Anupama Tandon

Spontaneous transmural migration of retained surgical textile into both small and large bowel: a rare cause of intestinal obstruction

Retained surgical textile is an infrequent but serious complication of abdominal surgery. Diagnosis is often delayed owing to non-specific clinical symptoms and inconclusive imaging features. Medicolegal implications further complicate the issue. We report a case of a 30-year-old woman who had previously undergone caesarean section and who presented with pain and features of intestinal obstruction. Contrast-enhanced CT revealed a heterogeneous ill-defined mass with mottled air densities lying within both the large and the small bowel. Barium study beautifully demonstrated the intraluminal mass in the transverse colon extending into the jejunum, with a fistulous communication between the two loops. To the best of our knowledge, this is the first reported case in which the gauze migrated simultaneously into the large and small bowel, and where the exact site of migration was clearly mapped out on pre-operative imaging studies.

External jugular venous aneurysm: A clinical curiosity

Jugular venous aneurysm is an extremely rare condition. The patients presented with a painless swelling in the neck that appears while coughing, straining, bending, or breath holding. Detection of a soft and compressible swelling in the course of an external jugular vein (EJV) superficial to the sternomastoid muscle, non-filling on compression of the EJV during Valsalva maneuver clinches the diagnosis of EJV aneurysm. Color Doppler ultrasound allows precise delineation of the lesion and is considered the gold standard for confirming the diagnosis. Surgical excision is indicated mostly for cosmetic reasons and symptomatic aneurysms. We, herein, report a patient with saccular external jugular venous aneurysm to highlight the typical clinical presentation and diagnosis of this rare entity.

Accuracy of individual descriptors and grading of nodal involvement by axillary ultrasound in patients of breast cancer.

Background. Four-node sampling is a useful substitute for sentinel node biopsy in low resource settings. USG is being increasingly used as a preoperative tool to evaluate axilla. We conducted this study to assess the accuracy of different descriptors of axillary ultrasound and to formulate a model on grading of axillary involvement. Material and Methods. Thirty-four patients with clinically negative axilla underwent preoperative axillary ultrasound. The suspicious nodes were marked and details of various descriptors were noted. These nodes were sampled during axillary dissection and correlation of ultrasonographic findings with histopathological report was done to calculate accuracy of different descriptors. Based on this, a grading system of axillary lymph nodes involvement was formulated. Results. Based on the presence of various descriptors, five grades of nodal involvement could be defined. The most accurate descriptors to indicate nodal involvement were loss of hilar fat and hypoechoic internal echoes with specificity of 83% and positive predictive value of 92% each. The combination of descriptors of round shape with loss of hilar fat and hypoechoic internal echos had 100% specificity and positive predictive value. Conclusions. Grading of nodal involvement on axillary USG can be useful for selecting the most suspicious nodes for sampling during axillary dissection.

Radiography and sonography of clubfoot: A comparative study.

Background: Congenital talipes equinovarus is a common foot deformity afflicting children with reported incidence varying from 0.9/1000 to 7/1000 in various populations. The success reported with Ponseti method when started at an early age requires an imaging modality to quantitate the deformity. Sonography being a radiation free, easily available non-invasive imaging has been investigated for this purpose. Various studies have described the sonographic anatomy of normal neonatal foot and clubfoot and correlated the degree of severity with trends in sonographic measurements. However, none of these studies have correlated clinical, radiographic and sonographic parameters of all the component deformities in clubfoot. The present study aims to compare the radiographic and sonographic parameters in various grades of clubfoot. Materials and Methods: Thirty-one children with unilateral clubfoot were examined clinically and graded according to the Demeglio system of classification of clubfoot severity. Antero-posterior (AP) and lateral radiographs of both normal and affected feet were obtained in maximum correction and AP talo-calcaneal (T-C), AP talo-first metatarsal (TMT) and lateral T-C angles were measured. Sonographic examination was done in medial, lateral, dorsal and posterior projections of both feet in static neutral position and after Ponseti manouever in the position of maximum correctability in dynamic sonography. Normal foot was taken as control in all cases. The sonographic parameters measured were as follows : Medial malleolar- navicular distance (MMN) and medial soft tissue thickness (STT) on medial projection, calcaneo-cuboid (C-C) distance, calcaneo-cuboid (C-C) angle and maximum length of calcaneus on lateral projection, length of talus on dorsal projection; and tibiocalcaneal (T-C) distance, posterior soft tissue thickness and length of tendoachilles on posterior projection. Also, medial displacement of navicular relative to talus, mobility of talonavicular joint (medial view); reducibility of C-C mal alignment (lateral view); talonavicular relation with respect to dorsal/ ventral displacement of navicular (dorsal view) and reduction of talus within the ankle mortise (posterior view) were subjectively assessed while performing dynamic sonography. Various radiographic and sonographic parameters were correlated with clinical grades. Results: MMN distance and STT measured on medial view, C-C distance and C-C angle measured on lateral view and tibiocalcaneal distance measured on posterior view showed statistically significant difference between cases and controls. A significant correlation was evident between sonographic parameters and clinical grades of relevant components of clubfoot. All radiographic angles except AP T-C angle were significantly different between cases and controls. However, they did not show correlation with clinical degree of severity. Conclusion: All radiographic angles except AP T-C angle and sonographic parameters varied significantly between cases and controls. However, radiographic parameters did not correlate well with clubfoot severity. In contrast, sonography not only assessed all components of clubfoot comprehensively but also the sonographic parameters correlated well with the severity of these components. Thus, we conclude that sonography is a superior, radiation free imaging modality for clubfoot.

Primary dural follicular lymphoma masquerading as meningioma: a case report.

Patient presented with a dural-based mass lesion and was diagnosed as having meningioma on imaging. Post-resection histological examination revealed a low grade follicular lymphoma. The patient received cranial radiotherapy and is recurrence-free at 6-month follow-up. Primary dural follicular lymphoma is an exceedingly rare entity with only as few as six reported cases. Herein, the clinico-radio-pathological appearances and treatment protocol of this entity are discussed.

Pseudoachondroplasia: A rare cause of rhizomelic dwarfism

Pseudoachondroplasia is a rare rhizomelic short-limbed skeletal dysplasia. Its inheritance is varied; autosomal dominant pattern and germline or somatic mutations can occur. Children at 2–3 years of age present with short height, gait disturbances, or limb deformities. Characteristic skeletal changes include shortening of long bones, predominantly of femur and humerus with irregular, flared metaphysis and fragmented epiphysis. Platyspondyly is also present, but the interpedicular distance is normal. The diagnosis is essentially based on imaging, and thus, it is important to be aware of the radiological features. Here, we report a case of two brothers where the elder sibling had classical radiological features of pseudoachondroplasia, whereas the younger one had early changes of this disorder.

Intraparenchymal Angiomatous Meningioma: A Diagnostic Dilemma.

Meningioma arises from the arachnoid cap cells of the cerebrum. Intraparenchymal meningiomas or meningiomas without dural attachment are rare. We report a case of 40-year-old male who presented with a history of headache, dizziness and gradual loss of vision since one year. Clinicoradiological diagnosis of a high grade glioma was considered. Tumour was excised and haematoxylin and eosin stained sections revealed a tumour comprised predominantly of variable sized blood vessels showing hyalinization in a background of plump spindle cells with oval vesicular nuclei. In view of these features angiomatous meningioma was suspected. However, to confirm the diagnosis, a panel of immunohistochemical markers including vimentin, EMA and GFAP was done and a final diagnosis of angiomatous meningioma was offered. Angiomatous meningioma is a rare variant of meningioma and even much rarer in the intraparenchymal location. Angiomatous meningioma should be considered in the differential diagnosis of highly vascular intraparenchymal brain tumours.

Virtual cystoscopy (pneumo-cystoscopy)-Its utility in the prospective evaluation of bladder tumor

Aim: To evaluate the role of virtual cystoscopy (VC) comparing it with cystopanendoscopy (CPE) for detecting bladder tumor(s). Material and Methods: Ethical clearance was obtained from the Institutional ethics committee. After an informed consent 30 patients fulfilling the inclusion criteria were enrolled in the prospective non-randomized clinical study and were evaluated as per protocol with VC performed by a qualified radiologist who was blinded to the findings of CPE performed by a qualified urologist. The results so obtained were analyzed using appropriate statistical tools. Results: The mean age of the patients was 56 years. Sensitivity of VC in detecting bladder lesions was 92%. However, when axial images were also interpreted along with VC, the sensitivity increased to 96% for detecting bladder lesions. The specificity of VC with axial CT was 40% in respect of detecting bladder lesions. VC with axial CT was 85.7% sensitive in identifying multiple bladder tumors. There were no complications on account of performing VC. Minor problems were encountered with VC and CPE in 16.7% and 13.3% patients respectively. Conclusions: VC with axial CT is 96% sensitive in detecting bladder lesions and 85.7% sensitive in detecting the multiplicity of the tumors. VC may be a useful complementary diagnostic tool for the workup of select patients with suspected bladder lesions. However, larger randomized controlled studies are needed to better define the precise clinical and diagnostic role of VC in routine practice. Settings and Design: Prospective Clinical Comparative Non Randomized Clinical Study.

Multiple intracystic floating balls: an unusual but unique sonographic pattern of mature cystic teratoma

Mature cystic teratoma is the most common benign ovarian neoplasm occurring in the reproductive age group.1 Sonography is invariably the primary modality for diagnosis. The great diversity in components of teratomas results in varied sonographic appearances. Certain features like tip-of-iceberg sign, fat-fluid level, dermoid mesh and rokitansky protuberance (dermoid plug) are specific to this entity and considered diagnostic.2 A sonographic appearance of …

Disseminated histoplasmosis: a rare case presentation

Disseminated histoplasmosis (DH) is a progressive granulomatous disease caused by a thermal dimorphic fungus, Histoplasma capsulatum. Mycelia, the naturally infectious form of Histoplasma, occurs in two forms: macroconidia and microconidia. The latter are inhaled following activities, such as spading of the soil and demolition of old buildings, and settle in the alveoli. They are then ingested by macrophages and transform into yeasts which spread via the blood stream to cause disseminated disease. These macrophages release cytokines and attract more macrophages to fight the fungus; they then coalesce to form granulomas. It usually takes two weeks to activate the T-cell mediated immune response, the failure of which results in the progressive spread of infection to other organs.