Alessandro Severo Alves de Melo

Intestinal and appendiceal paracoccidioidomycosis

Dear. Editor,A male, 20-year-old patient with hematochezia and enteror-rhagia associated with weight loss. Colonoscopy demonstratednonspecific rectitis, and histopathological analysis was compat-ible with Crohn’s disease. The treatment was initiated and remis-sion was observed.After five months, the medication was interrupted withoutmedical advice, and recurrence of the same initial symptoms wasobserved after one month, in addition to papular lesions, some ofthem pustular, scattered throughout the body and scalp. After fivedays of immunosuppressive therapy, progression of the papularlesions, onset of intensely painful, hemorrhagic lesions in the oralmucosa, and painful lymph nodes enlargement in cervical chainswere observed. Then, the patient was transferred to the authors’institution where the assessment by the Unit of Dermatology raisedthe suspicion of paracoccidioidomycosis (PCM), confirmed by orallesions smear and silver staining demonstrating the typical pin-wheel cells. Rectosigmoidoscopy demonstrated granulomatousproctosigmoiditis and biopsy confirmed the diagnosis. Abdomi-nal computed tomography (CT) identified ileocecal mass, appen-diceal thickening with parietal contrast enhancement, adjacentperitoneal fat infiltration, mesenteric and retroperitoneal lymphnodes enlargement, besides parietal thickening of the rectum withpararectal gaseous foci at right, caused by fistulas, and perirectalfat blurring (Figure 1).He was treated with amphotericin B which, after four days,resulted in improvement of the dermatological and painful condi-tion. The tomographic follow-up revealed involution of the ileoce-cal, appendicular and rectal involvement.The Brazilian radiological literature has recently highlightedthe relevance of imaging methods in the diagnosis of the diges-tive system diseases

Calcificação pulmonar metastática: relato de caso *

Neste trabalho e relatado o caso de uma paciente do sexo feminino de 48 anos de idade, portadora de insuficiencia renal cronica, em dialise ha 13 anos, tendo iniciado o quadro com hemoptise, febre, tosse produtiva e dispneia aos grandes esforcos. A radiografia de torax apresentou opacidades mal definidas predominando nos tercos medios e inferiores dos pulmoes. A tomografia computadorizada de torax evidenciou opacidades em vidro fosco associadas com nodulos centrolobulares mal definidos, com atenuacao em vidro fosco. A paciente foi submetida a lavagem broncoalveolar, que foi negativa para micobacterias e fungos. Com base nesses achados, foi realizada biopsia pulmonar a ceu aberto, que revelou calcificacao pulmonar metastatica.

Primary intercavernous lymphoma of the central nervous system

A male, 63-year-old, HIV-negative patient was admitted to the hospital with intermittent frontal headache, right facial pain and diplopia for at least two months. Neurological examination revealed both cranial nerves VI paresis and facial pain in the area innervated by the branches V2 and V3 of the right trigeminal nerve. No alteration was observed in the other cranial nerves. The patients presented with normal gait and unaltered muscle strength and balance. Laboratory tests and cerebrospinal fluid puncture revealed normal results. Cranial magnetic resonance imaging (MRI) demonstrated an expansile, intrasellar homogeneous, solid, well delimited lesion, with isosignal on T1and T2-weighted sequences with a lower enhancement pattern in relation to the hypophysis. The lesion occupied both cavernous sinuses, particularly at right. The way in which the lesion extended suggested the involvement of the intercavernous sinus (Figure 1). The patient was submitted to surgical treatment, with an uneventful postoperative period. Anatomopathological analysis (Figure 2A) demonstrated diffuse non-Hodgkin’s B-cell lymphoma. The patient underwent complementary radiotherapy, and successive follow-up with MRI did not demonstrate lesion recurrence in up to five years (Figure 2B). Central nervous system (CNS) lymphoma is a quite rare neoplasm, affecting most the supratentorial region. In the case of immunocompetent patients, CNS lymphoma manifests as a single, solid lesion, generally without necrosis, with hypo/isosignal on T2and isosignal on T1-weighted sequences, and intense contrast-enhancement. Anatomically, cavernous sinuses are irregularly-shaped, trabeculated/compartmentalized venous sinuses located along the lateral aspect of the sella turcica. Cranial nerves III, IV, V1 and V2 are located within the lateral dural wall, and not within the cavernous sinus. The two cavernous sinuses communicate with each other via anterior and posterior intercavernous venous plexuses. Such connections allow for extension of the inflammatory or neoplastic process to the contralateral sinus. In the case of cavernous sinus lymphoma, considering the proximity to several cranial pairs, cranial nerve lesions may be observed; however this is an uncommon finding. CNS lymphomas are rarely found, particularly in immunocompetent individuals. In the present case, the unprecedented characteristic is the infra-hypophyseal involvement by dissemination through the intercavernous sinus. Despite its rarity, particularly in immunocompetent individuals, the finding of a solid, homogeneous lesion with isosignal on T1and T2-weighted sequences in the region of the cavernous sinuses should raise the hypothesis of lymphoma.

Aspectos tomográficos e anatomopatológicos da sarcoidose pulmonar

Objetivo: Analisar os aspectos radiologicos observados nas tomografias computadorizadas de alta resolucao de pacientes com sarcoidose e fazer a correlacao com os achados anatomopatologicos. Materiais e Metodos: Foram revistos os aspectos radiologicos observados nas tomografias computadorizadas de alta resolucao de dez pacientes com sarcoidose e feita correlacao com material obtido de biopsias cirurgicas ou necropsias de quatro desses pacientes. Resultados: O aspecto mais frequentemente observado foi o de nodulos, com distribuicao perilinfatica, predominando ao longo das bainhas broncovasculares e da superficie pleural, com nodulos subpleurais e cissuras nodulares. Outros achados menos comuns foram as opacidades em vidro fosco e o espessamento de septos interlobulares. Conclusao: Em geral, todos esses achados corresponderam, anatomopatologicamente, ao acumulo de granulomas nessas regioes. Unitermos: Tomografia computadorizada; Sarcoidose; Anatomopatologia; Doencas pulmonares.

Applications of Magnetic Resonance Imaging of the Thorax in Pleural Diseases: A State-of-the-Art Review

The aim of this review was to present the main aspects of pleural diseases seen with conventional and advanced magnetic resonance imaging (MRI) techniques. This modality is considered to be the gold standard for the evaluation of the pleural interface, characterization of complex pleural effusion, and identification of exudate and hemorrhage, as well as in the analysis of superior sulcus tumors, as it enables more accurate staging. The indication for MRI of the thorax in the identification of these conditions is increasing in comparison to computerized tomography, and it can also be used to support the diagnosis of pulmonary illnesses. This literature review describes the morphological and functional aspects of the main benign and malignant pleural diseases assessed with MRI, including mesothelioma, metastasis, lymphoma, fibroma, lipoma, endometriosis, asbestos-related pleural disease, empyema, textiloma, and splenosis.

Lesões traumáticas do mediastino: aspectos na tomografia computadorizada

Traumatic mediastinal lesions are unusual findings in patients with thoracic trauma but may represent poor prognosis and be associated with severe lesions. Mediastinal trauma is increasingly being diagnosed by computed tomography due to the fast acquisition times of helical techniques, allowing the evaluation of critically ill patients and the adoption of efficient therapeutic measures. The authors studied 11 patients with mediastinal lesions who were submitted to computed tomography due to thoracic trauma. The most frequent finding was mediastinal bleeding characterized by infiltration of mediastinal fat, dense material within the mediastinal spaces or hematoma. Hemopericardium was the second most common lesion in this series, appearing as dense or liquid material in the pericardium. Aortic lesions such as wall irregularities or pseudoaneurisms were less commonly seen (three patients). In this study blunt thoracic traumas were observed in six cases whereas penetrating trauma occurred in five cases. The causes of blunt trauma were pedestrians struck by car, motor vehicle accidents and falls. Penetrating trauma was due to lesions produced by bullets or knifes.

Lesões traumáticas do parênquima pulmonar: aspectos na tomografia computadorizada

Traumatic lesions of the lung are common findings in patients with thoracic trauma. These lesions are increasingly diagnosed using computed tomography, mostly due to the fast acquisition time helical techniques that allow evaluation of critically ill patients and an efficient therapeutic management. The authors studied 150 patients with thoracic trauma submitted to computed tomography that demonstrated lung contusions, atelectasies, lacerations and hematomas. Lung contusions were the most frequent lesions appearing as consolidation or ground-glass attenuation areas. Atelectasies, in subsegmentar and compressive patterns, were the second most common lesions observed. Lacerations appeared as consolidations with air or liquid level. Lung hematomas, characterized by round opacities, were the most rare lung lesions seen in only five cases. In this study, blunt thoracic trauma accounted for the majority of 120 cases whereas penetrating trauma occurred in 30 cases. The causes of blunt trauma in decrescent order of frequency were motor vehicle accidents, pedestrian hit by car, falls, motorcycle accidents and trashing. Penetrating traumas were caused by bullets or knives.

Síndrome de Ogilvie após uso de vincristina: achados tomográficos

manifests clinically as a yellowish mass in the lateral corner of the eye, which becomes more evident with retropulsion of the globe. The imaging tests that can facilitate the diagnosis of subconjunctival fat prolapse are CT and magnetic resonance imaging (MRI) of the orbits, the most important radiological finding being that of a mass with fat density or fat-like signal intensity, respectively, located in the temporal aspect of the orbits, contiguous with intraconal fat. The treatment consists of transconjunctival excision, a simple, safe and effective surgical procedure. The rate of recurrence after transconjunctival excision is reported to be approximately 9%. Making a clinical diagnosis of subconjunctival fat prolapse is relatively easy. However, due to its rarity, it can be misdiagnosed as conjunctival dermolipoma, lymphoma, epidermoid cyst, or lacrimal gland prolapse. The main differential diagnosis is conjunctival dermolipoma, which consists of a benign lesion, usually present at birth, that affects young women, the mean age of such patients being 22 years. Although the clinical presentation of conjunctival dermolipoma is similar to that of the subconjunctival fat prolapse, the former is typically unilateral and fairly immobile. On CT and MRI, conjunctival dermolipoma presents as a crescent-shaped fatty mass in the temporal aspect of the orbit, not in communication with the intraconal fat. In conjunctival dermolipoma, surgical resection is indicated mainly for aesthetic purposes and tends to be more conservative. Although resection of a conjunctival dermolipoma is a simple procedure, there can be severe complications, including blepharoptosis, diplopia, and keratoconjunctivitis sicca. Therefore, a number of different surgical techniques aimed at a lowering the rate of complications and improving the aesthetic results have been described, including resection with conjunctival flap rotation. Cynthia Ramos Tejo1, Péricles Almeida da Costa1, Rafaella Martins Batista1, Yuri Raoni Ramalho Rocha1, Marcelle Alves Borba1

Specialized telecommunications system in the transmission of digital radiological images in hostile environments

The international standard of transport and storage of radiological images - DICOM, the National Electrical Manufacturers Association (NEMA) - was formed to integrate the industry segment in favor of a single model of operation, aiming above all integration, customization and possible economy. This methodology combines virtues, mainly by excluding the proprietary view of previous systems. The images of a radiological examination must be transmitted from source to receiver without interruption or delay, have a large volume of files and large size together (in megabytes). The international standard is designed to operate at optimum telecommunications environments - stable, secure and transmission rates of local networks. In order to enable the practice of medicine where there is the presence of health professionals, Telemedicine seeks the creation of technologies that enable its activity. Conventionally, these physical environments also lack virtuous telecommunications systems. The telecom environment in the State of Amazonas to clinical and hospital environments of the State Secretariat of Health of the Amazon is distributed via satellite to 128 kbps connections. The 62 cities of this state are in dense forest environments with high humidity, heavy rainfall and high rate of electrical storms. Currently, even in the state of Amazonas, is in use in 44 units and in installation phase in the remaining 21 hospitals of the State Government, transmitting full digital mammograms beyond satellite to the Medical Report Center, located at the Hospital Francisca Mendes (Manaus/AM) of Federal University of Amazonas. The system has been customized to the case and is able to carry more than 380,000 exams per year, coming from the State Hospitals for Medical Reports Center. A simulator of deployed communications equipment will be presented at the Congress, demonstrating its practicality and dynamism when compared to international systems.

Usefulness of dynamic contrast-enhanced MRI in the evaluation of osteonecrosis of the proximal fragment in scaphoid fractures

Luiza Werneck1, Clarissa Canella2, Flavia Costa1, Alessandro Severo Alves de Melo3, Edson Marchiori4 1. Clínica de Diagnóstico Por Imagem (CDPI), Rio de Janeiro, RJ, Brazil. 2. Clínica de Diagnóstico Por Imagem (CDPI), Rio de Janeiro, RJ, e Universidade Federal Fluminense (UFF), Niterói, RJ, Brazil. 3. Universidade Federal Fluminense (UFF), Niterói, RJ, Brazil. 4. Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil. Correspondence: Dra. Clarissa Canella. Avenida das Américas, 4666, sala 325, Barra da Tijuca. Rio de Janeiro, RJ, Brazil, 22640-102. E-mail: clacanella@yahoo.com.br. Dear Editor, A 26-year-old man who had fractured his scaphoid four weeks previously presented with persistent wrist pain. Magnetic resonance imaging (MRI) showed a fracture line through the scaphoid waist (Figure 1). A gadolinium contrast-enhanced coronal T1-weighted sequence with fat saturation was acquired, as were time-signal intensity curves of the proximal and distal scaphoid poles. The complete absence of enhancement of the proximal pole of the scaphoid, together with the fact that the time-signal intensity curve was lower for the proximal pole than for the distal pole, denoted satisfactory perfusion of the proximal pole. The scaphoid is the most commonly fractured bone of the carpus, and healing is interrupted by nonunion in 5–15% of cases. Scaphoid fracture nonunion may progress to avascular necrosis of the scaphoid in cases of long-standing nonunion, after failed surgery, in certain fractures of the proximal third of the scaphoid, or when an occult fracture is not treated. The proximal pole of the scaphoid is prone to avascular necrosis due to the distal location of the main feeding vessels and the retrograde pattern of the intraosseous blood supply. Stress fracture of the scaphoid waist is believed to contribute to osteonecrosis of the scaphoid resulting from repetitive dorsiflexion of the wrist, the waist being the weakest point in the scaphoid. A number of recent studies conducted in Brazil have highlighted the importance of MRI in the evaluation of diseases affecting the musculoskeletal system. The use of a reliable noninvasive diagnostic tool to assess the viability of the proximal scaphoid pole is necessary to help surgeons plan the treatment of scaphoid nonunion, because there is currently no consensus regarding when conservative or surgical treatment is indicated. Recently, gadolinium contrast-enhanced MRI has been shown to be the most accurate modality for evaluating scaphoid viability. In fact, some authors have suggested that dynamic contrastenhanced MRI represents a valuable tool in assessing whether conservative or surgical treatment is indicated to achieve a good functional outcome . According to those authors, if dynamic contrast-enhanced MRI shows poor perfusion of the proximal pole of the scaphoid, primary surgical intervention would be indicated. Despite the fact that time-signal intensity curves of the proximal and distal scaphoid poles are actually widely used, there have been a few reports suggesting that the analysis of these curves does not provide additional predictive value over standard delayed enhancement MRI for acute scaphoid fracture.