Priya Hira

An unusual case of CV junction tuberculosis presenting with quadriplegia.

Study Design. Isolated tubercular involvement of craniovertebral junction in a human immunodeficiency virus–positive patient causing paraplegia and sudden death with radiologic features is presented. Objectives. Isolated involvement of craniovertebral junction by tuberculosis causing quadriparesis is a rare entity. The role of imaging features is presented in diagnosis of craniovertebral junction tuberculosis, which is a treatable disease. Early detection of this entity with prompt treatment can prevent a fatal outcome. Summary of Background Data. Tuberculosis of the cervical spine is a rare and potentially dangerous manifestation of extrapulmonary tuberculosis. The incidence is probably less than 1% of all cases of spinal tuberculosis. However, in the developing countries this constitutes an increasingly important cause of craniovertebral junction instability and cervicomedullary compression. Most of the patients present with pain in the neck and local tenderness. Neurologic deficits of varying degrees have been reported in 24–40% of cases of craniovertebral junction tuberculosis. Quadriplegia followed by sudden death is exceptional (as seen in our case). The incidence of craniovertebral junction tuberculosis in immunocompromised patients is not known. Dramatic recovery is possible if craniovertebral junction tuberculosis is detected early in its course. Prompt medical and surgical treatment may avert a potential catastrophic event in such cases. Imaging methods such as computed tomography and magnetic resonance imaging are diagnostic of this condition and aid in the detection and prompt treatment of the same. Method. Frontal radiograph of the cervical spine and chest, and lateral view of cervical spine followed by plain and contrast enhanced computed tomography scan of the cervical spine was performed to detect the lesion. Result. These radiographic features were correlated with the clinical findings. The computed tomography findings of bone destruction, prevertebral and extradural peripherally enhancing soft tissue and infiltrating opacities in the lung apexes were consistent with tuberculosis. Conclusions. The computed tomography findings described in this report are very specific for tuberculosis of the craniovertebral junction. Clinical and radiologic correlation could help in making the early diagnosis and prompt treatment possible.

Ileosigmoid knot: A case report

The ileosigmoid knot is an uncommon but life-threatening cause of closed loop intestinal obstruction. Its treatment is different from a simple volvulus in that it has to be operated upon immediately. Preoperative CT scan diagnosis and prompt treatment can lead to a good outcome. Findings of simultaneous ileal and sigmoid ischemia with non-ischemic colon interposed in between should, in an appropriate clinical setting, indicate this condition. The presence of the whirl sign, medially deviated distal descending colon and cecum, and mesenteric vascular structures from the superior mesenteric vessels that converge toward the sigmoid colon on CT scan help clinch the diagnosis.

Wandering Spleen with Torsion Causing Pancreatic Volvulus and Associated Intrathoracic Gastric Volvulus: An Unusual Triad and Cause of Acute Abdominal Pain

CONTEXT Wandering spleen is a rare medical entity in which the spleen is orphaned of its usual peritoneal attachments and thus assumes an ever wandering and hypermobile state. This laxity of attachments may even cause torsion of the splenic pedicle. Both gastric volvulus and wandering spleen share a common embryology owing to maldevelopment of the dorsal mesentery. Gastric volvulus complicating a wandering spleen is, however, an extremely unusual association, with a few cases described in literature. CASE REPORT We present a case of a young female who presented with acute abdominal pain and vomiting. Radiological imaging revealed a intrathoracic gastric volvulus, torsion in an ectopic spleen, and additionally demonstrated a pancreatic volvulus - an unusual triad, reported only once, causing an acute abdomen. CONCLUSION The patient subsequently underwent an emergency surgical laparotomy with splenopexy and gastropexy.

Germline mutations and genotype–phenotype correlation in Asian Indian patients with pheochromocytoma and paraganglioma

BACKGROUND Genetic aetiology of pheochromocytoma (PCC) and paraganglioma (PGL) is increasingly being studied; however, Asian Indian data on this aspect are scarce. OBJECTIVE To study the prevalence of germline mutations and genotype-phenotype correlation in Asian Indian PCC/PGL patients. DESIGN In this study, 150 index patients (M:F, 73:77) with PCC/PGL were evaluated. Phenotypic data were collected. Germline mutations in five susceptibility genes (RET, VHL, SDHB, SDHD and SDHC) were tested by sequencing and NF1 was diagnosed according to phenotype. RESULT Of the total population, 49 (32.7%) PCC/PGL patients had germline mutations (VHL: 23 (15.3%), RET: 13 (8.7%), SDHB: 9 (6%), SDHD: 2 (1.3%) and NF1: 2 (1.3%)). Amongst the 30 patients with familial and/or syndromic presentation, all had germline mutations (VHL: 14 (46.7%), RET: 13 (43.3%), SDHB: 1 (3.3%) and NF1: 2 (6.7%)). Out of 120 patients with apparently sporadic presentation, 19 (15.8%) had a germline mutation (VHL: 9 (7.5%), SDHB: 8 (6.7%) and SDHD: 2 (1.7%)). Mutation carriers were younger (29.9 ± 14.5 years vs 36.8 ± 14.9; P = 0.01) and had a higher prevalence of bilateral PCC (26.5% vs 2.9%, P < 0.001) and multifocal tumours (12.2% vs 0.96%, P = 0.06). Based on syndromic features, metastasis, location and number of tumours, around 96% mutations in our cohort could be detected by appropriately selected single gene testing. CONCLUSION Asian Indians with PCC/PGL differ from Western cohorts in having preponderance of VHL mutations in multifocal tumours and apparently sporadic unilateral PCC. Syndromic presentation, metastasis, location and number of PCC/PGL can be effectively used for guiding genetic prioritisation.

Venous Complications of Pancreatitis: A Review

Pancreatitis is notorious to cause vascular complications. While arterial complications include pseudoaneurysm formation with a propensity to bleed, venous complications can be quite myriad. Venous involvement in pancreatitis often presents with thrombosis. From time to time case reports and series of unusual venous complications associated with pancreatitis have, however, been described. In this article, we review multitudinous venous complications in the setting of pancreatitis and propose a system to classify pancreatitis associated venous complications.

Comparison of 68Ga-DOTANOC PET/CT and contrast-enhanced CT in localisation of tumours in ectopic ACTH syndrome

Background Localising ectopic adrenocorticotrophic hormone (ACTH) syndrome (EAS) tumour source is challenging. Somatostatin receptor-based PET imaging has shown promising results, but the data is limited to case reports and small case series. We reviewed here the performance of 68Ga-DOTANOC positron emission tomography (PET)/computed tomography (CT) and contrast-enhanced CT (CECT) in our cohort of 12 consecutive EAS patients. Materials and methods Retrospective data analysis of 12 consecutive patients of EAS presenting to a single tertiary care centre in a period between January 2013 and December 2014 was done. CECT and 68Ga-DOTANOC PET/CT were reported (blinded) by an experienced radiologist and a nuclear medicine physician, respectively. The performance of CECT and 68Ga-DOTANOC PET/CT was compared. Results Tumours could be localised in 11 out of 12 patients at initial presentation (overt cases), whereas in one patient, tumour remained occult. Thirteen lesions were identified in 11 patients as EAS source (true positives). CECT localised 12 out of these 13 lesions (sensitivity 92.3%) and identified five false-positive lesions (positive predictive value (PPV) 70.5%). Compared with false-positive lesions, true-positive lesions had greater mean contrast enhancement at 60s (33.2 vs 5.6 Hounsfield units (HU)). 68Ga-DOTANOC PET/CT was able to identify 9 out of 13 lesions (sensitivity 69.2%) and reported no false-positive lesions (PPV 100%). Conclusion CECT remains the first-line investigation in localisation of EAS. The contrast enhancement pattern on CECT can further aid in characterisation of the lesions. 68Ga-DOTANOC PET/CT can be added to CECT, to enhance positive prediction of the suggestive lesions.

Spinal Hydatid as a Rare Cause of Posterior Mediastinal Lesion: Understanding Cervicothoracic Sign on Chest Radiography.

Summary Background Location of an intrathoracic lesion on chest radiograph is facilitated by application of ‘silhouette sign’. This helps narrow down the differential diagnoses. The list of probable diagnoses reduces further on determination of the density of the lesion. A spinal hydatid presents as a fluid-density posterior mediastinal lesion on chest radiograph with destruction of the vertebral body and preservation of the disc space. Spinal hydatid is, however, rare. Case Report We describe a case of a 30-year-old female with gradual-onset paraperesis since six months. Chest radiograph was suggestive of a posterior mediastinal lesion with fluid density and destruction of D4 vertebra. MRI findings were consistent with spinal hydatid. The patient was started on perioperative benzimidazole therapy with resection of the hydatid cyst. The drug therapy was continued for six months post-operatively. Conclusions A chest radiograph helps localise the site and possible contents of the lesion. It also guides further investigations. MRI is the imaging modality of choice for spinal pathologies causing cord compression including spinal hydatid. Echinococcal involvement of the spine is a rarity but needs to be considered in the differential diagnoses for spinal causes of gradual-onset paraperesis.

Hemangioma of Rib: A Different Perspective

Summary Background Hemangiomas are one of the common primary benign tumors of the intraosseous and soft tissue compartments in humans. Vertebral hemangiomas being the most common of all are seen in daily radiological practice. Hemangioma of the rib is rarely seen. Case Report We reported on a case of a rib lesion which had a classic imaging pattern of hemangioma. We highlighted the use of pre-operative embolization of such a vascular rib lesion before surgically removing the lesion by thoracotomy to reduce the risk of bleeding. Conclusions We also emphasized overt complications of overzealous needling of such a vascular lesion for histopathological diagnosis as in our case.

Imaging findings in lipoma arborescens

A 27-year-old man presented with painless swelling of the right knee of 4 months’ duration. There was no history of trauma or other joint involvement. The patients serum rheumatoid factor was negative. Radiograph of the knee revealed increased lucency in the prefemoral region (figure 1A). Ultrasonography depicted echogenic, frond-like hypertrophy of the synovium in the suprapatellar bursa (figure 1B). This hypertrophied synovium was of low density on CT (figure 1C). Additionally, there was mild joint effusion. MRI depicted a T1 and T2 hyperintense synovial mass (figure 2A), villous and globular in …

Juvenile Granulosa Cell Tumour of the Ovary with Unilocular Pure Cystic Presentation: A Case Report and Review of Literature

Summary Background Granulosa cell tumours of the ovary are rare, hormonally active, oestrogen-secreting tumours of the ovary existing in two forms: the adult form and the even rarer juvenile form. These tumours present as predominantly solid lesions while the cystic, unilocular presentation is uncommon. Case Report We present an 18-year-old unmarried girl who presented with complaints of chronic pain, abdominal distension and presence of facial hair. Radiological examination revealed a large, purely cystic, unilocular lesion without any solid components, debris or septations. Histopathological diagnosis was of a juvenile granulosa cell tumour. Conclusions Radiological criteria suggestive of malignant ovarian masses include thick, irregular walls and septae; papillary projections and solid, echogenic foci. Nonetheless, we propose that a malignant ovarian lesion should be included in the differential diagnosis of a unilocular, purely cystic ovarian lesion.