Anju Garg

Primary tubercular osteomyelitis of the sternum

Tubercular involvement of the sternum, leading to osteomyelitis, is a rarely described entity even in countries where tuberculosis is endemic. Presentation in pediatric age group is even more uncommon. We describe a 12 year old girl who presented with a mass over the manubruim sterni and fever. CT chest demonstrated a soft tissue mass in the anterior mediastinum, eroding the cortex of the manubrium. Tubercular etiology was suggested by presence of epithelioid granulomas and acid fast bacilli in the Ziehl-Neelsen staining of the aspirate from the lesion. the patient responded well to antitubercular treatment.

Automated Primary Screening Devices

failure might vary widely. During the past year there has been a lull in the previously very active promotion of primary screening devices. It appears that economic projections for the manufacturers did not materialize. This offers a good opportunity to assess the situation and to suggest where the development might go from here. The first question to be raised requires that we return to the beginning. What is the problem that automation of primary screening is to solve? The often-quoted Wall Street Journal article (Bogdanich W: The pap test misses much cervical cancer through lab’s errors. Nov 2, 1987) called attention to several concerns. There were concerns about the reliability of the reading of a Pap smear, about the possibility of shortages in highly trained personnel and about labor costs. The resulting availability of capital for technology development undoubtedly responded to the need to support the control of cervical cancer, but one has to consider that a prime motivation was the potential for economic gain. There is nothing wrong with that notion in principle, but inevitably it had major consequences. The first consequence was that technical solutions to the problem were explored almost entirely with the medical/economic situation in the United States in mind. A device had to process a slide within a very short time frame so that system throughput would meet revenue projections. Device costs were weighed against amortization schemes, projected unit sales and return on investment capital. There were discussions about acceptable false negative rates and how these might be pegged to revised estimates of false negative rates in current laboratory practice. There were serious and justified concerns about the risk of lawsuits in the United States. One cannot help, though, particularly on the ocAfter 35 years of basic research and development, automated screening devices for cervical cancer went into clinical trials and entered clinical practice. The results have been encouraging and might be called a success in several ways. The United States FDA approved two devices; both proved to perform at a level equal to or better than claimed by the manufacturers. Beyond that the field tests established that it should be possible to design systems that might find approval by the cytopathology community. The devices in the clinical trials were, after all, only first-generation designs. There is no complex technology that performs at the level of its potential until several generations of designs have evolved. As first-generation devices, given the very substantial difficulties of the problem and the circumstances under which their development took place, they performed remarkably well. Eliminating design compromises dictated either by the state of technology at the time of development or by the development climate concomitant with venture capital financing would produce the next generation of primary screening systems that come much closer to a performance level well respected by medical professionals. One might hear the argument that since performance of the first-generation devices was critically assessed by the FDA in the United States, why should the profession call for improvements? It is true that the FDA approved these devices. However, one has to understand that the FDA here merely certified that the devices perform at the level claimed by the manufacturer. If one wanted to be unkind, one might suggest that the industry set its own standard. In practice it would essentially be the laboratory director who decides whether a claimed performance level can be maintained and is acceptable or not. The extent to which such a decision would be based on a thorough understanding

Spectrum of findings on magnetic resonance imaging of the brain in patients with neurological manifestations of dengue fever.

Objective To describe the spectrum of magnetic resonance imaging (MRI) findings in patients with neurological manifestations of dengue. Materials and Methods We included nine patients with dengue fever (three females and six males; age range, 9–30 years), all of whom presented with neurological manifestations. The MRI examinations, performed in 1.5 T or 3 T scanners, included T1-weighted, T2-weighted, and fluid-attenuated inversion recovery (FLAIR) sequences. Diffusion-weighted imaging with apparent diffusion coefficient mapping was also employed. Fast low-angle shot and susceptibility-weighted gradient-recalled echo sequences, as well as contrast-enhanced T1-weighted scans, were also obtained in order to assess parenchymal enhancement. MRI scans were analyzed for lesion distribution and imaging features. Results All patients showed areas of altered signal intensity that appeared as hyperintensity on T2-weighted and FLAIR sequences. The most commonly affected site was the basal ganglia-thalamus complex. Other affected sites were the cerebellum, cerebral cortex, white matter, and brainstem. In all cases, we observed patchy areas of restricted diffusion and focal areas of hemorrhage. Conclusion Dengue encephalitis commonly affects the basal ganglia, thalamus, cerebellum, cerebral cortex, and white matter. Therefore, MRI should be an indispensable part of the evaluation of patients with neurological complications of dengue fever.

Psammomatous Colloid Carcinoma of the Breast with Micropapillary Pattern

1 week, the patient presented with reduced hematoma dimensions on US, without evidence of internal flow on Doppler. Pseudoaneurysm is an uncommon complication due to a transmural rupture of an arterial wall and the subsequent formation of a hematoma that maintains in communication with the arterial lumen. Cases are reported in the literature of breast pseudoaneurysms secondary to trauma, vascular catheterization, postoperative and after percutaneous procedures such as biopsy by large-core needle (core biopsy) and vacuum-assisted biopsy. It is more frequent in older patients, patients with atherosclerotic disease and in those in use of anticoagulant therapy. The ultrasonographic appearance consists of heterogeneous collection with typical vascularization on Doppler. Patients are often asymptomatic and simple US monitoring may be sufficient on the basis of its morphological characteristics. Spontaneous thrombosis depends on the size of pseudoaneurysm, length of the communication with the arterial vessel and anticoagulative state of the patient. In the absence of spontaneous thrombosis, therapeutic options for pseudoaneurysm include US-guided compression, percutaneous injection of thrombin or alcohol, embolization, and surgical repair. The recognition of clinical signs during the procedure and use of Doppler can offer an early diagnosis and greater chance of successful nonsurgical occlusion.

Cystic Lymphangiomatous Hamartoma Masquerading as Massive Ascites

We report a 4-year-old boy presenting with a tense massive ascites and large hydrocele. History and physical examination were unremarkable. Routine laboratory studies were normal. Abdominal ultrasonography revealed massive ascites. Contrast CT was suggestive of a large cyst covering the entire peritoneal cavity. At laparotomy, a large cystic tumor was found extending into the scrotum through the left inguinal ring. Histopathologic examination diagnosed the tumor as a cystic lymphangiomatous hemartoma. Although abdominal lymphangiomas are seen in children, but presenting as massive ascites with hydrocele is very rare.

Abdominal cocoon – A rare case of intestinal obstruction: A report of two cases

We present the imaging findings in 2 adolescent girls with abdominal cocoon formation, a rare cause of intestinal obstruction. It may be primary/idiopathic or secondary in nature and is characterized by small bowel encapsulation. Familiarity with the imaging findings and a high index of suspicion helps in reaching the diagnosis pre-operatively in this rare condition and hence planning surgical management.

Pediatric acute leukemia presenting as bilateral renal enlargement. Report of a case with fine needle aspiration cytologic features suggestive of megakaryocytic differentiation.

BACKGROUND Fine needle aspiration (FNA) cytologic diagnosis of acute myeloid leukemia involving the kidney has rarely been reported, but acute leukemia with cytologic features suggestive of megakaryocytic differentiation has not been described before. CASE An 8-month-old male presented with an abdominal swelling, bilateral cervical and inguinal lymphadenopathy and enlarged left epididymis. Ultrasonography of the abdomen revealed a space-occupying lesion in the liver and bilateral enlargement of the kidneys. FNA smears from the right kidney and right submandibular lymph node showed numerous blast cells. Since rare blast cells were positive for myeloperoxidase, a cytodiagnosis of involvement by acute myeloid leukemia (AML) was made. However, following the hematologic diagnosis of acute megakaryoblastic leukemia (M7) from peripheral blood and bone marrow smear examination, FNA smears were reviewed. There were cytoplasmic blebs or protrusions in the blast cells and cytologic features suggestive of their differentiation toward micro-megakaryocytes and megakaryocytes. There was also evidence of shedding of platelets, including numerous giant platelets. The reviewed FNA cytodiagnosis was suggestive of AML (M7). CONCLUSION Extramedullary involvement by acute megakaryoblastic leukemia (M7) can be suspected based on cytomorphologic features in FNA smears.

Imaging spectrum of spinal dysraphism on magnetic resonance: A pictorial review

Congenital malformations of spine and spinal cord are collectively termed as spinal dysraphism. It includes a heterogeneous group of anomalies which result from faulty closure of midline structures during development. Magnetic resonance imaging (MRI) is now considered the imaging modality of choice for diagnosing these conditions. The purpose of this article is to review the normal development of spinal cord and spine and reviewing the MRI features of spinal dysraphism. Although imaging of spinal dysraphism is complicated, a systematic approach and correlation between neuro-radiological, clinical and developmental data helps in making the correct diagnosis.

Goldenhar syndrome with contralateral pulmonary aplasia: a rare association

We present a case of a 13-year-old boy with clinical features of Goldenhar syndrome (hemifacial microsomia with malformed ears) and associated contralateral pulmonary aplasia. The patient did not have any associated respiratory symptoms. Pulmonary aplasia is an uncommon association of Goldenhar Syndrome. A case of contralateral pulmonary aplasia has been rarely reported in the literature to the best of our knowledge.

Giant Unruptured Sinus of Valsalva Aneurysm: An Unusual Cause of Right Heart Failure

Aneurysm of sinus of Valsalva is a rare cardiac abnormality. Unruptured aneurysm of sinus of Valsalva is usually asymptomatic and often discovered incidentally. However, a large aneurysm can, in rare cases, cause compression of the ventricular outflow tract. We report a case of 17-year-old male with congestive right heart failure with a large, partially thrombosed unruptured aneurysm of the right sinus of Valsalva. The aneurysmal sac was compressing the right ventricular outflow tract causing marked dilatation of the right ventricle and atrium that was confirmed on contrast-enhanced computed tomography imaging. Unruptured sinus of Valsalva aneurysm causing right heart failure in adolescence has been rarely reported in literature.