Erratum to "Imaging diagnosis of a giant choledochal cyst in an infant" [Radiology Case Reports 17 (2022) 404-411].

[This corrects the article DOI: 10.1016/j.radcr.2021.10.051.].

Imaging Approach to Pulmonary Infections in the Immunocompromised Patient.

Pulmonary infections are the major cause of morbidity and mortality in immunocompromised patients and almost one-third of intensive care unit patients with pulmonary infections belong to the immunocompromised category. Multiple organisms may simultaneously infect an immunocompromised patient and the overwhelming burden of mixed infections further predisposes critically ill patients to acute hypoxemic respiratory failure. Notwithstanding that lung ultrasound is coming into vogue, the primary imaging investigation is a chest radiograph, followed by thoracic CT scan. This review based on our experience at tertiary care teaching hospitals provides insights into the spectrum of imaging features of various pulmonary infections occurring in immunocompromised patients. This review is unique as, firstly, the imaging spectrum described by us is categorized on basis of the etiological infective agent, comprehensively and emphatically correlated with the clinical setting of the patient. Secondly, a characteristic imaging pattern is emphasized in the clinical setting-imaging-pattern conglomerate, to highlight the most likely diagnosis possible in such a combination. Thirdly, the simulating conditions for a relevant differential diagnosis are discussed in each section. Fourthly, not only are the specific diagnostic and tissue sampling techniques for confirmation of the suspected etiological agent described, but the recommended pharmaco-therapeutic agents are also enumerated, so as to provide a more robust insight to the radiologist. Last but not the least, we summarize and conclude with a diagnostic algorithm, derived by us from the characteristic illustrative cases. The proposed algorithm, illustrated as a flowchart, emphasizes a diagnostic imaging approach comprising: correlation of the imaging pattern with clinical setting and with associated abnormalities in the thorax and in other organs/systems, which is comprehensively analyzed in arriving at the most likely diagnosis. Since a rapid evaluation and emergent management of such patients is of pressing concern not only to the radiologist, but also for the general physicians, pulmonologists, critical care specialists, oncologists and transplant surgery teams, we believe our review is very informative to a wide spectrum reader audience.

Imaging diagnosis of a giant choledochal cyst in an infant.

The usual etiologies of giant abdominal cystic masses in infants are mesenteric cyst, enteric duplication cyst, ovarian cyst in females, cystic lymphangioma, however, the presentation of a choledochal cyst in a gigantic form, is unusual. The primary modality for diagnosis of this entity is ultrasound, followed by MRI. The characteristic ultrasound features of a choledochal cyst are a well-defined cystic lesion which may be found to replace any segment of the biliary tree and is distinctly separate from the gallbladder. The associated anomalies are biliary atresia, gallbladder atresia, hepatic fibrosis and those of the pancreatico-biliary ductal system. MRI with MRCP has a conclusive role in confirming the ultrasound diagnosis. Choledochal cysts are currently classified as proposed by Todani et al, into five types. Herein, we report the case study of a 4-month-old male infant afflicted with a gigantic, Type1 Choledochal cyst, complicated by perforation, which was diagnosed by us at the first instance itself, using ultrasound examination and confirmed by MRI. The diagnosis was further confirmed at surgery and histopathology. The recommended treatment of cyst resection accompanied by a hepatico-jejunostomy bypass procedure, was successfully performed in the reported infant.

Contrast enhanced ultrasound quantitative parameters for assessing neoadjuvant chemotherapy response in patients with locally advanced breast cancer.

OBJECTIVES: To evaluate the role of contrast-enhanced ultrasound (CEUS) quantitative parameters in predicting neoadjuvant chemotherapy (NACT) response in patients with locally advanced breast cancer (LABC). METHODS: 30 patients with histologically proven LABC scheduled for NACT were recruited. CEUS was performed using a contrast bolus of 4.8 ml and time intensity curves (TICs) were obtained by contrast dynamics software. CEUS quantitative parameters assessed were peak enhancement (PE), time-to-peak (TTP), area under the curve (AUC) and mean transit time (MTT). The parameters were documented on four consecutive instances: before NACT and 3 weeks after each of the three cycles. The gold-standard was pathological response using Miller Payne Score obtained pre NACT and post-surgery. RESULTS: A decrease in mean values of PE and an increase in mean values of TTP and MTT was observed with each cycle of NACT among responders. Post each cycle of NACT (compared with baseline pre-NACT), there was a statistically significant difference in % change of mean values of PE, TTP and MTT between good responders and poor responders (p-value < 0.05). The diagnostic accuracy of TTP post-third cycle was 87.2% (p = 0.03), and MTT post--second and third cycle was 76.7% (p = 0.004) and 86.7% (p = 0.006) respectively. CONCLUSION: In responders, a decrease in the tumor vascularity was reflected in the CEUS quantitative parameters as a reduction in PE, and a prolongation in TTP, MTT. ADVANCES IN KNOWLEDGE: Prediction of NACT response by CEUS has the potential to serve as a diagnostic modality for modification of chemotherapy regimens during ongoing NACT among patients with LABC, thus affecting patient prognosis.

Clinical and imaging features of idiopathic granulomatous mastitis - The diagnostic challenges and a brief review.

Idiopathic granulomatous mastitis (IGM), or granulomatous lobular mastitis is a rare, benign, inflammatory condition of the breast, without an identifiable underlying etiology. The clinical and imaging diagnosis of this entity is challenging with the presentation frequently mimicking inflammatory breast carcinoma (IBC). Mammography and breast ultrasound (US) have an important role in its detection, however, biopsy is imperative for histopathological confirmation. We present three cases of biopsy proven IGM, highlighting the variability of the clinical and imaging features,brieflyreview the relevant literature and discuss the challenges associated with its diagnosis and management.

Prospective revalidation of IOTA "two-step", "alternative two-step" and "three-step" strategies for characterization of adnexal masses - An Indian study focussing the radiology context.

OBJECTIVES: The purpose of this study was to revalidate the diagnostic performance of IOTA "two step" (Simple Descriptors and Simple Rules), " alternative two step" (Simple Rules Risk Calculation tool / SRrisk score), and three step (two step with subjective assessment) strategies, for characterization of adnexal masses as benign or malignant, using histopathology as gold standard. MATERIALS AND METHODS: This prospective, study comprised of 100 patients with newly diagnosed adnexal masses, who underwent ultrasound evaluation first by a level I and then by a level III investigator (EFSUMB criteria). Initially, the level I investigator evaluated each adnexal mass, applying IOTA "two-step" strategy and simultaneously assigned a risk category, by applying the simple rules risk score (SRrisk score) or performing the "alternative two step" strategy. Subsequently the inconclusive masses were evaluated by the level III investigator using "real time subjective assessment", thereby performing the third step. Following histopathology diagnosis, the performance of each strategy was evaluated using diagnostic tests. RESULTS: The sensitivity, specificity, PPV, NPV, and diagnostic accuracy of "two-step" strategy were 87.5%, 79.2%, 89.4%, 76%, and 84.7%, respectively; those of "alternative two-step" strategy were 91.5%, 75.6%, 84.4%, 86.1% and 88%; and those of "three-step" strategy were 98.2%, 93.3%, 94.7%, 97.7% and 96%, respectively. CONCLUSION: All IOTA strategies showed good diagnostic performance for characterization of adnexal masses and the "three-step" strategy performed best. We believe this is the first ever prospective re-validation and comparative evaluation of all three IOTA strategies by Indian Radiologists. Since ultrasound is the primary modality for evaluation of adnexal masses, based on the good results of our study, a recommendation for henceforth standard application, of the three-step IOTA strategy in routine Radiology practice appears justified. Although, IOTA strategies been proposed and validated mainly by Gynaecologists and Oncology surgeons, based on the results of our study, this paradigm can now be made to shift back to the arena of Radiology and Radiologists, the imaging experts.

Contrast-enhanced voiding urosonography (CEVUS) as a novel technique for evaluation in a case of male urethral diverticulum.

Male urethral diverticulum is an uncommon entity, the abnormality being more frequently encountered in females. The pathology may be congenital or acquired and the more frequent acquired type usually occurs following trauma. Afflicted patients usually lack specific symptoms, although in a few instances, symptoms of lower urinary tract obstruction, calculi, or infection may prevail. Imaging investigations utilizing a composite Retrograde urethrography (RGU)- Voiding cystourethrography (VCUG) protocol are accepted as standard approach and ultrasound is considered a secondary supplementary investigation. However, recent literature reports the utility of contrast-enhanced ultrasound (CEUS) as a novel technique in the evaluation of urinary bladder and urethra, for vesico-ureteric reflux (VUR) in children and for urethral diverticula in women. We report a case of acquired post-traumatic urethral diverticulum in an adult male patient and document a relatively unexplored novel application of contrast enhanced voiding uro-sonography (CEVUS) for the evaluation of this malady.

Niche role of MRI in the evaluation of female infertility.

Infertility is a major social and clinical problem affecting 13-15% of couples worldwide. The pelvic causes of female infertility are categorized as ovarian disorders, tubal, peritubal disorders, and uterine disorders. Appropriate selection of an imaging modality is essential to accurately diagnose the aetiology of infertlity, since the imaging diagnosis directs the appropriate treatment to be instituted. Imaging evaluation begins with hystero- salpingography (HSG), to evaluate fallopian tube patency. Uterine filling defects and contour abnormalities may be discovered at HSG but usually require further characterization with pelvic ultrasound (US), sono-hysterography (syn: hystero-sonography/saline infusion sonography) or pelvic magnetic resonance imaging (MRI), when US remains inconclusive. The major limitation of hysterographic US, is its inability to visualize extraluminal pathologies, which are better evaluated by pelvic US and MRI. Although pelvic US is a valuable modality in diagnosing entities comprising the garden variety, however, extensive pelvic inflammatory disease, complex tubo-ovarian pathologies, deep-seated endometriosis deposits with its related complications, Mulllerian duct anomalies, uterine synechiae and adenomyosis, often remain unresolved by both transabdominal and transvaginal US. Thus, MRI comes to the rescue and has a niche role in resolving complex adnexal masses, endometriosis, and Mullerian duct anomalies with greater ease. This is a review, based on the authors' experience at tertiary care teaching hospitals and aims to provide an imaging approach towards the abnormalities which are not definitively diagnosed by ultrasound alone.

Assessment of labor progression by intrapartum ultrasonography among term nulliparous women.

OBJECTIVE: To assess cervical dilation, fetal head station, and fetal head position by intrapartum ultrasonography and to compare the approach with digital vaginal examination (DVE). METHODS: An observational study conducted from October 2015 to January 2017 among term nulliparous women in active labor at a tertiary hospital in Delhi, India. Cervical dilation, head station, and head position were assessed by DVE, followed by ultrasonography within 10 minutes. The women's preference was also evaluated. RESULTS: Overall, 458 observations were obtained for 215 women. Cervical dilation measured by DVE was strongly correlated with ultrasonography findings (intraclass correlation coefficient, 0.945; 95% confidence interval, 0.932-0.956; κ=0.837; P<0.001). Data for fetal head station and head position showed a fair correlation (κ=0.353 and κ=0.554, respectively; both P<0.001). The majority of women (186/215, 87%) reported a preference for ultrasonography over DVE for assessment of labor progression in a future pregnancy. CONCLUSION: Intrapartum ultrasonography was preferred as an objective assessment tool for labor progression among term nulliparous women and therefore should be practiced in all labor rooms. Further studies on interobserver variation are recommended to establish the reproducibility of intrapartum assessment by ultrasonography.

Approach to pediatric renal tumors: an imaging review.

Renal tumors comprise 7% of all childhood cancers. A wide variety of renal tumors can affect the pediatric kidneys, which can be broadly classified as primary benign tumors, primary malignant tumors, and metastatic lesions. This article aims to enumerate usual benign and malignant renal tumors that can occur in childhood and emphasizes the characteristic imaging appearances which aid in their differential diagnosis. Additionally, the leading role of the Radiologist in primary diagnosis of renal infiltration by hematological malignancies and contiguous invasion by neuroblastoma is also introduced and unraveled. Imaging protocol comprises initial Ultrasound evaluation with subsequent computed tomography (CT) and/or Magnetic resonance imaging (MRI), all of which are invaluable in confirming the diagnosis, documenting the organ of origin, describing extent of local and distant spread. The complimentary role of nuclear medicine studies in delineating differential renal function, post-operative complications, and metastasis is also highlighted.

Imaging diagnosis of Crouzon syndrome in two cases confirmed on genetic studies - with a brief review.

Crouzon syndrome is the most common form of craniofacial dysostosis, characterised by a classical triad of abnormal skull shape, abnormal facies, and exophthalmos. The clinically overt dental abnormalities in these patients, distracts clinicians from the developmental neurological defects and therefore this entity remains relatively under - highlighted in radiology literature. We report and highlight the role of imaging in diagnosis of Crouzon syndrome in two patients, and discuss the relevant differential diagnosis. Moreover, our report is among the few Indian studies in which Crouzon syndrome was confirmed by genetic studies. The classical clinical triad of Crouzon syndrome was observed in both patients. The skull radiographs and cranial CT with 3D reconstruction VRT (Volume rendered technique), revealed characteristic radiological features. Genetic studies reconfirmed the clinical and radiological diagnosis of Crouzon syndrome, in both patients.

A Case of Mistaken Identity: Glutaric Aciduria Type I Masquerading as Postmeningitic Hydrocephalus.

We report the characteristic neuroimaging features of a rare metabolic leukodystrophy in an 8-year-old boy, born of consanguineous parenthood. The child presented with macrocrania, regression of milestones, and dystonia. The patient was referred for magnetic resonance imaging with a clinical diagnosis of postmeningitic hydrocephalus. Imaging revealed ventriculomegaly, diffuse brain atrophy, bilaterally symmetric widened sylvian fissure with temporal lobe hypoplasia, periventricular white-matter hyperintensities, and atrophy with hyperintensity in bilateral basal ganglia was also seen. These imaging features were signatory to arrive at a diagnosis of glutaric aciduria type 1. This disorder may mimic other neurological diseases such as postmeningitic hydrocephalus, which delays the diagnosis. Since early diagnosis and treatment can arrest progression, increased awareness about this condition among radiologists will certainly prevent erroneous diagnosis as had occurred in our patient.

Role of Ultrasonographic Placental Thickness in Prediction of Fetal Outcome: A Prospective Indian Study.

BACKGROUND INFORMATION: Placenta is the connecting organ between the mother and the fetus. It supplies oxygen and all the necessary elements for the growth and development of the fetus. In normal pregnancy, the growth of the placenta remains concordant with the growth of the fetus. The sonographic assessment of placenta can give information about the nutritional status of the fetus. It is known that normal placental thickness approximately equals gestational age. It is historically documented that placental weight is one-fifth of the fetal weight and abnormally thin or thick placenta is associated with increased incidence of perinatal morbidity and mortality. However, there are very few studies correlating placental thickness with Neonatal outcome. OBJECTIVES: To correlate ultrasonographic placental thickness at 32 and 36 weeks pregnancy with neonatal outcome. To propose placental thickness as a simple test for prediction of neonatal outcome. METHODS: Placental thickness at 32 and 36 weeks was measured by ultrasound, in 130 pregnant mothers with confirmed dates and uncomplicated singleton pregnancy. Placental thickness was categorized as normal (10th-95th percentile), thin (<10th percentile) and thick (>95th percentile) at each stage and was correlated with birth weight and neonatal outcome. RESULTS: Neonatal outcome was good in women with normal placental thickness (10th-95th percentile) at 32 and 36 weeks and was compromised in women with thin (<10th percentile) and thick (>95th percentile) placentae. CONCLUSION: Placental thickness at 32 and 36 weeks corresponds well with gestational age and is a good prognostic factor in assessing neonatal outcome. Therefore, placental thickness should be measured in addition to biometric parameters in antenatal women undergoing ultrasound.

Primary presentation of Jeune's syndrome as gastric motility disorder in an infant: A case report.

We report a case of a 4-week-old female neonate with Jeune's asphyxiating thoracic dystrophy (JATD) and coexistent situs anomaly, primarily presenting as gastric motility disorder. The child presented with abdominal distension and nonbilious vomiting since birth with failure to thrive. However, skeletal survey revealed JATD. Upper gastrointestinal contrast study showed situs inversus with delayed gastric emptying. Pyloric biopsy and intraoperative antro-duodenal manometry confirmed association of gastric motility disorder. Awareness of the unusual possibility of primary presentation of Jeune syndrome as gastric motility disorder will improve the management approach in such infants.

Evaluation of two-staged Fowler-Stephens laparoscopic orchidopexy (FSLO) for intra-abdominal testes (IAT).

INTRODUCTION: The best operative intervention for intrabdominal testis (IAT) has not been standardized as yet. The question of whether to bring down an IAT with a single-staged vessel-intact laparoscopic orchidopexy (VILO) or a two-staged laparoscopic Fowler-Stephens orchidopexy (FSLO) is still undergoing debate, with both the procedures being popular. The present study has been designed to evaluate the factors predicting the success or failure of two-staged FSLO for (IAT). METHODS: 43 boys with 49 non-palpable testes underwent diagnostic laparoscopy out of which 35 underwent two-staged FSLO. Size of the testis was measured with a graduated probe in both stages. Independent variables such as age, height, testis-to-internal ring distance (T-IR), neo internal ring-to-midscrotal distance (NIR-MS), and mobility-to-contralateral ring (MCIR) were analysed. Postoperatively 34 IATs were followed up clinically as well as ultrasonologically after 6 months, to see for the size, position, and vascularity. Based on this, the patients were divided into two groups, Group A (successful) and Group B (Failed). RESULTS: 24 IATs had a successful outcome (Group A) and 11 were failure (Group B). The overall success rate of the study was 68.6%. The difference in mean age of patients in both groups was insignificant (p = 0.89) (Fig. 1), and similarly, the difference in mean height was insignificant (p = 0.61). The difference in mean T-IR in both the groups was insignificant (1.85 versus 2.77 cm; p = 0.09) and mean NIR-MS was 5.41 cm in Group A and 5.10 cm in Group B, and the difference again was insignificant (p = 0.23). CONCLUSION: The success rate of FSLO was 68.6%. None of the above-described independent variables have any effect on the outcome of two-staged FSLO. While VILO remains the treatment of choice for IAT located at or near the ring, but IAT higher than this, two-staged FSLO gives a better chance for achieving intra-scrotal orchidopexy.

"Caught by the Eye of Sound" - Epigastric Swelling due to Xiphisternal Tuberculosis.

BACKGROUND: Common causes of an epigastric mass include hepatomegaly, pancreatic pseudocyst and epigastric hernia, less common causes being carcinoma of the stomach or pancreas, whereas diseases of the sternum presenting as an epigastric swelling is extremely uncommon. We report a case of tubercular infection of the sternum located in the xiphoid process resulting in its presentation as an epigastric swelling. CASE REPORT: A 30-year-old immunocompetent woman with complaints of an epigastric swelling and undocumented pyrexia for four months was referred for sonographic evaluation with a clinical suspicion of an incompletely treated liver abscess. The patient was examined with ultrasound, sternal radiographs, CT and MRI. Ultrasound revealed a heterogeneous epigastric collection with linear echogenic components suggestive of bone fragments. These appearances suggested chronic infective osteomyelitis of the xiphoid process of the sternum. Lateral chest radiograph demonstrated lytic destruction of the xiphisternum. Tubercular etiology was considered and further evaluation with Multidetector Computed tomography (MDCT) and Magnetic Resonance Imaging (MRI) demonstrated erosive osteomyelitis of the xiphoid process with enhancing inflammation and collection in the adjoining soft tissue. Ultrasound-guided aspiration, PCR and Amplified Mycobacterium tuberculosis DNA test confirmed tubercular infection. CONCLUSIONS: We report a new case of osteo-articular tuberculosis localized to the xiphisternum, a rare clinical entity with an extremely unusual clinical presentation as an epigastric mass. The role of ultrasound in primary diagnosis and as an interventional diagnostic modality for guided aspiration is highlighted.

Sonographic Diagnosis in a Rare Aetiology of Neonatal Scrotal Swellings: A Case Report of Congenital Nephrotic Syndrome.

BACKGROUND: Common etiologies of scrotal swelling in neonates include hydrocoele, inguinal hernia and testicular torsion; less common is epididymo-orchitis. Congenital nephrotic syndrome (CNS), a rare entity, is known to present as progressive renal failure and its leading presentation with scrotal involvement has not been reported. MATERIAL/METHODS: We report a rare case of CNS with primary clinical presentation as scrotal cellulitis and epididymo-orchitis. In this neonate, scrotal and abdominal ultrasound examination was performed and the laboratory data were obtained. RESULTS: Sonography revealed bilaterally enlarged echogenic kidneys, testis and epididymis with echogenic peritoneal fluid tracking into both scrotal sacs. Laboratory data revealed proteinuria and severe depletion of serum IgG. Culture of the peritoneal fluid showed gram-negative organisms. A final diagnosis of CNS, complicated with peritonitis tracking into the scrotal sacs was arrived at. CONCLUSIONS: CNS may have a rare presentation with distracting symptoms of scrotal cellulitis and epididymo-orchitis, as seen in our patient. However, diligent use of abdomino-scrotal sonography, supported by relevant laboratory data can clinch the accurate diagnosis.

Imaging diagnosis of neonatal anemia: report of two unusual etiologies.

Anemia in neonatal period is rare, with the common causes being Rh and ABO blood group incompatibility, hemorrhagic disease of newborn, congenital hemolytic anemia, hemoglobinopathies, and TORCH (toxoplasmosis, rubella, cytomegalovirus, herpes virus) infections. Congenital leukemia and infantile osteopetrosis (OP) are among the rare causes of neonatal anemia. A review of the literature shows approximately 200 reported cases of congenital leukemia. Articles describing the imaging features of congenital leukemia are still rarer. Infantile OP, another rare disorder with a reported incidence of 1 in 250,000 has characteristic imaging features, which are diagnostic of the disease. We report a case each, of two rare diseases: Congenital leukemia and infantile osteopetrosis. Additionally, our report highlights the radiological and imaging features of congenital leukemia and infantile OP and their crucial role in arriving at an early diagnosis.

Chest wall tuberculosis - A clinical and imaging experience.

AIMS: Tuberculous infection of the thoracic cage is rare and is difficult to discern clinically or on radiographs. This study aims to describe the common sites and the imaging appearances of chest wall tuberculosis. MATERIALS AND METHODS: A retrospective review of the clinical and imaging records of 12 confirmed cases of thoracic cage tuberculosis (excluding that of the spine), seen over the last 7 years, was performed. Imaging studies available included radiographs, ultrasonographies (USGs), and computed tomography (CT) scans. Pathological confirmation was obtained in all cases. RESULTS: All patients had clinical signs and symptoms localized to the site of involvement, whether it was the sternum, sternoclavicular joints, or ribs. CT scan revealed sternal destruction in three patients and osteolytic lesions with sclerosis of the articular surfaces of the sternoclavicular joints in two patients. In five patients with rib lesions, USG elegantly demonstrated the bone destruction underlying the cold abscess. All cases were confirmed to be of tuberculous origin by pathology studies of the aspirated/curetted material, obtained by CT / USG guidance. CONCLUSIONS: Tuberculous etiology should be considered for patients presenting with atypical sites of skeletal inflammation. CT scan plays an important role in the evaluation of these patients. However, the use of USG for demonstrating rib destruction in a chest wall cold abscess has so far been under-emphasized, as has been the role of CT and USG guided aspiration in confirming the aetiology.

Disseminated intravascular coagulation with intracranial haematoma in neonatal congenital syphilis.

Disseminated intravascular coagulation (DIC) although a well known complication in neonatal sepsis is extremely rare in congenital syphilis and there are scanty reports of this entity in the literature. Intracranial bleeding following DIC in neonatal congenital syphilis is even rarer, and has been reported only once earlier. We are reporting the second case of neonatal DIC with intracranial haematoma due to congenital syphilis in a newborn. Our patient also had clinical and biochemical evidence of hepatitis which predisposes to DIC. Extensive investigations and emergent use of imaging modalities including ultrasound and CT scan led to early diagnosis and treatment in our patient, who could therefore be salvaged from an otherwise life threatening disease.