Rg Sood

Role of Perfusion CT Differentiating Hemangiomas from Malignant Hepatic Lesions.

Objective: The purpose of the study was to determine the role of computed tomography (CT) perfusion in differentiating hemangiomas from malignant hepatic lesions. Materials and Methods: This study was approved by the institutional review board. All the patients provided informed consent. CT perfusion was performed with 64 multidetector CT (MDCT) scanner on 45 patients including 27 cases of metastasis, 9 cases of hepatocellular carcinoma (HCC), and 9 cases of hemangiomas. A 14 cm span of the liver was covered during the perfusion study. Data was analyzed to calculate blood flow (BF), blood volume (BV), permeability surface area product (PS), mean transit time (MTT), hepatic arterial fraction (HAF), and induced residue fraction time of onset (IRFTO). CT perfusion parameters at the periphery of lesions and background liver parenchyma were compared. Results: Significant changes were observed in the perfusion parameters at the periphery of different lesions. Of all the perfusion parameters BF, HAF, and IRFTO showed most significant changes. In our study we found: BF of more than 400 ml/100 g/min at the periphery of the hemangiomas showed sensitivity of 88.9%, specificity of 83.3%, positive predictive value (PPV) of 57.1%, and negative predictive value (NPV) of 96.7% in differentiating hemangiomas from hepatic malignancy; HAF of more than 60% at the periphery of hemangiomas showed sensitivity of 77.8%, specificity of 86.1%, PPV of 58.3% and NPV of 93.9% in differentiating hemangiomas from hepatic malignancy; IRFTO of more than 3 s at the periphery of hemangiomas showed sensitivity of 77.8%, specificity of 86.1%, PPV of 58.3%, and NPV of 93.9% in differentiating hemangiomas from hepatic malignancy. Conclusion: Perfusion CT is a helpful tool in differentiating hemangiomas from hepatic malignancy by its ability to determine changes in perfusion parameters of the lesions.

Virilizing Adrenal Oncocytoma

Adrenal oncocytoma is a rare adrenal neoplasm with only 57 cases reported in literature. Adrenal oncocytomas can achieve large sizes and are usually nonfunctioning. They are detected accidentally during abdominal scans. Most of these adrenal neoplasms are benign. A functioning adrenal oncocytoma manifested with virilization in a 16-year-old female child. There seems to be little benefit in biopsying these tumors and surgery remains the optimum management.

Encephalocraniocutaneous lipomatosis with calvarial exostosis - Case report and review of literature.

Encephalocraniocutaneous lipomatosis (ECCL), also known as Haberland syndrome, is a rare syndrome with unknown etiology. The syndrome is characterized by a triad of unique cutaneous, ocular, and central nervous system (CNS) manifestations. The cutaneous hallmark, nevus psiloliparus (NP), along with overlying alopecia is a constant feature. Choristoma of the eyelid is the most common ocular manifestation, while intracranial lipoma is the predominant CNS finding. Genetic counseling is required to emphasize that the disorder, although congenital, is not inheritable. We present a 21-year-old female with cutaneous, ocular, and CNS features satisfying the diagnostic criteria for ECCL. To our knowledge, this is the first case of ECCL having a large temporal exostosis. The objective of this article is to better understand the phenotypic spectrum of this syndrome whose molecular basis is still unknown.

Cerebellitis as an atypical manifestation of scrub typhus

A 21-year-old-man presented in a semiconscious state with 2 days’ inability to walk and 5 days’ history of fever (102.2°F) and rash. Examination revealed severe ataxia, slurred speech, and a scrotal scar (figure 1). Head CT and CSF studies were normal. Brain MRI revealed diffuse cerebellar cortical hyperintensity on T2 and fluidattenuated inversion recovery images (figure 2, A and B), with restriction (figure 2C) and postcontrast enhancement (figure 2D) suggesting inflammation. Weil-Felix test (OX-K-1:320) and immunoglobulin M ELISA were positive for scrub typhus. Improvement occurred after oral doxycycline. Isolated cerebellar involvement is rare in scrub typhus, a mite-born infection caused by Orentia tsutsugamushi that classically presents with fever, rash, and eschar. Laboratory confirmation is required to differentiate it from co–endemic diseases like typhoid, leptospirosis, and dengue.

Quantitative computed tomography (CT) assessment of emphysema in patients with severe chronic obstructive pulmonary disease (COPD) and its correlation with age, sex, pulmonary function tests, BMI, smoking, and biomass exposure

Summary Background To evaluate the role of HRCT in quantifying emphysema in severe COPD patients and to study the variations in the pattern of emphysema in relation to age, sex, FEV1, smoking index, biomass exposure, and BMI. Material/Methods Automatic lung segmentation of HRCT scans in 41 severe COPD patients (GOLD stage III or more) was done using an emphysema protocol. The extent of emphysema was assessed using the density mask method with a threshold of –950 HU (%LAA-950). The percentage of emphysema in each lung lobe and both lungs was correlated with 6 parameters – age, sex, BMI, smoking index, biomass exposure, and FEV1. Results Smoking resulted in homogenously distributed emphysema regardless of the severity of smoking. BMI was inversely correlated with the extent of emphysema. A significant association was found between the percentage of emphysema in the right lower lobe and BMI (P=0.015), between biomass exposure and the percentage of emphysema in RUL, RLL, and both lungs (P values of 0.024, 0.016, and 0.036, respectively). The extent of emphysema was disproportionately low compared to the amount of obstruction on PFTs, indicating an airway predominant variety of COPD with significant biomass exposure. Conclusions Smoking is associated with a relatively homogenous distribution of emphysema with no regional predilection. Biomass exposure produces predominantly right-sided emphysema. BMI decreases with increasing levels of emphysema in the right lower lobe. These risk factors of emphysema patterns are helpful in deciding on the management, including surgical options.

A variant of type VI choledochal cyst: combined dilatation of cystic duct and common bile duct

Choledochal cysts are cystic dilatation of the biliary tree which may involve the extrahepatic or the intrahepatic biliary radicals or both, most commonly involving the main portion of the common bile duct. Although congenital these may be diagnosed at any age, though in more than 60 % diagnosis is made before the age of 10 years [1]. These range in incidence from 1 in 1000 in Asian population (most of the cases are seen in Japan) to less than 1 in 100,000 in Western countries, and there is also an unexplained female:male preponderance, commonly reported as 4:1 or 3:1 [1]. We report an extremely rare case of combined dilatation of both the cystic duct as well as the common bile duct (CBD) in a 14-year-old boy who presented with mild epigastric discomfort. Cystic dilatation of the cystic duct is very rare and not well recognized. Awareness of this type of malformation as a distinct entity of choledochal cyst would help in correct preoperative diagnosis and subsequent management. A 14-year-old male patient was brought by his parents with complaints of mild pain in the epigastrium since the last 3 days. The patient was well built with no signs of malnutrition and had normal vitals. There was past history of similar episodes of mild pain which occurred once in every 3–4 months since the last 3 years. No history of fever or jaundice was present. On abdominal examination, there was no swelling, tenderness, guarding or rigidity. His blood tests including liver function tests and tumour markers were within normal limits. Ultrasound of the abdomen revealed cystic dilatation of the common bile duct along with dilatation of the adjacent portion of the cystic duct (Fig. 1a, ESM 1). On colour Doppler flow imaging no flow was seen (ESM 2). No intraluminal echogenic content was seen in the biliary system. Intrahepatic biliary radicals were normal. Gall bladder was distended and was normal in wall thickness. No peri-cholecystic fluid was seen. Pancreatic duct was not dilated and pancreas was normal. Rest of the abdominal organs were normal. Based on the sonographic appearance, an impression of type VI choledochal cyst (cystic duct dilatation) along with cystic dilatation of CBD (type I cyst) was made. These findings were confirmed on MRCP which was done to better define the anatomy and to search for any other pathology. It revealed a dilatation of about 7 cm in length and 4 cm in transverse diameter involving both the CBD and proximal cystic duct; both the ducts were joined by a wide communication (Fig. 1b). Further, it was seen on MRCP (clip 1) that the distal most part of CBD (1.4 cm) was of normal calibre, measuring 4 mm and was opening normally into the second part of duodenum. The pancreatic duct measured 1.5 mm and was normal. Considering the inherent risk of malignancy, surgical removal of the cyst was suggested. However, in the absence of any significant symptoms, the parents of the boy refused any surgical intervention. He was discharged with the advice of close follow-up. Alonso-Lej et al. proposed the first classification system for choledochal cysts in 1959 [2], describing three types of biliary duct dilation. Todani and colleagues in 1977 [3] expanded this classification to include intrahepatic duct cysts as well as multiple cysts; this modified classification is presently the most accepted one. Cystic dilatation of the Electronic supplementary material The online version of this article (doi:10.1007/s40477-015-0186-x) contains supplementary material, which is available to authorized users.

Aneurysm of an aberrant splenic artery: An extremely rare occurrence

An aberrant splenic artery arising from the superior mesenteric artery, also known as the splenomesenteric trunk, is a rare anatomical variant seen in less than 1% of the population and is more common in females. Aneurysms of the splenic artery originating anomalously from the superior mesenteric artery are extremely rare; only 35 cases of aneurysm of an aberrant splenic artery have been described so far in the English medical literature. We report an extremely rare case of aneurysm of aberrant splenic artery in a 28-year-old man in whom the lesion was detected during routine abdominal scanning and confirmed on computed tomography angiography. Aneurysms of an anomalous splenic artery originating from the superior mesenteric artery are extremely rare; however, they are clinically important because possible rupture could be catastrophic. Exploring these variations is important especially if surgical intervention is contemplated. This could greatly affect the surgical planning and avoid injuries to major arteries and organs intraoperatively.

Post shunt meningeal fibrosis: Role of contrast enhanced MRI in differentiation from chronic subdural hematoma

Post shunt meningeal fibrosis is an uncommon complication following VP shunt insertion and it presents with a diagnostic dilemma. It is a rare post shunt entity that may mimic chronic subdural hematoma on unenhanced CT and MR. Thus it is important to recognize it before any therapeutic intervention is being considered. We present a case of 47 year male who underwent VP shunt insertion for tubercular hydrocephalus 4 years ago. He presented with chronic headache for 6 months for which MRI brain was done. MRI finding revealed post shunt meningeal fibrosis thus differentiating from chronic subdural hematoma and hence obviated surgical drainage.

Role of CT angiography in pulmonary embolism and its comparative evaluation with conventional pulmonary angiography

OBJECTIVES : The purpose of this study is to assess the role of spiral CT angiography in suspected cases of pulmonary embolism and to do comparative evaluation of CT angiography with conventional pulmonary angiography. MATERIAL AND METHODS : Twenty five patients of suspected pulmonary embolism (PE) underwent spiral CT angiography from the level of arch of aorta to the dome of diaphragm .Scanning was done with collimation of 5mm and an interval of 5mm at 130 mA and 120 kV. 100 cc of contrast containing 300 mg I/ ml, diluted with 60cc of normal saline in ratio 5:3 was injected at a flow rate of 3ml/sec with a scan delay of 20 seconds. Retro - reconstruction was done at 3mm interval. RESULTS : Spiral CTA showed a sensitivity of 80 % and a specificity of 85.7% for the diagnosis of pulmonary embolism. It also provided ancillary findings in the form of parenchymal and mediastinal structural information. CONCLUSION : CTA is an effective alternative to PA in diagnosis of suspected cases of PE. With its non- invasive nature, low cost, over and above high sensitivity and specificity, it may be used as the first line of investigation in the diagnosis of PE.

Prevalence of osteoporosis and osteopenia in stable patients of chronic obstructive pulmonary disease in Sub-Himalayan region of Himachal Pradesh, India

Background: Chronic obstructive pulmonary disease (COPD) is a lifestyle-related chronic inflammatory pulmonary disease and a major cause of morbidity and mortality globally. Osteoporosis and osteopenia are common observations in COPD and degree of the loss of bone mineral density (BMD) has been found to be proportionate to the severity of the disease. Objectives: Our objective was to study the prevalence of osteoporosis and osteopenia in stable COPD patients in Indian Sub-Himalayan population. Materials and Methods: This study was performed on 84 patients of COPD attending as outpatient in the Pulmonary Medicine Department after application of inclusion and exclusion criteria. A control group of 60 healthy controls was selected for comparison with COPD group. Spirometry was done on patients to stage the severity of COPD according to global initiative for chronic obstructive lung disease criteria. Dual-energy X-ray absorptiometry scan of the lumbar spine was done using bone densitometer to determine the severity of reduced BMD. The patients were categorized according to the World Health Organization criterion for definition of reduced BMD. Results: In the present study, a total of 45.2% patients had osteoporosis, 41.6% patients had osteopenia while the rest 13% patients had normal bone density in the COPD group. The prevalence of low bone density was about 4 times higher in COPD group as compared to control group. There were 15.48 times higher chances of low BMD in COPD patients as compared to healthy controls. Conclusions: Reduced BMD is a common comorbid entity in COPD patients which leads to increase in bone fragility and susceptibility to fracture. It is recommended that all the patients with COPD should be screened for osteoporosis to initiate the treatment for the disorder before they develop fractures.