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

Rice bodies…

Elderly gentleman came to the ED because he was wandering around the neighborhood.  A bystandard called 911.  He was pleasantly confused, had a mental status consistent with dementia.  The only other pertinent physical exam finding was some erythema, cellulitic appearance to his ankle.  We obtained a tibia and fibula xray looking for gas in the setting of cellulitis and this is what we found:


Rice bodies 2Rice bodies 1

 

The densities in the soft tissue of his legs are “Rice bodies.”  They are sometimes seen in systemic cysticercosis.  These bodies are calcified dead cysts from the organism Taenia Solium.  Typically this tapeworm is found in pork.  Taenia Solium is rare in the U.S., it is more prevalent in underdeveloped countries especially with a diet that has potential to include raw or undercooked pork.  This should also be on your differential with new onset seizures (1).

 

Multiple calcifications 1

 

He also had rice bodies on head CT.  Possibly the cause of his dementia?

Author:  Russell Jones, MD

References

(1) Parasites – Taeniasis.  http://www.cdc.gov/parasites/taeniasis/.  Accessed 1/2015.


Filed under: CT, Head, Leg XR, Non-Trauma, Skin/soft tissue, XR Tagged: Rice Bodies

Student Corner: A Cavitary Lesion

Cavitary lesions in the lungs are gas or fluid filled compartments in an area of pathology, such as a consolidation or a mass. Interestingly, a specific set of pathologies are known to cause this specific finding. Cavitary lesions can be detected on a chest x-ray, as is shown below.

cavitary-mass with IDCavitary masscavitary mass lateral with IDCavitary mass 2

Legend: Red Ellipse–cavity (with margins), Blue Ellipse–air-fluid level

The lesion practically jumps out of the picture on the AP view, but the colored circles are there just to point out the entire area of pathology (blue) and the cavity within (red). The pathology is a bit harder to see on lateral view, but the cavity has an air-fluid level that is easily identified as a vertical line separating a lighter fluid filled portion from an air filled portion. This air-fluid interface is often called a meniscus. You might remember being in chemistry class and measuring water out of tall beakers where the water stuck to the sides of the glass creating a concave meniscus. The surface tension of water allows it to stick to both itself and surrounding surfaces. If you look close enough, you’ll notice that the air-fluid level in the image above, best visualized in the AP view, has a slightly concave shape because the liquid at the bottom is sticking to the solid sides of the cavity.

The underlying pathophysiology is an interesting concept to understand when discussing cavitary lesions. A cavity can form in lung tissue for various reasons, but infection is the major underlying cause. Abscesses are localized collections of pathogens, fluid and immune system components that are walled off from the surrounding tissue, therefore creating a fluid-filled cavity. Tuberculosis is a disease process that involves caseous necrosis, which results in coagulation of cell proteins and liquefaction of cellular components. Eventually, the liquid portion drains out through the lymph system or through the bronchi, leaving air pockets behind. Necrotizing pneumonia and non-infectious processes such as ischemia and neoplasm can also cause a similar picture. Rheumatologic diseases such as granulomatosis with polyangitis and sarcoidosis also cause cavitary lesions by causing localized inflammation, which in turn leads to an area of increased mass, which then in turn can cavitate once the inflammatory reaction recruits fluid to the area. In other words, most of these processes, even if they aren’t inherently related to one another, all converge on the same mechanism of causing a localized area of inflammation.

With such a wide array of categories to choose from, it is perhaps more important than usual to contextualize the radiographic image with information about the patient.

This particular patient is a 30 year old male who presents with a cough.  He has been traveling around the world to multiple continents including Sub-Saharan Africa.  The extensive travel history, including to continents with rare infectious diseases leaves infection at the top of the differential. Things like Staphylococcal pneumonia, fungal infections and even amebiasis are possible because of the patient’s travel history. For a complete list of the infectious causes of a cavitary lesion, check the first two references at the bottom of the page.

References/resources:

Gadkowski LB, Stout JE. Cavitary Pulmonary Disease. Clinical Microbiology Reviews 2008;21(2):305-333. doi:10.1128/CMR.00060-07. (LINK)

Ryu, Jay H. et al. Cystic and Cavitary Lung Diseases: Focal and Diffuse. Mayo Clinic Proceedings , Volume 78 , Issue 6 , 744 – 752. (LINK)

Good pathologic image of caseous necrosis with resulting cavitation

Image Contributor:  James Luz, MD

Author:  Jaymin Patel


Filed under: Chest XR, Non-Trauma, Respiratory, XR Tagged: Pneumonia