Imaging Manifestations of Genitourinary Tuberculosis.

The genitourinary region is one of the most common sites of extrapulmonary tuberculosis (TB) involvement. The imaging features of genitourinary TB are protean and can mimic other entities, including malignancy, and pose a diagnostic dilemma. Hematogenous seeding and lymphatic spread of mycobacteria from pulmonary, tonsillar, and nodal TB are implicated in the pathogenesis of genitourinary TB. In addition, contiguous extension from the urinary tract and sexual transmission are described as sources of genital TB. Genitourinary TB can be indolent and results in nonspecific signs and symptoms; thus, imaging has a vital role in the working diagnosis for these cases. Classic uroradiologic signs of genitourinary TB are primarily described from the era of intravenous urography and conventional radiography. Now, CT, CT urography, MRI, and US are used in the diagnosis and management. Familiarity with the imaging features of genitourinary TB may help guide the diagnosis and, in turn, lead to timely management. US has a vital role in the evaluation of scrotal and female genital TB. MRI offers superior soft-tissue contrast resolution and excellent depiction of anatomic detail. The various imaging manifestations of genitourinary TB are highlighted. ©RSNA, 2021.

Secondary Hypertension and Complications: Diagnosis and Role of Imaging.

Hypertension is a common problem; if left untreated, it can result in significant complications, including those involving the cardiovascular system and end organs. Approximately 10% of patients with hypertension are classified as having secondary hypertension, defined as hypertension attributable to a specific and potentially remediable cause. The evaluation for secondary hypertension typically begins with acquiring the patient history and performing a physical examination and screening laboratory tests. Directed imaging may be performed, on the basis of laboratory test results, to assess for potential causes of secondary hypertension. The causes can be broadly classified as endocrine (eg, hyperaldosteronism, pheochromocytoma, hyperparathyroidism) and nonendocrine (eg, aortic coarctation, renal vascular hypertension). In addition, patients with hypertension can develop significant complications that also are diagnosed with imaging, including conditions involving the cardiovascular system (eg, aortic aneurysm, acute aortic syndrome) and central nervous system (eg, stroke, subarachnoid hemorrhage, and posterior reversible encephalopathy syndrome). The imaging workup and imaging appearances of some of the causes of secondary hypertension are reviewed, treatment options are discussed, and the imaging appearances of hypertension-related complications are described. It is important for radiologists to accurately diagnose the secondary causes of hypertension, as many of them are treatable, and treatment may result in improved symptoms or resolution of hypertension. ©RSNA, 2019.

A Standardized Ultrasound Scoring System for Preoperative Prediction of Difficult Laparoscopic Cholecystectomy.

PURPOSE: Laparoscopic cholecystectomy (LC) has become the treatment of choice for cholelithiasis. Still some patients required conversion to open cholecystectomy (OC). Our aim was to develop a standardized Ultrasound based scoring system for preoperative prediction of difficult LC. METHODS AND MATERIALS: Ultrasound findings of 300 patients who underwent LC were reviewed retrospectively. Four parameters (time taken, biliary leakage, duct or arterial injury, and conversion) were analyzed to classify LC as easy or difficult. The following ultrasound findings were analyzed: GB wall thickness, pericholecystic collection, distended GB, impacted stones, multiple stones, CBD diameter and liver size. Out of seven parameters, four were statistically significant in our study. A score of 2 was assigned for the presence of each significant finding and a score of 1 was assigned for the remaining parameters to a total score of 11. A cut-off value of 5 was taken to predict easy and difficult LC. RESULTS: 66 out of 83 cases of difficult LC and 199 out of 217 cases of easy LC were correctly predicted on the basis of scoring system. A score of >5 had sensitivity 80.7% and specificity 91.7% for correctly identifying difficult LC. Prediction came true in 78.8% difficult and 92.6% easy cases. US findings of GB wall thickness, distended GB, impacted stones and dilated CBD were found statistically significant. CONCLUSION: This indigenous scoring system is effective in predicting conversion risk of LC to OC. Patients having high risk may be informed and scheduled appropriately and decision to convert to OC in case of anticipated difficulty may be taken earlier.

Giant-cell tumor of the patella in a skeletally immature girl.

BACKGROUND: We reported on a case of a giant-cell tumor of the patella which occurred in a skeletally immature patient. This combination of unusual age of presentation and atypical location made our case clinically and radiologically unique. CASE REPORT: A 13-year-old girl presented with complains of knee pain and swelling. After radiological investigations and percutaneous needle biopsy a diagnosis of giant-cell tumor of the patella was made, for which the patient underwent patellectomy with en bloc resection of the lesion and the diagnosis was confirmed by histopathological examination. CONCLUSIONS: It was concluded that early diagnosis may be difficult in such cases and hence, GCT should be considered in the differential diagnosis of a destructive lesion of the patella, regardless of the age of presentation.

Orbital malignant peripheral nerve sheath tumor: A case report and review.

Malignant peripheral nerve sheath tumor of the orbit is an exceedingly rare entity. These tumors exhibit locally aggressive behavior, recurrences, distant metastasis, and poor response to existing treatment protocols. Orbital nerve sheath tumors are often associated with neurofibromatosis 1, and malignant transformation of neurofibroma into malignant nerve sheath tumor has also been seen. The recommended treatment for localized disease is radical or wide surgical excision to achieve negative margins followed by chemoradiation. For extensive disease, chemotherapy and radiotherapy can be utilized to stabilize the disease. Due to poor response and outcomes with current regimens, the focus has been shifted to approaches utilizing molecular targets and immunological agents. Despite all the advancements, the outcomes still remain discouraging for moderate- to high-grade lesions and thus necessitate studies to design promising treatment modalities.

Clinical examination vs. MRI: evaluation of diagnostic accuracy in detecting ACL and meniscal injuries in comparison to arthroscopy.

BACKGROUND: To compare the diagnostic accuracy of clinical examination and MRI in evaluation of meniscal and ACL injuries using arthroscopic findings as reference standard. MATERIAL/METHODS: A total of 51 patients with traumatic knee injuries were identified and prospectively followed up with clinical examination, MRI and arthroscopy. Clinical examination and MRI findings were compared with arthroscopic findings. Sensitivity, specificity, PPV, NPV and diagnostic accuracy were calculated with statistical analysis. RESULTS: Out of 24 patients with arthroscopic evidence of medial meniscal injury, clinical examination and MRI correctly identified 20 and 18 patients, respectively. Clinical examination was characterized by better sensitivity and specificity with regard to diagnosis of medial meniscal tear. On arthroscopy, lateral meniscal tear was present in 13 patients; clinical examination and MRI both identified 8 of them correctly. Similarly, out of 9 patients with arthroscopic evidence of ACL tear, clinical examination and MRI correctly identified 7 and 8 patients, respectively. There were only marginal differences in sensitivity and specificity of clinical examination and MRI in diagnosis of lateral meniscal and ACL injury. CONCLUSIONS: Careful clinical examination is much better than MRI with regard to the diagnosis of medial meniscus injury and is as reliable as MRI with regard to diagnosis of lateral meniscus injury and ACL tears. MRI should be used to rule out such injuries rather than to diagnose them.

Right phrenic nerve palsy: a rare presentation of thoracic aortic aneurysm.

Phrenic nerve palsy causing hemidiaphragm paralysis is a very uncommon feature of thoracic aortic aneurysm. In one case, a 45-year-old man complained of chronic chest pain, dysphagia, and hoarseness of voice; posteroanterior view chest radiograph revealed lobular enlargement of the superior mediastinum and elevated right hemidiaphragm. Contrast-enhanced computed tomography (CT) of the thorax revealed a giant partially thrombosed aneurysm originating from the ascending aorta and extending into the aortic arch, causing a widening of the aorta-pulmonary window and a compression of the thoracic esophagus. Right hemidiaphragm elevation was explained by the gross mass effect of the aneurysm on the right hilum, causing right phrenic nerve palsy. The patient was to be operated on for surgical correction of the aneurysm, but died before surgery due to spontaneous rupture.

Recurrent solitary fibrous tumor of eyelid: A rare entity.

Orbital and adnexal solitary fibrous tumors (SFT) are rare entities. The clinico-radiological and histologic features overlap with those of other spindle cell variants, and hence the use of immunohistochemical stains helps in making an accurate diagnosis. Furthermore, a thorough surgical resection is imperative to prevent tumor recurrences. We report a rare case of SFT arising primarily from the eyelid with multiple recurrences.

Painless left hemorrhagic pleural effusion: an unusual presentation of leaking saccular aortic arch aneurysm.

Most thoracic aortic aneurysms are asymptomatic and are detected by chance on routine chest imaging for some other reasons. Only rarely it is symptomatic due to leak and dissection which is a potentially life threatening event that commonly presents with severe pain. In this report, we present the case of a 67-year-old man who presented with shortness of breath, intermittent cough, fever, and left sided painless hemorrhagic pleural effusion. Further investigation by plain radiography, computed tomography and magnetic resonance imaging revealed a saccular aneurysm arising from the lateral aspect of the mid-transverse arch of the aorta, along with a dissecting descending aortic aneurysm with false lumen communicating with left pleural space. The patient refused any surgical procedure and was treated conservatively with blood transfusions and anti hypertensive medication. On the 8th day patient finally succumb to a fatal episode of shock. We suggest dissecting thoracic aneurysm be included in the differential diagnosis of non-traumatic hemorrhagic pleural effusion in an elderly patient presenting with dysnea, cough and fever, which otherwise suggest the clinical diagnosis of bronchogenic carcinoma. Computed tomography of the chest should be immediately performed as the diagnostic procedure of choice.

Giant extraosseous Ewing sarcoma of the lung in a young adolescent female--a case report.

Extraosseous Ewing sarcoma is a rare soft tissue tumour that is histologically indistinguishable from the bone Ewing sarcoma. The translocation involving chromosome 22 along with CD 99 expression is pathognomonic and is useful in differentiating from other small round cell tumours. Primary lung involvement by this malignant tumour is very uncommon and up to this date only ten cases have been reported. We report a further case in a 15 year-old-female who presented with a huge lung mass causing an opaque haemithorax.

Atypical multifocal hydatid disease of cranial vault: simultaneous orbital and extradural meningeal involvement.

Hydatid disease is endemic in regions where livestock is raised. Liver and lungs are the most commonly affected organs by the disease. Cranial vault and orbital hydatid disease is extremely rare. Signs and symptoms along with serological investigation are often inconclusive in cranial hydatid, making radiological diagnosis extremely important. Surgical removal of the cyst is the mainstay of treatment. Postoperative medical therapy, along with regular follow-up, is the key to detect any recurrence. We report an unusual case of cranial hydatid which showed diffuse scalp infiltration along with orbital and extradural extension.

Role of Whole-Spine Screening Magnetic Resonance Imaging Using Short Tau Inversion Recovery or Fat-Suppressed T2 Fast Spin Echo Sequences for Detecting Noncontiguous Multiple-Level Spinal Tuberculosis.

STUDY DESIGN: Retrospective review. PURPOSE: The purpose of the present study was to evaluate the role of whole-spine screening using short tau inversion recovery (STIR) or fat-suppressed T2W fast spin echo (FSE) sequences in patients with spinal tuberculosis (TB). OVERVIEW OF LITERATURE: The identification of noncontiguous multiple-level spinal tuberculosis (NMLST), symptomatic or not, is important because of its management implications. Most centers do not perform routine whole-spine magnetic resonance imaging (MRI), and the reported incidence of NMLST varies from 1.1% to 74.1%. METHODS: We completed a retrospective review of clinical and radiographic data of 365 patients with spinal TB who presented at Jawaharlal Nehru Medical College, Aligarh over 5 years. The final analysis included 187 patients who full filled the inclusion criteria, consisting of availability of whole-spine MRI and confirmation of vertebral TB. Diagnosis of NMLST was considered when other vertebral lesions were identified in addition to the primary vertebral disease, with the lesions separated by at least one normal spinal segment. The primary site was defined as the site for which the patient had been referred for MRI. RESULTS: NMLST was identified in 47 of 187 patients investigated using whole-spine MRI. The incidence was 25.1%, which was higher than that in earlier reports where whole-spine MRI was not routinely performed. The lumbar spine was involved in 37 patients, thoracic spine in 25, cervical spine in 16, and sacrum in five patients. Combined lumbar spine and thoracic spine involvement was observed in 19 patients. Thirteen patients had lumbar and cervical spine involvement, nine had thoracic and cervical spine involvement, four had combined lumbar and sacral spine involvement, and the remaining two had thoracic and sacral spine involvement. CONCLUSIONS: Tubercular spondylitis may affect the spine at multiple noncontiguous sites with the majority of additional affected sites remaining asymptomatic. Routine whole-spine MRI using all recommended sequences is not cost-effective and hence not feasible. Therefore, we recommend whole-spine screening using STIR or fat-suppressed T2W FSE sequences in all patients with suspected spinal TB. This screening is cost-effective compared with full-protocol MRI and detects additional cases of NMLST over conventional practice.

Extreme Ophthalmomyiasis externa with simultaneous facial and scalp involvement.

BACKGROUND: Ophthalmomyiasis is a rare entity seen mainly in immunocompromised host with neglected wounds under poor hygienic conditions. CASE: We report a case of extreme ophthalmomyiasis with extensive facial and scalp involvement in an old rural inhabitant following evisceration. CONCLUSION: Proper wound care and personal hygiene are of paramount importance for good wound healing.

Neurocutaneous melanosis: Review of a rare non-familial neuroectodermal dysplasia with newer association of cerebellopontine angle cistern lipoma.

Neurocutaneous melanosis is a rare neuroectodermal dysplasia with a grave prognosis. It is actually a disorder of neuronal migration at the time of the embryogenesis hence classified as a neurocristopathy. The patients are initially identified by the skin manifestations of the disease in the form of melanocytic naevus which can be hairy or non-hairy. These patients may or may not present with neurological symptoms but often show CNS abnormalities especially on MRI of the brain and the spine. A lot has been described about the disease since the first case described by Rokitansky in 1861, but every time a new CNS pathology is being added to the long list of currently documented pathologies. Herein we describe a case of a 5 yr old boy with seizures and hairy melanocytic naevus over the trunk and back who was diagnosed as a case of Neurocutaneous melanosis on subsequent evaluation by CT and MRI. We also describe the new association of CP angle cistern lipoma with neurocutaneous melanosis.

Delleman Oorthuys syndrome.

Oculocerebrocutaneous or Delleman syndrome is a rare congenital syndrome characterized by microphthalmia/anophthalmia with or without orbital cysts, focal skin defects, intracranial cysts and skin appendages. We here report a case of 1-year-old male child with periocular skin tags, lid colobomas, and dermal hypoplasia. The patient had delayed developmental milestones and history of tonic-clonic seizures. Magnetic resonance imaging of the head revealed a large arachnoid cyst, aplastic cerebellar vermis and polymicrographic pattern of the cerebral cortex. A complex cyst of spleen was also noted on abdominal ultrasonography. Orbital cysts depending on the size can be excised or left alone. Neuroimaging evaluation of patients with congenital orbital cysts and skin appendages is emphasized for early and appropriate management.

Schwannoma of the scrotum: case report and review of the literature.

Schwannomas are benign nerve sheath tumors composed of Schwann cells, which normally produce the insulating myelin sheath covering the peripheral nerves. Common locations include the head, neck, mediastinum, and retroperitoneum. These tumors are usually asymptomatic until they become large and compress the surrounding tissues. Most schwannomas occur during the third and fourth decades of life, with an equal gender distribution. We present the case of a schwannoma that originated in the scrotum.

Bilateral persistent hyperplastic primary vitreous: a close mimic of retinoblastoma.

Bilateral persistent hyperplastic primary vitreous (PHPV) is a rare disorder of eye. It is one of the most important differential diagnoses of retinoblastoma, hence early and accurate diagnosis is important. We here report a case of an 11-month-old child which was referred to ocular OPD with complaints of bilateral leukocoria. Examination revealed greyish-white masses posterior to both lenses, raising the clinical suspicion of retinoblastoma. Ultrasonography demonstrated echogenic masses extending from the posterior surface of the lens to the optic disc with reduced axial lengths. These masses demonstrated flow on color Doppler evaluation. CT scan revealed hyperdense masses behind the lens without any evidence of intralesional calcification. Clinical features and imaging findings point towards the diagnosis of bilateral PHPV. PHPV is a developmental disorder of the globe in which the hyaloid vasculature fails to regress normally. While unilateral PHPV is common, bilateral PHPV is a rare entity. It is one of the most important conditions mimicking retinoblastoma; hence early and accurate diagnosis is required. Ophthalmological examination is still the best way to confirm the diagnosis. However, if the diagnosis remain unclear, further evaluation using ultrasonography, Color Doppler, and CT scan is useful.

Isolated pontine tuberculoma presenting as "fou rire prodromique".

The authors present the case of a young child with "fou rire prodromique" as an initial manifestation of pontine tuberculoma. This report is the first description of fou rire prodromique as the presenting sign of CNS tuberculosis. The combination of clinical information and CT findings allowed for precise localization of the lesion and suggested tuberculoma as the possible etiology.

Thymoma with coexisting undifferentiated pleomorphic sarcoma: a case report.

We report here a case of thymoma simultaneously associated with undifferentiated pleomorphic sarcoma. A 45-year-old male presented with axillary lump. Radiographic studies showed a mediastinal mass. On fine needle aspiration cytology and histopathological examination, a diagnosis of thymoma with coexisting undifferentiated pleomorphic sarcoma was made. Although thymomas are associated with many extrathymic malignancies, it's association with undifferentiated pleomorphic sarcoma is rare. This case is being reported on to reinforce that clinicians should bear in mind the possibility of extrathymic malignancies in patients with thymomas.