Total anomalous pulmonary venous return (TAPVR) is a rare congenital heart defect, and patients are usually symptomatic at a very young age. Survival to adulthood without surgical correction is extremely rare. We report a 33-year-old woman with a heart murmur and a history of a successful pregnancy. Echocardiogram revealed a large atrial septal defect with suspicious pulmonary vein anomaly. Chest radiograph demonstrated classical 'snowman' configuration. Cardiac catheterisation was consistent with anomalous pulmonary venous drainage. Cardiac CT confirmed supracardiac TAPVR, whereby all the pulmonary veins drain into the anomalous vein and finally to the superior vena cava. She remained asymptomatic and underwent a successful surgical repair.
Internal jugular vein (IJV) aneurysm is a rare entity, and a thrombosed aneurysm poses diagnostic and management challenges. We came across a 53-year-old woman who presented with fever, vomiting and right neck swelling for a week. Laboratory investigations showed neutrophilic leucocytosis, raised acute phase reactant and blood culture yielded Klebsiella pneumoniae Ultrasound and contrast-enhanced CT neck revealed a large fusiform aneurysm of the right IJV with filling defect extending from the aneurysm into the right transverse sinus. There was a cavity at the right lower third molar tooth. MRI confirmed the findings with additional enhancing focus at right lower periodontal region. The swelling reduced after 2 weeks of medical therapy, and follow-up imaging 4 months later showed complete resolution of the aneurysm with residual thrombosis. After extensive workup, dental infection remains the only identifiable primary source leading to thrombophlebitis of the right IJV and subsequent sequelae.
A 57-year-old male chronic smoker with underlying diabetes mellitus presented with dysphonia associated with cough, dysphagia and reduced effort tolerance of 3 months' duration. Videoendoscope finding revealed bilateral polypoidal and erythematous true and false vocal fold with small glottic airway. The patient was initially treated as having tuberculous laryngitis and started on antituberculous drug. However, no improvement was observed. CT of the neck showed erosion of thyroid cartilage, which points to laryngeal carcinoma as a differential diagnosis. However, the erosion was more diffuse and appeared systemic in origin. The diagnosis of laryngeal perichondritis was made when the histopathological examination revealed features of inflammation, and the tracheal aspirate isolated Pseudomonas aeruginosa The patient made a good recovery following treatment with oral ciprofloxacin.
Cerebral venous sinus thrombosis (CVST) is caused by either acquired or inherited pro-thrombotic states. Hyperthyroidism is a less recognised predisposing factor of CVST, and the causality has been debated. We report a case of a life-threatening CVST in a 40-year-old woman, with uncommon dual risk factors: hyperthyroidism and advanced squamous cell carcinoma of the cervix. CVST should be considered as a differential diagnosis when a patient with hyperthyroidism presents with new-onset headache or other neurological symptoms. Further assessment to elucidate other covert risk factors may need to be continuously carried out, when the causal relationship of one apparent cause has not been well established.
Organising pneumonia (OP) in rheumatoid arthritis (RA) may be part of pulmonary manifestation (disease related) or disease-modifying antirheumatic drugs (DMARDs) related. We report a case series of RA patients with DMARDs related OP. A 65-year-old woman developed OP 3 weeks after initiation of methotrexate (MTX). High-resolution CT (HRCT) scan of the thorax revealed bilateral consolidations in the lung bases. She had complete radiological resolution 6 months after corticosteroid therapy with cessation of MTX. The second case was of a 60-year-old woman on MTX with recent addition of leflunomide due to flare of RA. She developed worsening cough 4 months later and HRCT scan revealed consolidation in the left upper lobe with biopsy proven OP. She responded within 6 months of corticosteroid therapy with clinical and radiological resolution. This case series highlights that OP may developed with low-dose MTX (as early as 3 weeks) and leflunomide and the diagnosis requires a high index of suspicion.
Head and neck synovial sarcoma is rare. We report the case of a 71-year-old man who presented with progressive dysphagia, odynophagia, shortness of breath on exertion and hoarseness of voice. Nasendoscopy revealed a smooth, non-fungating, non-ulcerative mass arising from the left lateral pharyngeal wall. CT showed a well-defined, heterogenous enhancing lesion arising from the left pyriform fossa. Initial biopsy taken was inconclusive and patient underwent a transcervical complete excision of the tumour, where histopathological analysis confirmed the diagnosis of monophasic synovial sarcoma of the left pyriform fossa. This patient also received adjuvant radiotherapy postoperatively and remained disease free 1 year after completion of treatment.
Primary cardiac valve tumours are rare. This is a case report of a 32-year-old non-smoker man with a history of stroke 1 year prior and no other cardiovascular risk factors. The patient was admitted to our acute stroke ward for recurrent left hemiparesis, slurring of speech, facial asymmetry and central retinal artery occlusion. Initial laboratory investigations and ECG were normal. An urgent CT brain showed a large hypodense area at the right frontal, parietal, temporal, occipital region with effaced sulci and right lateral ventricle with midline shift and cerebral oedema in keeping with acute infarction. We proceeded with CT angiography of the cerebral and carotid on the following day, which revealed no evidence of thrombosis, aneurysm or arteriovenous malformation. There were no abnormal beaded vessels to suggest vasculitis. Transthoracic echocardiography revealed a large mobile mass in the left atrium. Meanwhile, MRI cardiac confirmed a large ill-defined mobile solid mass attached to the mitral valve's inferoseptal component suggestive of mitral valve myxoma. This case report highlights the significance of considering a cardiogenic source of emboli in patients with large cerebral infarcts and other cardiac embolic phenomena. Imaging modalities such as echocardiography and cardiac MRI will help detect treatable conditions, such as valvular myxoma and prevent further complications.
Morgagni hernia is the rarest type of congenital diaphragmatic hernia, which can present late in adulthood. Here, we report a case of Morgagni hernia in an elderly woman who presented as an acute coronary syndrome with raised troponin level. X-ray of the chest (CXR) showed air-fluid level in the right lower hemithorax with loss of right diaphragmatic outline and subsequently confirmed strangulated Morgagni hernia with CT. She was treated with emergency laparotomy to reduce the hernia content and surgical repair with mesh done. In conclusion, Troponin can be falsely positive in Morgagni hernia patients, possibly due to strain on the heart by herniated bowel contents. Basic imaging such as a (CXR) is useful in the case of chest pain to rule out the non-cardiac causes. Although 'time is the myocardium' in the setting of all cases of chest pain with raised troponin, CXR should be done before treatment that poses bleeding risk and unnecessary delay in laparotomy.
A 54-year-old Chinese man presented with ascites for 2 weeks. He had a preceding 2-year history of intermittent dysphagia, lethargy and general malaise. Blood investigations revealed leucocytosis with eosinophilia of 26.5%, whereas paracentesis showed turbid fluid with high protein content (45 g/L) and a high white blood cell count of 5580/µL, predominantly eosinophils (90%). An incidental assay of vitamin D showed a very low level of 13.5 ng/mL. No other cause of ascites was found. Gastroscopy was normal except for duodenitis. However, biopsies from lower oesophagus confirmed the presence of eosinophilic infiltration. Following vitamin D replacement, the patient experienced marked improvement in symptoms of dysphagia within 2 weeks and no recurrence of ascites after 3 months. The reason for the patient's vitamin D deficiency remains unclear. The marked improvement in the patient's health indicates a causative role of vitamin D deficiency in causing eosinophilic esophagogastroenteritis and associated eosinophilic ascites.
We present an interesting case of late-onset intracranial bleeding (ICB) as a complication of Streptococcus gordonii causing infective endocarditis. A previously healthy young woman was diagnosed with infective endocarditis. While she was already on treatment for 2 weeks, she had developed seizures with a localising neurological sign. An urgent non-contrasted CT brain showed massive left frontoparietal intraparenchymal bleeding. Although CT angiogram showed no evidence of active bleeding or contrast blush, massive ICB secondary to vascular complication of infective endocarditis was very likely. An urgent decompressive craniectomy with clot evacuation was done immediately to release the mass effect. She completed total 6 weeks of antibiotics and had postoperative uneventful hospital stay despite having a permanent global aphasia as a sequel of the ICB.
Primary primitive neuroectodermal tumour (PNET) and extraskeletal Ewing's sarcoma belongs to the Ewing's family of tumours. Primary tumours arising from breast are very rare. There are only a few case reports published on primary extraskeletal Ewing's sarcoma and PNET arising from breast. We present an extremely rare case of an inoperable primary Ewing's sarcoma arising from left breast with contralateral breast, lymphatic and lung metastasis.
A morphology study was essential to the development of the cementless femoral stem because accurate dimensions for both the periosteal and endosteal canal ensure primary fixation stability for the stem, bone interface, and prevent stress shielding at the calcar region. This paper focused on a three-dimensional femoral model for Asian patients that applied preoperative planning and femoral stem design. We measured various femoral parameters such as the femoral head offset, collodiaphyseal angle, bowing angle, anteversion, and medullary canal diameters from the osteotomy level to 150 mm below the osteotomy level to determine the position of the isthmus. Other indices and ratios for the endosteal canal, metaphyseal, and flares were computed and examined. The results showed that Asian femurs are smaller than Western femurs, except in the metaphyseal region. The canal flare index (CFI) was poorly correlated (r < 0.50) to the metaphyseal canal flare index (MCFI), but correlated well (r = 0.66) with the corticomedullary index (CMI). The diversity of the femoral size, particularly in the metaphyseal region, allows for proper femoral stem design for Asian patients, improves osseointegration, and prolongs the life of the implant.
The COVID-19 pandemic is a global, national, and local public health concern which has caused a significant outbreak in all countries and regions for both males and females around the world. Automated detection of lung infections and their boundaries from medical images offers a great potential to augment the patient treatment healthcare strategies for tackling COVID-19 and its impacts. Detecting this disease from lung CT scan images is perhaps one of the fastest ways to diagnose patients. However, finding the presence of infected tissues and segment them from CT slices faces numerous challenges, including similar adjacent tissues, vague boundary, and erratic infections. To eliminate these obstacles, we propose a two-route convolutional neural network (CNN) by extracting global and local features for detecting and classifying COVID-19 infection from CT images. Each pixel from the image is classified into the normal and infected tissues. For improving the classification accuracy, we used two different strategies including fuzzy c-means clustering and local directional pattern (LDN) encoding methods to represent the input image differently. This allows us to find more complex pattern from the image. To overcome the overfitting problems due to small samples, an augmentation approach is utilized. The results demonstrated that the proposed framework achieved precision 96%, recall 97%, F score, average surface distance (ASD) of 2.8 ± 0.3 mm, and volume overlap error (VOE) of 5.6 ± 1.2%.
Content-based medical image retrieval (CBMIR) system enables medical practitioners to perform fast diagnosis through quantitative assessment of the visual information of various modalities.
Diagnosing acute appendicitis in children can be difficult due to atypical presenting symptoms. While there are reported cases of acute appendicitis or appendiceal masses causing unilateral hydronephrosis, bilateral hydronephrosis as a complication of appendiceal mass is very rare. We report a case of a child who presented with cardinal symptomatology associated with the urogenital tract. Ultrasound (US) investigation showed a pelvic mass causing bilateral hydronephrosis. An initial diagnosis of a pelvic teratoma was made based on the US and computed tomography (CT) scan findings. The final diagnosis of an appendiceal mass causing bilateral hydronephrosis was established intraoperatively.
This paper describes an extremely rare case of a huge aneurysmal bone cyst (ABC) in the pelvis, occurring in the patient's 5(th) decade of life. The patient presented with a history of painless huge pelvic mass for 10 years. Plain radiograph and computed tomography showed huge expansile lytic lesion arising from the right iliac bone. A biopsy was performed and histology confirmed diagnosis of aneurysmal bone cyst. Unfortunately, the patient succumbed to profuse bleeding from the tumour.
Foreign body granuloma is a reaction to either a biodegradable substance or inert material. In a breast cancer patient who had undergone an excision or mastectomy with axillary clearance, a foreign body granuloma in the axilla may be misinterpreted as an axillary lymph node. We report our experience with a case of cotton-ball granuloma of the axilla in a breast cancer patient, which mimics a lymph node radiologically from the CT scan, mammogram and ultrasonography. Following biopsy and excision, the mass was diagnosed histologically as a foreign body granuloma.
To optimize the delay time before the initiation of arterial phase scan in the detection of focal liver lesions in contrast enhanced 5 phase liver CT using the bolus tracking technique.
Radiofrequency ablation (RFA) therapy is recognised as a safe and effective treatment option for osteoid osteoma. This case report describes a 27-year-old man who underwent computed tomography (CT)-guided percutaneous RFA for a femoral osteoid osteoma, which was diagnosed based on his clinical presentation and CT findings. The patient developed worsening symptoms complicated by osteomyelitis after the procedure. His clinical progression and subsequent MRI findings had led to a revised diagnosis of a Brodie's abscess, which was further supported by the eventual resolution of his symptoms following a combination of antibiotics treatment and surgical irrigations. This case report illustrates the unusual MRI features of osteomyelitis mimicking soft tissue tumours following RFA of a misdiagnosed Brodie's abscess and highlights the importance of a confirmatory histopathological diagnosis for an osteoid osteoma prior to treatment.