Ferdia Bolster

Unsuspected Cardiovascular Involvement in Relapsing Polychondritis A Case of Aortitis With Critical Coronary Artery Stenosis Secondary to Relapsing Polychondritis

A 51-year-old man presented with a prodrome of arthralgia, intermittent oral ulceration, and raised inflammatory markers. He was extensively investigated; however, no firm diagnosis could be established, and he remained under regular surveillance by rheumatology and infectious disease services. After 12 months, he presented with painful ear swelling. Clinical examination revealed a swollen tender ear (Figure 1) and a soft diastolic heart murmur. Serum inflammatory markers were raised, with a c-reactive protein (CRP) of 28 mg/L and an erythrocyte sedimentation rate (ESR) of 25 mm/h. Figure 1. Tender, erythematous left ear. Biopsy of affected cartilage showed characteristic features of auricular chondritis (Figure 2). Echocardiogram (Movie I in the Data Supplement) revealed mild aortic incompetence, a left ventricular ejection fraction of 60%, aortic root dilatation, and an incidental patent foramen ovale (Movie II in the Data Supplement). Computed tomography (CT) of the thorax demonstrated no tracheal abnormality; however, aortic root dilatation of 4.6 cm was noted (Figure 3). A fasting positron emission tomography-CT (PET-CT) showed increased F-18 fluorodeoxyglucose accumulation in the ascending aorta (Figure 4), and a diagnosis of relapsing polychondritis with secondary aortitis with structural aortic dilatation was made. Figure 2. Left ear biopsy identified cartilage with perichondrial inflammatory granulation tissue. Figure 3. Coronal computed tomography of thorax with contrast demonstrating aortic root dilatation of 4.6 cm at the level of the sinuses with mural …

The structural consequences of calcium crystal deposition.

Calcium pyrophosphate dihydrate and basic calcium phosphate (BCP) crystals are the most common calcium-containing crystals associated with rheumatic disease. Clinical manifestations of calcium crystal deposition include acute or chronic inflammatory and degenerative arthritides and certain forms of periarthritis. The intra-articular presence of BCP crystals correlates with the degree of radiographic degeneration. Calcium crystal deposition contributes directly to joint degeneration. Vascular calcification is caused by the deposition of calcium hydroxyapatite crystals in the arterial intima. These deposits may contribute to local inflammation and promote further calcification, thus aggravating the atherosclerotic process. Calcium crystal deposition results in substantial structural consequence in humans.

Gadolinium-loaded polychelating amphiphilic polymer as an enhanced MRI contrast agent for human multiple myeloma and non Hodgkin's lymphoma (human Burkitt's lymphoma)

Liposomes, loaded with gadolinium (Gd) ions using different membrane-incorporated chelating lipids and functionalized with monoclonal anti-CD138 (syndecan-1) antibody were prepared. Nuclear Magnetic Resonance Dispersion (NMRD) analysis showed that use of the polychelating amphiphilic polymer (PAP) increases both the Gd content and the spin–lattice relaxivity of the Gd-loaded-PAP–liposomes as compared to Gd–DTPA–BSA equivalents. The potential application of contrast syndecan-1– and Rituximab–liposomes, for application as a novel minimally invasive diagnostic agent for multiple myeloma and non Hodgkins lymphoma was investigated.

Whole-body magnetic resonance imaging in skeletal muscle disease.

The evaluation of muscle diseases has traditionally integrated clinical with biochemical findings, occasionally resorting to muscle biopsy. This article reviews the role and imaging appearances of muscle diseases at MRI, specifically emphasising the role of WBMRI in global assessment of muscle abnormality, and in particular its role in determining distribution and extent of muscle abnormality.

Generalized arterial calcification of infancy—Findings at post-mortem computed tomography and autopsy

Generalized arterial calcification in infancy is a rare genetic disorder characterized by abnormal calcification of large and medium sized arteries and marked myointimal proliferation resulting in arterial stenosis. The condition is often fatal secondary to complications of cardiac ischemia, hypertension and cardiac failure. In this report we describe the findings at post mortem computed tomography, histology and autopsy.

Hemiplegic migraine: neuroimaging findings during a hemiplegic migraine attack.

CASE A 19-year-old male presented with sudden onset right-sided weakness and slurred speech following a severe headache. His past medical history was relevant for a similar episode 3 years previously; however, he did not seek medical advice at this time. He denied any recent drug or alcohol use, or any recent head injury. He had no family history of migraine. Routine biochemical, hematological, and lumbar puncture test results were normal. On clinical exam, he had a dense right hemiparesis, inattention, and aphasia. An urgent noncontrast computerized tomography (CT) brain (Fig. 1) on admission demonstrated subtle asymmetrical sulcal effacement in the left cerebral hemisphere suggestive of cerebral edema. There was no intracranial hemorrhage and no evidence of an ischemic event. There was no enhancing lesion or abnormal enhancement following the administration of contrast. In light of these findings on CT, he underwent a magnetic resonance imaging (MRI) of the brain. T2-FLuid Attenuated Inversion Recovery (FLAIR)weighted images (Fig. 2) showed increased cortical hyperintensity and cortical swelling of the left cerebral hemisphere consistent with unilateral cerebral edema and were consistent with the clinical findings of right-sided weakness. Diffusion-weighted MR images (Fig. 3) show no abnormal signal intensity. Post-contrast T1-weighted MR (Fig. 4) imaging demonstrated no abnormal enhancement. On day 2 of admission, he subsequently developed seizures, which spontaneously settled. The remained of his hospital admission was uncomplicated, and his neurological deficit had begun to

Antiplatelet medications and evolving antithrombotic medication.

In treatment and prevention of thromboembolic events, the two major classes of anticoagulants are the antiplatelet agents and the antithrombotic agents. The antithrombotic agents have traditionally been heparin and warfarin, both of which were isolated in the 1930s, and have been used effectively since becoming commercially available in treatment and thromboprophylaxis of venous thromboembolic events (VTE). Though effective, they have a narrow therapeutic window and the antithrombotic response is variable, depending on the patient, and requires regular monitoring and adjustment to maintain the necessary therapeutic range. Recently developed novel anticoagulants in the prevention and treatment of VTE are now available and are increasingly encountered in day-to-day practice. A general understanding of these agents is essential in the planning of any interventional procedure in order to optimally balance the risk of hemorrhage, during or after a procedure, with the risk of periprocedural thrombosis.

Renal Cell Carcinoma: Accuracy of Multidetector Computed Tomography in the Assessment of Renal Sinus Fat Invasion.

Purpose The purpose of this study was to evaluate the accuracy of multidetector computed tomography (MDCT) in the preoperative assessment of renal sinus fat invasion (RSFI) in patients with renal cell carcinoma (RCC) and to assess imaging features that improve detection of RSFI on CT. Methods This is a single-institution retrospective review of 53 consecutive patients with histologically proven RCC who underwent triple-phase preoperative contrast MDCT prior to partial or radical nephrectomy. Two experienced radiologists (R1 and R2), blinded to the final histology result, independently reviewed the preoperative MDCT studies to assess for RSFI. Histopathology was used as the gold standard for the presence of RSFI. Results Of 55 surgically resected RCCs that were evaluated with contrast-enhanced MDCT, 34.5% (19/55) of RCCs had RSFI on final histopathology. Multidetector CT demonstrated high sensitivity (R1, 100%; R2, 93.7%) for the detection of RSFI, but a low positive predictive value (R1, 40%; R2, 53%) and specificity (R1, 38.4%; R2, 66.6%). Interreader agreement for RSFI was moderate (&kgr; = 0.56). Renal tumors were significantly larger in cases with RSFI (6.3 ± 3.219 cm) than tumors without RSFI (4.1 ± 2.9 cm) (P = 0.0275). Renal sinus fat invasion was more commonly associated to an irregular tumor margin at the tumor renal sinus fat interface (P < 0.001). Conclusions Multidetector computed tomography demonstrates a high sensitivity but low positive predictive value in diagnosing RSFI with implications for prognosis and treatment planning. Tumor size, location, irregular tumor margin at the tumor/renal sinus interface, and invasion into pelvicaliceal structures can aid in the diagnosis of RSFI on preoperative MDCT.

Systemic air embolism complicating upper gastrointestinal endoscopy: a case report with post-mortem CT scan findings and review of literature

ABSTRACT Endoscopy of the gastrointestinal and biliary tract is a common procedure and is routinely performed for therapeutic and diagnostic purposes. Perforation, bleeding and infection are some of the more common reported side effects. Air embolism on the other hand, is a rare complication of gastrointestinal endoscopy. We report a 77-year-old African-American female with a history of pancreatic cancer, which was resected with a Whipple procedure. As part of diagnostic and therapeutic procedure, an endoscopic retrograde cholangiopancreatography was planned several months after the surgery. The patients heart rate suddenly slowed to 40 bpm during the procedure and she became cyanotic and difficult to oxygenate after the endoscope was introduced and CO2 gas was insufflated. A forensic autopsy was performed with post-mortem computed tomography (PMCT) and revealed extensive systemic air embolism. The detailed PMCT and autopsy findings are presented and current literature is reviewed.

Paraneoplastic Limbic Encephalitis and Small-Cell Lung Carcinoma

Journal of Thoracic Oncology ® • Volume 10, Number 5, May 2015 A 64-year-female smoker presented with a prolonged history of altered behavior, personality changes, and seizures. Anti-HU and anti-RI antibodies were positive. Magnetic resonance imaging demonstrated hyperintensity in the right hippocampal region (Fig. 1A) and corresponding increased radiotracer activity on positron emission tomography–computed tomography (PET-CT) (Fig. 1B, C). This initial PET-CT was negative for malignancy. A follow-up PET-CT 6 months later showed increased uptake in a right hilar node (Fig. 2). This node was sampled with endobronchial ultrasound and fine needle aspirate confirmed small cell carcinoma. Paraneoplastic limbic encephalitis is characterized by clinical presentation, presence of antineuronal antibodies, and imaging findings confirming involvement of the limbic system. Clinical symptoms and imaging abnormalities can predate the detection of malignancy by months to years. Control and treatment of the primary tumor with chemotherapy or other antineoplastic treatments may result in a neurologic improvement. Immunosuppression with steroids, intravenous immune globulin, plasma exchange, and other immunotherapies may also be of value. Symptomatic treatment should include seizure control with antiepileptic medications and medications to improve autonomic symptoms.