Jyoti Kumar

Extra-osseous fat fluid level: a specific sign for osteomyelitis.

Osteomyelitis may pose as a diagnostic dilemma on various imaging modalities and may be confused with neoplasms and other pathology. Although a rare finding, extra-osseous fat fluid level, especially when associated with spongy bone destruction, can be considered a specific sign of osteomyelitis. Previously, only two cases of extra-osseous fat fluid level in osteomyelitis have been reported, one on computed tomography (CT) and the other on magnetic resonance imaging (MRI). The former was a case of septic arthritis with intra-articular fat fluid level. A case of osteomyelitis is presented with the demonstration of extra-osseous fat fluid level. Our case is unique in providing exquisite CT and MRI correlation.

Intraosseous and intraarticular pneumatosis in anaerobic osteomyelitis.

A 14-year-old diabetic girl presented with fever and pain and swelling of the left hip for 1 week. There was no history of trauma or biopsy. Laboratory examination revealed leucocytosis with raised erythrocyte sedimentation rate and C-reactive protein. CT revealed gas within the femur, left hip joint and surrounding soft tissues (Figs. 1 and 2). There was marrow and soft-tissue oedema with multiple cortical breeches. Cultures from purulent material in the soft tissues yielded mixed skin flora and Bacteroides fragilis. Bone biopsy confirmed osteomyelitis. Intraosseous gas has been reported after biopsy, penetrating wounds and fractures. Very few cases of intraosseous and intraarticular pneumatosis have been reported in the setting of osteomyelitis [1, 2]. In the absence of direct communication of bone with air, it is highly suggestive of osteomyelitis, and the pathogens are usually anaerobic and/or polymicrobial. The presumed mechanism is anaerobic metabolism with production of hydrogen and carbon dioxide gases [1]. The presence of intraosseous gas usually signifies fulminant infection requiring aggressive treatment. The other rare causes of intraosseous gas are lymphangiomatosis of bone, necrosis and neoplasm [1].

Dengue haemorrhagic fever: an unusual cause of intracranial haemorrhage.

During an outbreak of dengue viral infection in India, a 68-year-old woman presented with fever and myalgia for 4 days and altered sensorium for 1 day. At presentation, she was comatose with a Glasgow Coma score of 6. Physical examination showed high fever (39°C), mild conjunctival injection and hepatosplenomegaly. The pulse rate and blood pressure were within normal limits. The tourniquet test was positive. Laboratory investigations showed mild leucocytosis, thrombocytopenia (65 000 per mm3) and increased haematocrit …

Multifocal non-Hodgkin lymphoma in an infant with cardiac involvement: whole-body MR imaging

Non-Hodgkin lymphoma (NHL) is rare in infancy, and we present a case of aggressive NHL of T-cell lineage in an infant with multifocal bone, cardiac, mediastinal nodal, paranasal sinus, calvarial, and soft-tissue deposits on presentation that were detected on whole-body MRI.

Multiple short-segment colonic duplications

Gastrointestinal tract duplication is an uncommon congenital anomaly that rarely involves the colon. We report an unusual case of multiple short-segment duplications of the colon not previously reported in the literature. The patient had a large diverticulum-type duplication of the descending and sigmoid colon and two other tubular duplications of the transverse and ascending colon, the latter two communicating with the colon at both ends of the duplications. The symptomatic diverticulum-type of duplication was surgically treated.

Bilateral severe mammary duct ectasia.

We present the imaging findings of severe bilateral mammary duct ectasia in a postmenopausal woman. Mammographic, ultrasonographic, and magnetic resonance findings are described. Needle biopsy was used to confirm the diagnosis. Etiology, clinical significance, and management strategies for this lesion are discussed.

Isolated nodular pulmonary amyloidosis

A 37-year-old woman presented to the chest clinic with recurrent, mild haemoptysis for the last 6 months. There was no other significant history. Physical examination was unremarkable. Her haematological and biochemical parameters were within normal limits. A chest radiograph showed well-defined nodules in both lungs. A computed tomography (CT) scan of the chest showed multiple lobulated nodules of varying sizes in both lungs,predominantlyperipherally(Figs. 1,2).A fewnodules showed focal, punctate calcifications. Therewere no pleural or pericardial effusions or mediastinal lymphadenopathy. Fibreoptic bronchoscopy showed no endobronchial lesion. A percutaneous CT-guided core biopsy was obtained from the middle lobe lung nodule. Histologically, the specimens contained acidophilic, amorphous, homogeneous material with a few foreign body giant cells, histiocytes and fibroblasts. Congo red staining gave an orange colour with apple green birefringence under polarized microscopy, features pathognomonic of amyloidosis (Fig. 3). In addition there were areas of necrosis and dystrophic calcification. The patient’s course after biopsy was uneventful. Serial chest radiographs have not shown any enlargement of the lesions as of 12 months after the biopsy and her haemoptysis has resolved. A detailed clinical and radiological evaluation was normal. Serum and urine protein electrophoresis and immunofixation were normal with no monoclonal bands. Bone marrow biopsy and immunohistochemistry were normal. There was no evidence of underlying plasma cell dyscrasia. An echocardiogram was within normal limits. Biopsies from the subcutaneous fat and rectal mucosa did not show any abnormality. Hence the diagnosis of isolated, nodular pulmonary amyloidosis was made. The respiratory tract is rarely the site of localized tracheobronchial or nodular amyloid deposits and is more often a part of widespread amyloid deposition involving many organs. There are three types of localized amyloidosis: tracheobronchial, nodular parenchymal and diffuse interstitial. Primary nodular amyloid lesions of the lung are uncommon and are not usually associatedwith primary Figure 1 Computed tomography scan of chest (lung window settings) shows multiple bilateral pulmonary nodules with lobulated margins, mainly located peripherally. Figure 2 Non-contrast computed tomography scan of chest (mediastinal window settings) shows focal punctate calcifications within a nodule in the right paracardiac location. Purpura fulminans in SLE

Chiari I malformation with holocord syrinx.

We present the magnetic resonance imaging findings of a classical case of Chiari I malformation with holocord syringohydromyelia. The clinical presentation, imaging findings and treatment options are discussed.

Posterior mediastinal teratoma

An 18-year-old man presented with persistent cough and mild respiratory distress for 1 month. He had experienced recurrent pulmonary infection and respiratory difficulty since 5 years of age. Physical examination showed a stony dull note on percussion and diminished breath sounds on the right side of his chest. Chest radiograph showed a large soft tissue densitymass with calcification occupying the right lower hemithorax and extending into the abdominal cavity. Computed tomography (CT) of chest (Fig. 1) showed well-encapsulated heterogeneous posterior mediastinal mass extending anteriorly. It was composed of soft tissue, fluid, fat and calcific densities. It appeared to extend into the abdominal cavity, displacing the left kidney inferiorly. Magnetic resonance imaging (MRI) (Fig. 2) delineated the continuity of the diaphragm, which was inverted. The aorta and oesophagus were not involved. Surgery confirmed the mass (Fig. 3) to be limited to the thorax, inverting the diaphragm but with no intra-abdominal extension. The pathological diagnosis was mature teratoma. The anterior mediastinum is the commonest site for intrathoracic teratoma. Very few cases of posterior mediastinal teratomas have been reported in the literature. One case of posterior mediastinal teratoma with intraabdominal extension through the oesophageal hiatus has also been described. To the best of our knowledge, such extensive diaphragmatic inversion with mediastinal teratoma has not been previously reported.

Hereditary haemorrhagic telangiectasia.

A nine-year-old boy presented with headache and two episodes of seizures in the previous 15 days. He had a history of mild recurrent epistaxes for the past 6 months. On examination, he was found to have telangiectases of the lips and buccal mucosa, but no other abnormality was found. Contrast-enhanced computed tomography (CT) of the brain (Fig. 1) showed arteriovenous malformations (AVM) in the region of brainstem and both thalami. Based on these findings, a diagnosis of hereditary haemorrhagic telangiectasia (HHT) was made. Screening CT of the thorax (Fig. 2) showed an AVM in the right lung. Triple-phase CT of the abdomen (Fig. 3) showed evidence of arterioportal and arteriosystemic shunts with multiple perfusion alterations (the transient hepatic parenchymal enhancement phenomenon) during the arterial phase. Coronal reformatted CT image also depicted the pulmonary and hepatic changes (Fig. 4). HHT, also known as Rendu–Osler–Weber disease is an autosomal dominant disorder that occurs with an