Post-Vaccination/Post-COVID Immune-Mediated Demyelination of the Brain and Spinal Cord: A Novel Neuroimaging Finding.

Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19), which not only produces respiratory symptoms but is known to involve almost every system, and its neuroinvasive properties have been well demonstrated throughout the pandemic. Also, to combat the pandemic, there was rapid development and induction of various vaccination drives, following which many adverse events following immunization (AEFIs) have been reported, which include neurological complications as well. Method: We present a series of three cases, post vaccination, with and without a history of COVID illness that showed remarkably similar findings on magnetic resonance imaging (MRI). Result: A 38-year-old male presented with complaints of weakness of the bilateral lower limbs with sensory loss and bladder disturbance a day after receiving his first dose of ChadOx1 nCoV-19 (COVISHIELD) vaccine. A 50-year-old male with hypothyroidism characterized by autoimmune thyroiditis and impaired glucose tolerance experienced difficulty in walking 11.5 weeks after being administered with COVID vaccine (COVAXIN). A 38-year-old male presented with subacute onset progressive symmetric quadriparesis 2 months after their first dose of a COVID vaccine. The patient also had sensory ataxia, and his vibration sensation was impaired below C7. All three patients had typical pattern of involvement of the brain and spine on MRI with signal changes in bilateral corticospinal tracts, trigeminal tracts in the brain, and both lateral and posterior columns in the spine. Conclusion: This pattern of brain and spine involvement on MRI is a novel finding and is likely a result of post-vaccination/post-COVID immune-mediated demyelination.

Diagnosis and differentiation of mature cystic teratoma of pancreas from its mimics: A case report.

INTRODUCTION: Mature cystic teratoma originating in the pancreas is very unusual, often observed as an incidental finding during routine examinations or recognized perioperatively as the patients present with very unspecific clinical symptoms. The confirmatory diagnosis of a pancreatic cystic teratoma is generally made by histopathology after surgical excision. So, the preoperative diagnosis is very challenging, especially differentiation from the other pancreatic pathologies. PATIENT CONCERNS: A 23-year-old woman was admitted to our hospital with a complaint of mild grade periumbilical abdominal pain. A pancreatic mass was revealed on a preliminary abdominal ultrasound examination. Her medical history was unremarkable with no long-standing illness or malignancy. DIAGNOSIS: Mature cystic teratoma in the head of the pancreas. INTERVENTIONS: Roux-enY choledochojejunostomy with gastrojejunostomy was performed, excising the tumor from the pancreatic head. OUTCOMES: The postoperative course was uneventful; the patient was asymptomatic and has no evidence of recurrence on a 2-year follow up. CONCLUSIONS: Pancreatic cystic teratoma is a benign, well-differentiated, and extremely rare congenital tumor. MRI is the choice of imaging modality and phase-GRE or fat suppression is the best technique for pre-operative diagnosis.

Significance of radiology in the diagnosis and management of ruptured left gastric artery aneurysm associated with acute pancreatitis: Case report.

RATIONALE: Left gastric artery aneurysms are very rare which progresses into hemorrhagic shock and diagnosis is very challenging particularly in patients with acute pancreatitis and cholecystitis whose vitals become unstable suddenly. PATIENT CONCERNS: A 72-year-old female has presented with severe progressing abdominal pain was treated with total parenteral nutrition for acute pancreatitis based on preliminary work up, but suddenly became unstable with dropping vitals over the ensuing 48 hours. Physical examination has a positive Murphy sign and appeared lethargic. She has no past history of any chronic systemic illness or malignancy. DIAGNOSES: Ruptured left gastric artery aneurysm and left hepatic artery aneurysm with intraperitoneal hemorrhage associated with acute pancreatitis and cholecystitis. INTERVENTIONS: Emergency interventional surgery was performed to embolize both the aneurysms and the giant aneurysmal sac of the left gastric artery was secured with a micrometallic occluding coil which eventually controlled the active hemorrhage. OUTCOMES: The patient became stable and was discharged after 15 days without any recurrence or complications during the 6-month follow-up. LESSONS: This case is a peculiar example of a missed diagnosis of left gastric artery aneurysm associated with acute pancreatitis and cholecystitis with deteriorating clinical condition. Exhaustive radiological investigations are necessary for early diagnosis correlating with presenting clinical situations. Radiologists should be familiar with the challenges in diagnosis and management.

Significance of MRI in the diagnosis and differentiation of clear cell sarcoma of tendon and aponeurosis (CCSTA): A case report.

RATIONALE: Clear cell sarcoma of tendon and aponeurosis (CCSTA) or soft parts is a rare malignant melanin producing tumor entity that is derived from the neural crest cells originating from soft tissues displaying melanocytic differentiation. Diagnosis of CCSTA is difficult as it is dependent on age, size, location, necrosis, calcifications, cystic degeneration, and local to distant metastatic deposits. These tumors have very poor prognosis with a survival rate of 5-10 years because of local recurrence, early to late metastasis to lymph nodes, lungs, bones, and liver. PATIENT CONCERNS: A 30-year-old Asian male has presented with a painful mass in the posterior aspect of the right ankle. He recalled of noticing an increase in the size of the lump after a traumatic insult 3 months ago. Physical examination revealed a mass of size 9x4 cm in the posterior ankle with no cutaneous ulcerative lesions. There is no history of any longstanding illness or malignancy. DIAGNOSES: Clear cell Sarcoma of Tendon and Aponeurosis (CCSTA) or CCS of Soft parts. INTERVENTIONS: Conventional radiography demonstrated merely a soft tissue mass in the posterior compartment of the right ankle and significant calcaneal bone erosion with the sparse trabecular pattern. Plain conventional tomography showed a well-defined soft tissue heterogeneous mass with a hypoattenuating osteo-destructive focal lesion in the calcaneus. Magnetic resonance imaging (MRI) - T1 weighted imaging (T1WI) revealed an iso-intense signal relative to adjacent muscle; heterogeneous high-signal intensity on fat saturated T2 weighted imaging (T2WI). On contrast examination, lesion on T1WI, showed a heterogeneous high signal intensity, central low signal intensity with peripheral and septal enhancement. The immune-histochemistry analysis was positive for HMB-45, S-100, myoD1 and Ki67 (30%). Correlating with imaging and immune-histochemistry, a confirmatory diagnosis of CCSTA was made. OUTCOMES: CCSTA is typically a slowly growing painless mass in the deep soft tissues of ear, pancreas, kidney, penis, abdomen, especially in the lower extremities- Achilles tendon and aponeurosis of the ankle or in foot of young adults. As, these tumors are highly malignant, difficult to diagnose, early recognition by imaging and surgical excision are the mainstay of management. LESSONS: Our case emphasizes the importance of recognizing radiological characteristics of CCSTA, and its differentiation from other soft tissue tumors, when presenting atypically. MRI plays a significant role in the diagnosis supported by histopathology and immune-histochemistry. So, radiologists should be familiar about this presentation that could guide other personnel for early detection of soft tissue tumors while including CCSTA into differential diagnosis for evaluation.