Christine Azzopardi

Teaching NeuroImages: Chordoma

A 30-year-old man presented with recurrent headaches. CT head revealed a clival chordoma (figure 1A). Chordomas originate from the embryonic remnants of the notochord and account for 2%–4% of all malignant bone tumors. They have a predilection for the axial skeleton, with 35% affecting the spheno-occipital region. The incidence peaks at ages 20–40 years. Male patients are affected twice as commonly as female patients.1 Clinical symptoms often result from local mass effect. On imaging, the tumor appears as a midline lesion and can contain heterogeneous calcifications. MRI demonstrates high signal on T2-weighted sequences and heterogeneous enhancement with a honeycomb appearance (figure 1).2 Indenting of the pons results in the characteristic thumb sign (figure 2). Differential diagnosis based on imaging appearance includes chondrosarcoma and metastasis.

Congenital tufting enteropathy and chronic arthritis: a clinical and radiological perspective

Congenital tufting enteropathy is a rare condition which presents in early infancy. It is a condition which should be suspected in infants who present with diarrhoea soon after birth. A rare association with arthritis has been observed with a handful of cases documented in the literature. Our case differs as the arthritis described is erosive in nature, a feature which is not present in other cases.

Xanthogranulomatous pyelonephritis: the case of a perplexing kidney

### Case report A previously healthy 2-year-old girl presented with turbid urine and pallor. She was otherwise asymptomatic and afebrile. Clinical examination revealed a large ballotable right-sided abdominal mass. Ultrasound revealed an enlarged right kidney with loss of the normal renal architecture, which was replaced with multiple hypoechoic nodules. A number of renal calculi were observed with typical acoustic shadowing (figure 1). A contrast-enhanced CT scan demonstrated the diagnostic ‘bears paw’ sign, multiple calculi, retroperitoneal lymphadenopathy and a small right psoas …

Adult colorectal intussusception.

### Case report A 30-year-old woman presented with severe lower, colicky abdominal pain and difficulty in passing flatus. Clinical examination revealed suprapubic tenderness. An abdominal CT was performed which revealed a soft-tissue mass in the pelvis demonstrating ‘a target sign’ appearance confirming the diagnosis of intussusception (figure 1). The effect of the intussusceptum within the intussuscipiens creates a layered appearance. There is loss of gas within the rectum, instead, this is replaced by a soft-tissue mass of fat density (Hounsfield units −10) (figure 2). A …

Not just another thunderclap headache: a case of isolated cortical vein thrombosis and subarachnoid haemorrhage

A 63-year-old woman presented with a severe frontal thunderclap headache associated with transient blurring of vision. No significant medical history other than blood hypertension was noted. On examination, there was no neck stiffness or fever, however, her blood pressure was 160/90 mm Hg. Ophthalmoscopic assessment excluded papilloedema and neurological examination was unremarkable. A non-contrast CT scan showed a small subarachnoid haemorrhage (SAH) in the frontal region bilaterally (figure 1A). A cerebral CT angiogram failed to reveal any aneurysms. She proceeded to have an MRI. The fluid-attenuated inversion recovery sequence confirmed the subarachnoid bleed (figure 1 …

Beware the person with the glass eye and the large liver

A 67-year-old woman presented to the emergency department reporting of epigastric fullness, fatigue and weight loss. Physical examination revealed three fingerbreadths of hepatomegaly. Blood tests were unremarkable, save for a moderately raised erythrocyte sedimentation rate. An urgent CT of her abdomen demonstrated two large liver lesions of low attenuation on the non-enhanced scan (figure 1A), showing heterogeneous enhancement in the arterial phase (figure 1B) with contrast washout after a 5 min delay (figure 1C), an appearance typical of hypervascular metastasis. Ultrasound-guided biopsy of one of these lesions was performed as a …

Mounier-Kuhn syndrome: more than just a cough.

A 35-year-old man presented with a chronic productive cough and a history of recurrent lower respiratory tract infections. Physical examination was unremarkable as were routine blood investigations. A chest radiograph demonstrated dilation of the trachea and main bronchi. Multiple perihilar cysts with air-fluid levels were seen (figure 1). Contrast-enhanced chest CT confirmed tracheal dilation with multiple tracheal diverticulae present in the posterior aspect of the proximal trachea (Ofigure 2). Both main bronchi were also dilated. Bilateral, cystic spaces with air-fluid …

When the going gets rough: a sequela of splenic trauma.

### Case report A 45-year-old man presented with left-sided flank pain 2 days after a rough game of football. On examination, extensive bruising was evident over his left chest wall. His vital parameters were stable with a blood pressure reading of 129/85 mm Hg and a slight tachycardia of 105 bpm. He was exquisitely tender over the left seventh to nineth ribs. Rib fractures were confirmed on plain radiography and an ultrasound of the abdomen was performed to exclude any underlying visceral injury. An abdominal ultrasound demonstrated free intra-abdominal fluid. A 1.5 cm round, hypoechoic lesion was present within the spleen. On colour Doppler examination bidirectional internal flow was observed …

Diarrhoeal episodes in travellers suffering from IBD

Background and aims There is limited data on the risk of developing diarrhoea in travelling patients with inflammatory bowel disease (IBD). We analysed the rate of developing diarrhoea among travellers suffering from IBD and their healthy controls. Methods We performed a retrospective case-controlled study among 78 patients with IBD and their healthy travelling companion controls, thus matching both groups to the same environmental conditions. Data was retrieved through a structured questionnaire, interview and clinical case notes review. Results Sixteen (20.5%) patients with IBD developed diarrhoea while abroad (p −0.0001) Statistical analysis using a χ2 test for independence (with Yates Continuity Correction). Prior to travelling, they were in clinical remission. Only one healthy control (1.3%) developed diarrhoea while abroad. In 11 patients (14.1%), the duration of diarrhoea was 3 days or less, and resolved on its own without antibiotics, any increase in their IBD medications and without a medical consultation. The other five patients had a flare-up of their disease and needed medications to put them back into remission. There was no statistically significant difference between patients having immunomodulator medications versus those having aminosalicylates only in developing diarrhoea when abroad. Conclusions Patients with IBD have a higher rate of developing diarrhoea compared with controls when travelling. Thus, such patients must always seek a pretravel medical consultation.

Lemierre syndrome: more than just a sore throat

A previously healthy, 35-year-old, immunocompetent man presented with a 2-day history of sore throat and unilateral swelling of the right neck. The patient was found to be tachycardic and pyrexic on clinical examination. Lemierre syndrome is the sequela of acute pharyngotonsillitis. The cause is often the anaerobe Fusobacterium necrophorum. 1 Patients present with septicaemia and a preceding history of upper respiratory tract infection. The infection primarily affects the palatine tonsils, spreading along the fascial planes into the carotid space resulting in thrombophlebitis of the internal …