Beyond pulmonary embolism: Alternative diagnosis and incidental findings on CT pulmonary angiography in sickle cell disease.

BACKGROUND: Sickle cell disease (SCD) is a genetic hematological disorder associated with severe complications, such as vaso-occlusive crises, acute chest syndrome (ACS), and an increased risk of thromboembolic events, including pulmonary embolism (PE). The diagnosis of PE in SCD patients presents challenges due to the overlapping symptoms with other pulmonary conditions. Our previous study revealed that nearly 96% of computed tomography pulmonary angiography (CTPA) scans in SCD patients were negative for PE, highlighting a gap in understanding the significance of CTPA findings when PE is absent. METHODS: In this retrospective follow-up study conducted at the Salmaniya Medical Complex in Bahrain, we examined SCD patients with HbSS genotypes who underwent CTPA from January 1, 2018, to December 31, 2021, for suspected PE, but the results were negative. The aim of this study was to identify alternative diagnoses and incidental findings from CTPA scans. Experienced radiologists reviewed the CTPA images and reports to assess potential alternative diagnoses and incidental findings, incorporating an additional analysis of chest X-rays to evaluate the diagnostic value of CTPA. Incidental findings were classified based on their location and clinical significance. RESULTS: Among the 230 evaluated SCD patients (average age 39.7 years; 53% male) who were CTPA negative for PE, 142 (61.7%) had identifiable alternative diagnoses, primarily pneumonia (49.1%). Notably, 88.0% of these alternative diagnoses had been previously suggested by chest radiographs. Furthermore, incidental findings were noted in 164 (71.3%) patients, with 11.0% deemed clinically significant, necessitating immediate action, and 87.8% considered potentially significant, requiring further assessment. Notable incidental findings included thoracic abnormalities such as cardiomegaly (12.2%) and an enlarged pulmonary artery (11.3%), as well as upper abdominal pathologies such as hepatomegaly (19.6%), splenomegaly (20.9%), and gallstones (10.4%). CONCLUSION: This study underscores the limited additional diagnostic yield of CTPA for identifying alternative diagnoses to PE in SCD patients, with the majority of diagnoses, such as pneumonia, already suggested by chest radiographs. The frequent incidental findings, most of which necessitate further evaluation, highlight the need for a cautious and tailored approach to using CTPA in the SCD population.

A Giant Upper Esophageal Leiomyoma: A Rare Case.

BACKGROUND Benign esophageal neoplasms are uncommon, representing less than 10% of esophageal tumors. Esophageal leiomyomas are benign mesenchymal esophageal tumors, typically involving the distal two-thirds of the esophagus. However, upper esophageal leiomyoma is unusual. Signs and symptoms are nonspecific and similar to any esophageal lesion. The role of radiologic imaging in the diagnosis of leiomyoma is vital. Enucleation is the preferred surgical method for treatment of esophageal leiomyoma. In our patient, the presence of a large tumor necessitated esophageal resection and reconstruction. CASE REPORT A previously healthy 55-year-old woman presented with a chronic productive cough, which did not improve with symptomatic treatment and was not associated with shortness of breath, fever, anorexia, or weight loss. A chest radiograph revealed a superiorly located posterior mediastinal mass, measuring 9.6×4.8×4.6 cm in maximum dimensions. The mass was further evaluated by contrast-enhanced computed tomography, which demonstrated a mass with stippled calcifications, consistent with esophageal leiomyoma. Surgical resection was successfully performed, and the patient had complete resolution of her symptoms. A follow-up visit revealed a postoperative complication of left vocal cord palsy. Speech-language therapy was recommended. CONCLUSIONS Esophageal leiomyoma can present solely with respiratory symptoms without any gastrointestinal involvement and can be misdiagnosed because of atypical symptoms, uncommon location, or atypical imaging features. Recognizing the imaging features and pathologic basis of esophageal leiomyoma is essential for detection, early diagnosis, and management. Endoscopic and radiologic tests are critical to differentiate esophageal leiomyoma from other esophageal lesions and to eliminate the risk of malignancy.

Metachronous prostate and colon adenocarcinomas.

Multiple primaries in patients with prostate cancer are uncommon. We report a case of prostate adenocarcinoma who did not receive any form of treatment, diagnosed 7 months later with colon adenocarcinoma. The patient underwent right extended hemicolectomy and recovered well. He is planned to receive adjuvant chemotherapy and hormonal therapy. Management of such cases can present a dilemma and multiple factors must be taken into consideration, particularly when the first primary tumour is still active.

Acute pancreatitis in a patient with COVID-19.

COVID-19 mainly causes pulmonary disease. Involvement of gastrointestinal and hepatobiliary systems, among other systems, has been reported. We report a case of acute pancreatitis in a patient with resolving COVID-19 pneumonia. History taking and investigations excluded other causes of pancreatitis. This case demonstrates the possibility of pancreatic injury in patients with COVID-19, in line with previously reported similar cases. We believe that it is imperative to screen patients presenting with acute pancreatitis for SARS-CoV-2. It is also important to take into consideration that patients with a complicated course who require an invasive procedure such as drainage might pose a risk of transmission to the operating surgeon or interventionist.