL metastatic disease to the gallbladder when evaluating potential cases of cholecystitis due to the overlapping spectrum of imaging findings. Cognizant radiologists can potentially save patients from surgical intervention as CLL is classically treated with chemotherapy.

Intussusception secondary to signet ring cell adenocarcinoma in adolescent.

Despite the overall decrease in incidence and mortality rates for older adults, colorectal cancer in young adults is increasing. We present a case of a 15-year-old male who presented with 1.5 weeks of intermittent, sharp, severe right-sided abdominal pain. Abdominal radiograph demonstrated an air-fluid level within the right hemiabdomen. Computed tomography demonstrated marked wall thickening and a mass at the junction of the ascending colon and hepatic flexure causing obliteration of the lumen with a fluid-filled, dilated ascending colon. Follow-up ultrasonography demonstrated a 5.9 × 3.9 cm targetoid lesion in the right upper quadrant concerning for intussusception. Contrast enema revealed failure of contrast filling beyond the hepatic flexure due to a lobulated central filling defect surrounded by a claw-like contrast extension. Pathology of the polypoid lesion revealed poorly differentiated signet ring cell adenocarcinoma of the colon at the hepatic flexure. Despite its rarity, this case elucidates the need to consider colorectal carcinoma in adolescent and young adult patients who present with recurrent abdominal signs and symptoms.

SARS-CoV-2 infection leading to ischemic and hemorrhagic brain lesions and acute respiratory distress syndrome.

Coronavirus disease 2019 (COVID-19) may present with pulmonary and extrapulmonary manifestations. We present a 41-year-old patient who presented with 1 week of increasing dyspnea and fever and initial chest radiography demonstrated bilateral diffuse infiltrates. Due to the patient's progressively worsening symptoms, he was intubated, paralyzed, sedated. He began proning, 100% fractional inspired oxygenation ventilation, and veno-venous extracorporeal membrane oxygenation. Computed tomography of the thorax revealed completely opacified lungs bilaterally with the exception of a small, aerated apicoposterior segment of the left lung. Computed tomography of the head demonstrated several areas of hemorrhage, areas of hypodensity consistent with posterior cerebral artery and middle cerebral artery territory infarcts, and findings consistent with transtentorial herniation. Given the radiologic findings and nonprogressive clinical status, the family placed the patient on comfort care and the patient died within minutes of extubation. As with our patient at the time of admission, presenting symptoms and clinical laboratory data provide reliable prognostic factors for patients with COVID-19.

Cerebral syphilitic gumma presenting with intracranial gumma and pathologic vertebrae fractures.

A 37-year-old female was admitted with worsening neurologic function. On arrival from an outside hospital, the patient was obtunded and intubated. Magnetic resonance imaging of the brain revealed nodular enhancement of the leptomeninges, intracranial osteolytic lesions, and diffuse vasogenic edema causing mass effect. Imaging of the thoracic spine revealed pathologic compression fractures of 4 thoracic vertebrae. On review of the patient's electronic medical record, the patient had previously received treatment for secondary syphilis with intramuscular benzathine penicillin G. Surgical biopsies of the frontal bone and dura showed diffuse, chronic inflammation while a biopsy of the adjacent brain parenchyma revealed replicating spirochetes. The patient was subsequently prescribed dexamethasone and benzathine penicillin G. She regained neurologic function but later signed out against medical advice without completing her treatment regimen.

Cutaneous metastatic seeding as a sequela of nephrostomy catheter placement.

Urothelial carcinoma and nephrolithiasis are a common cause of obstructive uropathy which can be relieved by percutaneous nephrostomy catheter placement. A rare, but known complication of this procedure is iatrogenic seeding of tumor cells along the nephrostomy tract. We describe a case of 68-year-old-female with cutaneous metastasis of high-grade urothelial carcinoma with seeding of tumor cells along the percutaneous nephrostomy catheter tract 8 months after the removal of the catheter. Given its severity, interventional radiologists should be mindful of the number of percutaneous access attempts, exchanges, and catheter manipulations in patients with urothelial carcinoma due to the risk of metastatic seeding along the percutaneous tract or to nearby tissues.

Pediatric milk protein allergy causing hepatic portal venous gas: Case report.

Hepatic portal venous gas (HPVG) is a rare imaging finding in infants and usually indicative of a severe disease process such as necrotizing enterocolitis, bowel ischemia, or bowel wall rupture / infarction. The diagnosis of HPVG may have serious implications such as parenteral nutrition, antibiotics and even surgery. In this case, we present an 8-week-old male with a history of prematurity presenting with HPVG, later concluded to be caused by milk protein allergy. Milk protein allergy is a rare cause of HPVG, but it should be recognized due to its benignity and potential prevention of unnecessary testing and interventions.

A successful endovascular repositioning of migrated transjugular intrahepatic portosystemic shunt (TIPS) stent.

The transjugular intrahepatic portosystemic shunt (TIPS) procedure is performed to create an intrahepatic tract between the hepatic and portal veins which helps to shunt blood away from the hepatic sinusoids. This shunt decreases the portal venous pressure and secondary morbidities, including variceal bleeding and recurrent ascites. However, stent migration is a known complication of TIPS stent placement which may occur both during the procedure or postprocedural. We present a case of a 58-year-old male with history of liver cirrhosis in the setting of alcohol abuse and chronic hepatitis C infection who presented with melena and hematemesis. Esophagogastroduodenoscopy showed 4 columns of large grade IV esophageal varices with stigmata of recent bleeding. Despite endoscopic variceal banding, the patient had persistent episodes of hematemesis and became hemodynamically unstable requiring pressor support. The decision was made to proceed with emergent transjugular intrahepatic portosystemic shunt placement. After obtaining transhepatic portal access and initial stent deployment, the stent migrated from the TIPS tract into the main portal vein. While maintaining through-and-through wire access, the stent was successfully mechanically retracted using an angioplasty balloon and it was appropriately repositioned within the original TIPS tract. The stent was then further secured in place with a slightly larger stent which was deployed within the hepatic portion of the initially migrated stent. This technique was successful and obviated complete removal of the stent and follow-up imaging demonstrated patent flow and adequate positioning several months after the procedure.

Wandering intravascular air gun BB pellet.

Approximately 13,500 children each year are treated for non-powder gun injuries of which approximately one-quarter of these injuries are puncture wounds. Although rare, vascular migration of the bullet or pellet (otherwise known as the "wandering bullet") may result in downstream organ damage secondary to vascular or venous occlusion, most commonly travelling anterograde and lodging within the lung venous system. Interestingly, we present a case of a 12-year-old female who was shot in the neck with a compressed-air gun loaded with ball-bearing pellets. Eventual retrograde vascular migration of the ball-bearing pellet from the right internal jugular vein to the hepatic vein caused hepatic venous occlusion and congestion. It is important for radiologists to remember the possibility of retrograde travel of bullets and pellets, and radiographs should be scrutinized for foreign bodies present in areas other than the region of injury. Bullet retrieval is determined by clinical evaluation and necessity, and if indicated, endovascular, percutaneous retrieval, or surgical exploration may be considered.

Novel case of percutaneous access of afferent limb of Roux-en-Y hepaticojejunostomy for biliary decompression and jejunoplasty in a patient with primary sclerosing cholangitis.

Primary sclerosing cholangitis is a rare condition characterized by multifocal fibrotic bile duct strictures and progressive liver disease. Due to its recurrence even after liver transplantation, an alternative surgical procedure, the Roux-en-Y hepaticojejunostomy, is practiced with positive outcomes. We present a case of a 55-year-old female with history of primary sclerosing cholangitis and Roux-en-Y hepaticojejunostomy approximately 25 years ago who presented to the emergency department with acute cholangitis. Computed tomography of the abdomen revealed a dilated loop of small bowel in the right upper quadrant and mid-abdomen with normal bile duct caliber. Interventional radiology was consulted for percutaneous biliary and Roux limb decompression. Ultrasound was utilized to identify and percutaneously access the dilated afferent jejunal limb. With the help of a T-fastener, the jejunal loop was tacked against the anterior abdominal wall and the system was successfully decompressed with a drain left in place. On follow-up, delayed contrast transit through the Roux limb and a stricture in the native jejunum distal to the anastomosis was identified. Hampering of the downstream flow of bile was noted and this was determined to be the likely cause of the initial episode of cholangitis. The strictured bowel segment was balloon-dilated by interventional radiology. Repeat injection of contrast revealed significant improvement in the caliber of the stenotic segment. At 3 weeks' postprocedure, a follow-up enteroscopy of the bowel was performed through the same percutaneous access site. Using this technique, the patient avoided a major invasive surgical procedure.

Differential Diagnosis of Landau-Kleffner Syndrome Versus Post Encephalitis Syndrome in a 13-year-old Boy With Autism Spectrum Disorder.

Landau-Kleffner syndrome (LKS) is a rare childhood neurological condition that causes developmental regression, loss of language skills and abnormal electroencephalogram (EEG) patterns. Its etiology is unknown. This report describes a case of a 13-year-old boy who at 3.5 years of age was bitten by a tick. Two months thereafter, he began losing previously acquired developmental and language skills, and developed seizures. The seizures subsided with valproic acid treatment, but the developmental delays persisted. Family history and disease progression reports obtained from the patient's father revealed that the patient displayed repetitive behaviors prior to the age of three. Clinical observation also showed the patient having numerous repetitive vocalizations and movements along with difficulty with switching sets. His developmental age at the time of presentation was determined to be 3 to 4 years of age. During the course of diagnostic testing, we were able to rule out tick-borne encephalitis (TBE) and rule in LKS in a premorbidly autistic child. This case describes the similarities between the three conditions and the diagnostic investigations used to arrive at a final diagnosis.