WWWTP #23 (What’s Wrong With This Picture?) Answer

Patient presented with cough, fevers.  This Chest Xray was obtained:

WWWTP 21 1

One finding on this Xray is very concerning.  The Xray showed free air under the diaphragm.

A further diagnostic study was obtained (CT abdomen/pelvis):

WWWTP 21 2 WWWTP 21 3

Turns out this patient has pneumatosis cystoides intestinalis.  He has a history of this disorder and has had a prior laparoscopy showing multiple cystic structures in the intestinal walls.

Findings on imaging:

1.  Chest Xray:  Concern for free air underneath the diaphragm.  He also has a tracheostomy, pacemaker, scoliosis, and a right lower lung infiltrate.

2.  CT abdomen/pelvis:  The coronal imaging shows multiple cystic structures full of free air in the cecal area.  The cross-sectional imaging above shows a large amount of pneumoperitoneum.

Luckily this patient has a history of pneumatosis cystoides intestinalis.  He has had multiple abdominal CT’s showing similar findings.  Clinically he had no abdominal tenderness.  Keep this rare diagnosis in mind for the patient presenting with free air in the abdomen!  Information about pneumatosis cystoides intestinalis:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3235639/

Author:  Russell Jones, MD

Image Contributor:  Mary Bing, MD


Filed under: Abdomen/Pelvis, Chest XR, Non-Trauma, Respiratory, WWWTP, XR Tagged: Pneumonia

WWWTP #23 (What’s Wrong With This Picture?)

Patient presented with cough, fevers.  This Chest Xray was obtained:

WWWTP 21 1

One finding on this Xray is very concerning.  What is it?

A further diagnostic study was obtained (CT abdomen/pelvis):

WWWTP 21 2 WWWTP 21 3

What’s Wrong With This Picture?

Answer to follow.

Author:  Russell Jones, MD

Image Contributor:  Mary Bing, MD


Filed under: WWWTP

Flank Pain…

Flank pain for several days, history of nephrolithiasis:

Flank Pain 1 Flank Pain 2 Flank Pain 3 Flank Pain 4

This patient has marked right hydronephrosis with significant right renal perinephric inflammatory cystic changes extending into the contiguous right psoas musculature and right retroperitoneum. There is perinephric stranding and edema.

The differential in this case includes renal abscess (most likely) with extension into the right psoas and retroperitoneum.  Additional considerations are atypical infection such as tuberculosis, and urothelial malignancy.

The patient ended up having Xanthogranulomatous pyelonephritis.  This is a subacute/chronic pyelonephritis usually incited by a staghorn calculus.  For more information on this entity please see radiopaedia.org:

http://radiopaedia.org/articles/xanthogranulomatous-pyelonephritis

Author:  Russell Jones, MD

References

1.  Knipe H, Gaillard F et al.  Xanthogranulomatous Pyelonephritis.  www.radeopaedia.org.  Accessed 1/2015.


Filed under: Abdomen/Pelvis, CT, Genitourinary, Non-Trauma Tagged: Renal Abscess

WWWTP #22 (What’s Wrong With This Picture?) Answer…

Patient presented short of breath.  Here is his chest xray:

WWWTP #22 PA WWWTP #22 LA

What’s wrong with this picture?

The findings are very subtle.  This patient has multiple lucencies in the bony structures including ribs, clavicles, scapula, and visualized proximal humerus:

WWWTP 22 edited

This patient turned out to have leukemia.  His shortness of breath was actually symptomatic anemia and he had a severe leukocytosis with a WBC nearing 180 K/MM3.

Remember to approach all imaging with a systematic approach so you don’t miss subtle findings like this!

Author:  Russell Jones, MD


Filed under: WWWTP Tagged: Dyspnea

WWWTP #22 (What’s Wrong With This Picture?) Answer…

Patient presented short of breath.  Here is his chest xray:

WWWTP #22 PA WWWTP #22 LA

What’s wrong with this picture?

The findings are very subtle.  This patient has multiple lucencies in the bony structures including ribs, clavicles, scapula, and visualized proximal humerus:

WWWTP 22 edited

This patient turned out to have leukemia.  His shortness of breath was actually symptomatic anemia and he had a severe leukocytosis with a WBC nearing 180 K/MM3.

Remember to approach all imaging with a systematic approach so you don’t miss subtle findings like this!

Author:  Russell Jones, MD


Filed under: WWWTP Tagged: Dyspnea