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All Posts in Category: CT Scan

Green is Gout – Dual Energy CT (DECT) and Gout

This 58-years old man presented with a painful swelling over the radial aspect of the wrist. The radiograph showed an osteolytic lesion. Because of his pacemaker, a CT scan was done, which showed multiple osteolytic lesions in the distal radius and carpal bones with calcified soft tissue.

A biopsy was done, which showed some form of crystal arthropathy. His serum uric acid levels were elevated.

A dual energy CT of both elbows, wrists, hand and both knees, ankles and feet was performed. All the blobs of “green” reflect the presence of urate crystals, typical of gout. Usually in the Indian setting, florid tophaceous gout like this is not common. But in this patient, it has allowed us to clinch the diagnosis.
#ctscan #dect #gout #dualenergyct from Instagram: http://ift.tt/1Roz1tJ

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The Unfolded Infected Rib – Rib Tuberculosis and CT Scan

This is a 34-years old man with a swelling over the left anterior chest wall. The CT scan shows the collection as well as the osteolytic lesions of the ribs and the sclerosis, typical of an infection like tuberculosis.
The unfolded rib image however puts it all in perspective. The osteolytic lesions and the sequestra with surrounding sclerosis involving 4th – 6th are just so much better appreciated.
#tuberculosis #rib #ctscan #unfoldedrib from Instagram: http://ift.tt/1MJCmOr

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PET/CT shows the lung mass on the right

Lung Cancer in India

Dr. Anuradha Shah

PET/CT shows the lung mass on the right

PET/CT shows the lung mass on the right

The incidence of Lung cancer all over the world continues to rise despite the advances in diagnostics and treatment. It also causes the maximum number of cancer related deaths.

In India, the number of new cases increased from around 65,000 in 2009 to 90,000 in 2013, registering a 15-20% increase annually.

The overall 5-year survival rate of lung cancer is poor (only 5%). The age of presentation in Indians is also younger (mid 50’s) while in the rest of world it presents in people in their mid 60’s.

The death rate of the disease is so high that prevention is the only way to avoid it.

Early detection helps in better long term survival.

What are the risk factors?

  • Smoking, even passive or second hand smoking is an important risk factor.
  • Lung cancer can also be caused due to environmental and genetic factors.

Who should get tested?

  • A long standing cough that is not relieved despite treatment for more than four weeks should be reason enough for a person to undergo further testing..
  • All smokers who smoke more than 1 packet a day for 20 years.

What can you do?

STOP SMOKING & CHEWING TOBACCO.

If you are a current smoker between 50-79 years and who has smoked 20 cigarettes/day for 20 years or who is still smoking or stopped less than 15 years back then a “Low dose computed tomography (CT)” is a useful screening tool to diagnose early lung cancer.

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Not all Growing Masses are Tumors – Aspergilloma – Fungal Ball in Cavity

Not all Growing Masses are Tumors
This 32 years old with a past history of treated tuberculosis presented with hemoptysis and a mass in the right upper lobe. A radiograph done 3 years ago shows a smaller mass. The CT scan shows soft tissue within a cavity with an air-crescent, the nodule showing mobility on the prone image. The radiographs do show the crescent as well. This is a typical growing fungal ball (Aspergilloma)
#ctscan #lung #fungalball #aspergilloma #aspergillus from Instagram: http://ift.tt/1N6EbUR
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Unfolded / Flattened Rib – Fibrous Dysplasia of the Rib

Fig. 1: A simulated radiograph created from CT scan data shows an expansile lesion of the right 5th rib (arrow).

Fig. 1: A simulated radiograph created from CT scan data shows an expansile lesion of the right 5th rib (arrow).

This 29-years old lady had a chest radiograph for cough and fever. It showed an expansile lesion of the right posterior 5th rib (Fig. 1). This pattern typically occurs with either fibrous dysplasia or enchondroma, though the commonest entity in an asymptomatic individual is fibrous dysplasia (1).

Nevertheless a CT scan was performed. Thick maximum intensity projection (MIP) axial (Fig. 2a) and coronal (Fig. 2b) images show an expansile osteolytic lesion with thickening of the cortical margins at places along with a subtle ground-glass matrix. This again is typical of fibrous dysplasia.

Fig. 2 (A,B): Thick MIP axial (A) and coronal (B) images show the expansile osteolytic lesion well with cortical thickening and thinning with a ground-glass matrix.

Fig. 2 (A,B): Thick MIP axial (A) and coronal (B) images show the expansile osteolytic lesion well with cortical thickening and thinning with a ground-glass matrix.

Fig. 2 (A,B): Thick MIP axial (A) and coronal (B) images show the expansile osteolytic lesion well with cortical thickening and thinning with a ground-glass matrix.

Fig. 2 (A,B): Thick MIP axial (A) and coronal (B) images show the expansile osteolytic lesion well with cortical thickening and thinning with a ground-glass matrix.

The Flattened/Unfolded Rib image (Fig. 4) reconstructed on the new Syngo Via platform (2, 3) with automatic numbering of the ribs shows this lesion extremely well.

Fig. 3. The Flattened/Unfolded Rib image with automatic numbering shows the lesion (arrow) with the expansion, size and dimensions exquisitely demonstrated.

Fig. 3. The Flattened/Unfolded Rib image with automatic numbering shows the lesion (arrow) with the expansion, size and dimensions exquisitely demonstrated.

Since the patient and orthopedic surgeon were still concerned about the diagnosis, a CT guided biopsy (Fig. 4) was performed that confirmed the presence of a fibro-osseous lesion.

Fig. 4: A CT guided biopsy (arrow) was performed that confirmed the diagnosis of a fibro-osseous lesion.

Fig. 4: A CT guided biopsy (arrow) was performed that confirmed the diagnosis of a fibro-osseous lesion.

Because of the curvature of the rib, it can be difficult to visualize rib lesions, especially subtle fracture on routing reading, even with multiplanar reconstructions (MPRs) and MIPs. The new Siemens Syngo Via has a Bone Reading module that automatically flattens out the ribs and spine and allows quick and accurate evaluation of rib pathology, both fractures (3) and tumors (4,5).

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Tuberculosis of the Myocardium Masquerading as Angiosarcoma

This is a 23-years old man who presented with right sided tachycardia. A CT scan of the chest was performed that showed a mass involving the RV and RA with enlarged necrotic mediastinal and right internal mammary nodes (Fig. 1). This was interpreted as a mass of unknown etiology, but nothing much was done.

Axial CT scan shows a mass (red arrows) involving the RV and RA.

Axial CT scan shows a mass (red arrows) involving the RV and RA.

Axial CT scan shows the mass (red arrows) in the AV groove and involving the RA appendage. Note the enlarge right internal mammary node (blue arrow)

Axial CT scan shows the mass (red arrows) in the AV groove and involving the RA appendage. Note the enlarge right internal mammary node (blue arrow)

Axial CT scan shows enlarged necrotic mediastinal nodes (blue arrow)

Axial CT scan shows enlarged necrotic mediastinal nodes (blue arrow)

 

 

 

 

 

 

 

A week later, for some reason, a cardiac CT was performed that showed normal coronary arteries (Fig. 2).

CT cardiac shows normal proximal coronary arteries

CT cardiac shows normal proximal coronary arteries

 

 

 

 

 

Two weeks later, a cardiac MRI was done. This showed the mass well (Fig. 3, video 3) involving the RV and RA as well as the RA appendage and the adjacent AV groove with mediastinal and internal mammary nodes.

Delayed hyperenhanced 4C view of the heart shows an enhancing mass (red arrows) involving the RV and RA

Delayed hyperenhanced 4C view of the heart shows an enhancing mass (red arrows) involving the RV and RA

 

A provisional diagnosis of angiosarcoma was made and a PET/CT study was performed the next day to look for lesions that might help give a clue to the diagnosis or amenable for biopsy. The PET/CT showed the mass well (Fig. 4A), along with active internal mammary (Fig. 4B) and mediastinal (Fig. 4C) nodes and it was decided to perform a CT guided biopsy of the internal mammary node (Fig. 5), which was performed the next day.

PET/CT shows the RV and RA mass (red arrows).

PET/CT shows the RV and RA mass (red arrows).

PET/CT shows a necrotic enlarged right internal mammary node

PET/CT shows a necrotic enlarged right internal mammary node

PET/CT shows an active mediastinal node as well.

PET/CT shows an active mediastinal node as well.

CT guided biopsy of the internal mammary node.

CT guided biopsy of the internal mammary node.

 

 

 

 

 

The biopsy report was caseating granulomatous inflammation of possible tuberculous etiology and the GeneXpert showed absence of rifampicin resistance.

The most common entity that presents as an RV mass is angiosarcoma. TB of the heart typically simulates sarcoidosis and usually presents as a “granulomatous cardiomyopathy” with nodes and areas of enhancement within the LV. TB presenting as a mass like lesion is unusual. This case teaches us how TB is still the greatest masquerader of all.

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