Zubair Ahmad

Hepatic abscess rupture into the pyelocalyceal system of right kidney

A 42-year old male patient presented with the complaints of right lumbar pain, high-grade fever, burning micturition and pyuria for past 4 days. He was diagnosed with a liver abscess which had ruptured into the superior pole of right kidney.

Anterior mediastinal neurofibrosarcoma—a rare manifestation of neurofibromatosis type-1

Anterior mediastinal neurofibroma and neurofibrosarcoma form a rare class of tumors seen in patients of neurofibromatosis. We describe a case of anterior mediastinal neurofibrosarcoma in a known case of neurofibromatosis type-1.

Truncus bicaroticus and arteria lusoria—a rare combination of aortic arch anomalies

A 54-year-old female presented to the outpatient Department of Internal Medicine with the history of progressive mild dysphagia for past 3 to 4 months with no history of significant weight loss. She had no significant past history. Her blood pressure, heart rate, respiratory rate, and body temperature were within normal limits. The complete blood counts, hemogram, and coagulation profile were also normal. Her chest radiograph and barium swallow studies were unremarkable. She was referred for contrast-enhanced computed tomography (CECT) of the neck and chest. The CT was performed using 64-slice Somatom Sensation (Siemens Healthcare, Germany). After the baseline non-contrast study, aortic arch anomalies (aberrant right subclavian artery and truncus bicaroticus) were suspected, and that is why CT aortogram was performed by injecting 90 ml of Iopromide (Ultravist370) at a rate of 4 ml/s, followed by delayed venous phase to look for the esophageal lumen, neck, mediastinum, and lungs. The aortic angiography findings were as follows (Figs. 1, 2, and 3):

Primary pulmonary leiomyosarcoma—case report of a rare aggressive neoplasm

A 50-year-old male non-smoker and non-alcoholic was presented to the Emergency Medicine with the chief complaints of chest pain, cough, and hemoptysis for 2 days. There was no history of fever. The patient was non-smoker and nonalcoholic with no history of similar complaints in the past. A chest radiograph from 2-months back which was obtained as a part of routine pre-anesthetic checkup for cholecystectomy did not show any abnormality. He had no previous history of any radiotherapy or chemotherapy. The general physical examination revealed no evident abnormality. The respiratory and heart sounds were normal. The blood pressure and pulse rate were 120/80 mmHg and 78 bpm, respectively. The patient had a temperature of 99 °F with respiratory rate of 16/min. A chest radiograph was done which revealed a radio-opaque irregular mass-like shadow in the right para-hilar region (Fig. 1). To evaluate further, contrast-enhanced computed tomography (CT) of the chest was performed using 64-slice SOMATOM Sensation scanner (Siemens Healthcare, Germany). The CT findings revealed a large heterogeneously enhancing soft tissue mass lesion located in the lumen of the right pulmonary artery and infiltrating into the posterior segment of the upper lobe of the right lung (Figs. 2 and 3). There was no associated calcification. There was no evidence of distant metastasis. The preliminary diagnosis of a lung mass was formulated. This was followed by CT-guided biopsy of the mass. The biopsy examination findings revealed the features suggestive of an aggressive leiomyosarcoma (Fig. 4). Immuno-histochemical studies were positive for Desmin. With the evidence of radiographic, CT, and histologic findings, the diagnosis of pulmonary leiomyosarcoma was finalized, and the patient was started on chemotherapy. The patient was planned for elective surgical resection of the tumor. Unfortunately, the patient died due to cardiac arrest after receiving just 2 cycles of chemotherapy.

Right-sided aortic arch with aortic origin of left pulmonary artery and patent ductus arteriosus—a rare combination of aortic arch anomalies

A 17-year-old female patient presented to the emergency medical reception with the chief complaints of intermittent chest pain and breathlessness for the past 1 week. There was history of palpitations and no history of fever. The family history and past medical history were insignificant. The clinical examination revealed tachycardia (102 bpm) and increased respiratory rate (20 breaths/min). The blood pressure was 118/80 mmHg and body temperature was 98.6 °F. The biochemical tests including kidney function tests, liver function tests, thyroid function tests, hemogram, and coagulation profile were within normal limits. The posteroanterior chest radiograph did not reveal any apparent abnormality. The contrast-enhanced computed tomography (CT) of the chest was performed using the 64-slice SOMATOM Sensation machine (Siemens Healthcare, Germany). The study revealed right-sided aortic arch with left pulmonary artery (LPA) arising from the proximal descending aorta with the main pulmonary artery (MPA) continuing as the right pulmonary artery (RPA) with a patent ductus arteriosus (PDA). The thoracic aorta descended on the right side of vertebral column which crossed to the left side in the abdomen at the aortic hiatus in the diaphragm. Cardiac magnetic resonance imaging (MRI) was also performed to check the functional status of the heart and see for any other septal or vascular anomalies but no extra anomaly was seen (Figs. 1 and 2). The final diagnosis of right-sided aortic arch and right-sided thoracic descending aorta with aberrant origin of LPA from the aorta with PDAwas formulated. The patient was referred to the cardiothoracic surgery for further management. They performed detachment of LPA from aorta and its attachment with the MPA and ligation and separation of the PDA (Fig. 3). The postoperative period was uneventful. The embryologic origin of PAs is from the ventral pharyngeal or splanchnic plexus connected to the aortic sac. The PAs are

Spontaneous intrabronchial rupture of bronchogenic cyst causing lobar pneumonia

Bronchogenic cysts may be asymptomatic or may present with symptoms of tracheal or esophageal compression. Several complications of bronchogenic cysts may occur. Intrabronchial rupture is an infrequent complication. A case of spontaneous intrabronchial rupture of a bronchogenic cyst with basal lobar pneumonia.

Target sign: appendicitis

‘‘Target sign’’ of appendicitis is seen on axial sonographic images characterized by fluid-filled hypo-echoic center surrounded by an echogenic mucosa and submucosa and hypo-echoic muscularis as shown in Fig. 1. This sign is a specific variant of ‘‘the bowel wall target sign’’ which is associated with the bowel wall thickening of variable causes [1]. This sign attributes its name to the appearance of a Bull’s eye target as seen in Fig. 2. On longitudinal images, nonperforated, inflamed appendix appears an elongated, fluid-filled, noncompressible, aperistaltic, blind ending tubular structure as seen in Fig. 3. The axial outer-to-outer wall diameter is more than 6 mm [2]. The other findings of appendicitis on sonography include an appendicolith, pericaecal, or periappendicular fluid; increased periappendicular echogencity due to fat infiltration; and enlargement of mesenteric lymph nodes [3]. The US features of appendicular perforation include

The “cyst within cyst” sign of intravesical ureterocele

During ultrasonography, an intravesical ureterocele may be seen as a peripherally based cystic lesion arising from the normal ureteral orifice, often associated with proximal ureteral dilatation. The thin echogenic wall of the ureterocele laterally located within the urine-filled bladder lumen has been described as a ‘‘cyst within a cyst’’ (Fig. 1). At excretory or CT urography, the classic appearance of the ureterocele has been described as that of a ‘‘cobra head’’ or ‘‘spring onion’’ [1, 2]. Ureterocele is a cystic dilatation of the intravesical part of distal ureter due to meatal obstruction which results in simple hyperplastic response. The size of ureterocele may be very small (up to 1 cm) to very large (filling the whole bladder) [1]. In young patients, the cause of the ureterocele is thought to be congenital, due to the persistence of Chwalla membrane, which is followed by obstruction at the fusion point between mesonephric duct and the urogenital system [3, 4]. In older patients, ureterocele development may be the result of acquired conditions such as inflammatory disease or other acquired conditions [1]. This ‘‘cyst within cyst sign’’ is also seen in the uncomplicated ovarian cyst in females [5].