Mystery Quiz

X Ray Visions Mystery Quiz- The Answer

August 30, 2007

Before you read the answer, you may want to review the initial Mystery Quiz posted last week.

Commentary by Andrew Hardie MD, Fellow, NYU Department of Radiology

Although this patient’s symptoms were not the most typical of this entity, the CT findings in this case are diagnostic of a perforated anterior duodenal ulcer. The most essential observation, and the one that alters management, is the presence of intraabdominal free air (arrows). The small collections of air in this case are not unusual for bowel perforations, especially proximally. One can see how occasionally these small volumes of free air may not be able to be seen on plain films, especially inadequately positioned films.

The specific location of the free air in this case directs one to suspect a duodenal perforation. Air is seen in the periportal region, around the duodenum (green arrows), and in this case, at the site of the perforation in the duodenal wall (red arrow).

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A point of interest is that only the anterior duodenal bulb wall is intraperitoneal. Therefore, this must be an anterior wall ulcer. A posterior wall ulcer will lead to gastrointestinal bleeding, because, if you remember your anatomy, the gastroduodenal artery lies directly posterior to the duodenal bulb. Although very rare, a perforated posterior wall ulcer would cause retroperitoneal air, not intraperitoneal air.

The patient in this case reported severe epigastric pain, which could be indicative of peptic ulcer disease. However, physical exam was not suggestive of peritonitis. It is important to remember that atypical presentations of perforated ulcers can occur, although this is more commonly seen in elderly patients. Also, in this case, the perforation could have occurred in the interval between admission and abdominal imaging. The patient was taken to the OR for immediate repair of the perforation and postoperative clinical course was uneventful. Upon further questioning, he did admit to heavy weekend alcohol use as well as recent increased NSAID use for some low back pain.

X-Ray Visions: Mystery Quiz

August 22, 2007

A 46 year old male with a past medical history of hypertension presents to the emergency room complaining of constant throbbing epigastric pain for one day. He rates the pain as 7/10, with some radiation to his chest. He reports some mild nausea, but denies diarrhea or constipation.  He does endorse a bloated sensation for the past few days. He has not had any fevers and denies melana or hematochezia.  He is an avid biker and reports unlimited exercise tolerance. He denies any previous history of chest pain.

The patient works as a landscaper. He does not smoke and drinks socially on the weekends. His only medication is hydrochlorothiazide 25 mg daily. He has never had any surgeries. His father died of lung cancer at age 72, his mother is alive and well.

Pt appears mildly anxious but is otherwise in no distress. He is afebrile, BP 150/90, pulse 98, respiration rate 16.  Physical exam is remarkable only for some mild epigastric tenderness without rebound tenderness or guarding.

ECG is sinus rhythm, no st or t changes.

WBC is 16 (82% neutrophils), h/h 14/42, plt 247

Basic metabolic panel is within normal limits. Liver function tests, amylase, lipase are also all within normal limits.

Initial cardiac enzymes are negative.

The patient is admitted to the medicine service by the emergency room as a “r/o MI.”

A CT A/P with po and IV contrast is ordered by the medical team:

 

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What is your leading diagnosis?

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Mystery Quiz #3-The Answer

May 15, 2007

Before you read the answer you should read the orginal post form last week

The Final Poll Results (26 votes): metastatic disease (26%) , mycobacterial disease (22%) ,fungal disease (22%), bronchiolitis obliterans with organizing pneumonia (boop) (13%), septic emboli (9%) ,vasculitis, e.g. wegener’s (4%), thromboembolic disease (4%), sarcoid (0%)

The patient had granulomatous inflammation on pathology with acid-fast organisms seen. The culture grew mycobacterium avium (MAC). After treatment with azithromycin, ethambutol and rifabutin for eighteen months, the follow-up imaging showed significant clearing of the infiltrates.

CT 3-07

This case highlights one of the imaging patterns that are associated with MAC infection, that is, mostly nodular appearing infiltrates without a predilection for the upper lobes, as seen with reactivation MTB. What was unusual in this case was the rapidity of the disease progression. In other regards, the presentation was typical: mild symptoms that are often difficult to distinguish from the patient’s underlying pulmonary disease, exertional breathlessness, sometimes associated with increased cough and sputum, occasionally associated with systemic symptoms such as weight loss. Read more »

Mystery Quiz

May 3, 2007

Posted By Robert Smith, MD Associate Professor of Medicine, Division Pulmonary and Critical Care Medicine

The patient is an 81 year old male with severe obstructive lung disease who was referred to the pulmonary service for an abnormal chest x-ray prior to femoral-popliteal bypass surgery.   The patient complained of chronic dyspnea on exertion but specifically denied hemoptysis, increased cough, fever or night sweats.   Initial cxr revealed the following:

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A chest ct showed only a spiculated appearing mass in the left upper lobe but was otherwise unremarkable.

A follow-up chest ct done 6 weeks later showed no change in the left upper lobe mass but now revealed additional new findings.

CT 1CT 2


What is your leading diagnosis?

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Mystery Quiz #2-The Answer

February 6, 2007

Before you read the answer you will probably want to review the original post of the mystery quiz from last week.

The pathology has been correctly identified.  The photomicrograph shows lipoid pneumonia, which in fact was due to chronic mineral oil ingestion (aspiration). The patient suffered from constipation, due to long usage of oxycondone, and medicated himself with mineral oil. The pathology shows lipid material, some of it pooled into large coalescent droplets, some in macrophages.

Lipoid pneumonia can result from a variety of aspirated lipids, deriving from mineral, animal or vegetable oils. Mineral oil, which is contained in laxatives, oral lubricants, and nose sprays, is the most common offending agent. Of note, mineral oil does not elicit a cough reflex and impairs mucociliary clearance, two factors which allow silent and ongoing aspiration. It is also a relatively inert material and causes little inflammation in the lung. In contrast, cod liver oil, an animal-derived material, is much more inflammatory and can cause hemorrhagic bronchopneumonia. Lipoid pneumonia, which usually presents as a mass lesion, can mimic lung cancer. Less often, lipoid pneumonia will present with diffuse involvement of lung parenchyma, as in the present case. Since fat is less dense than soft tissue density, lipoid pneumonia may be suggested by a heterogeneous radiographic appearance on imaging, or by a ground glass appearance, as seen in our case. Lipoid pneumonia has also been call “paraffinoma of the lung.” 

Mystery Quiz #2 (with a hint…)

January 30, 2007

Since we received little in the way of responses to our mystery quiz, we thought a hint might be in order, so here's the case again this time with a hint.  Please submit your answers by clicking on the "comments" link below this post.  As always, for those of you who are unwilling to attach your name,  you can post your comments anonymously. 

The patient is a 77 year old male whose chief complaint was severe left hip pain of five years duration.  As part of a preoperative evaluation for hip surgery, a routine chest x-ray was obtained as below.  Click on the thumbnails below for full size images:

   

A prior film done six months previously showed similar but less impressive findings. Upon review, the patient denied any pulmonary symptoms or significant history of smoking. There was no history of pets, occupational exposures, recent travel or illicit drug abuse.   His only medication was oxcodone.  His review of systems was notable only for chronic constipation.

Chest computed tomography showed the following:

     

The patient subsequently underwent a bronchoscopy with transbronchial biopsy.  The pathology specimens are shown below. 

 

What's your diangosis?  Click on the word "comments" below to respond.

 

Mystery Quiz #2

January 22, 2007

Posted By Robert Smith, MD Associate Professor of Medicine, Division Pulmonary and Critical Care Medicine

The patient is a 77 year old male whose chief complaint was severe left hip pain of five years duration.  As part of a preoperative evaluation for hip surgery, a routine chest x-ray was obtained as below.  Click on the thumbnails below for full size images:

   

A prior film done six months previously showed similar but less impressive findings. Upon review, the patient denied any pulmonary symptoms or significant history of smoking. There was no history of pets, occupational exposures, recent travel or illicit drug abuse.   His only medication was oxcodone. Read more »

How Frequently Should You Perform a Follow-Up Colonoscopy-A multiple choice quiz

January 2, 2007

Commentary By Michael Poles, M.D. Gastroenterologist, Assistant Professor of Medicine, Mircrobiology and Pathology.

Every once in a while I will be feeding this new blorganism (or is it bloganism?) with content from the world of gastroenterology. Today I would like to review an article of importance to both gastroenterologists and internists. There is likely no topic in gastroenterology more important than that of colorectal cancer screening. Colorectal cancer is the second most common cause of cancer death in the U.S., and it takes up an enormous of gastroenterologists’ work effort. The most accepted form of screening for colorectal cancer is by colonoscopy. The most commonly accepted guidelines for colorectal cancer screening and surveillance were proposed by the U.S. Multisociety Task Force (USMSTF) on colorectal cancer, but it is widely held that these guidelines are not correctly followed. The biggest problem regarding CRC screening is that we underscreen; the majority of patients, nationwide, who are eligible, do not undergo appropriate screening. The flipside is likely also true; patients may be over-screened, leading to increased patient-care costs and increased demands on the medical system. With this in mind, I turn to an article in the Annals of Internal Medicine by Dr. Boolchand from University of Arizona (Ann Intern Med. 2006;145:654-659). For this study, the investigators sent out a survey to a random sample of 500 physicians from the American College of Physicians and 500 physicians from the American Academy of Family Physicians. The physicians were asked about when they would reschedule colonoscopy in a fictional 55 year old patient with a variety of findings on an initial colonoscopy.

Now for the fun part, see how you would answer each of the following scenarios.  For each question, the patient is a 55-year-old man in good health who underwent a screening colonoscopy. The colonoscopy was completed to the cecum, the quality of the colon cleansing was excellent, and the patient had no family history of colon cancer.  

Patient 1) On colonoscopy, they found and removed a 6mm polyp that was a tubular adenoma on histology. Would you repeat the procedure in:

A) 6 months

B) 1 year

C) 3 years

D) 5 years

E) 10 years

F) Repeat is not indicated

Patient 2) On colonoscopy, they found and removed a 6mm polyp that was a hyperplastic polyp on histology. Would you repeat the procedure in: 

A) 6 months

B) 1 year

C) 3 years

D) 5 years

E) 10 years

F) Repeat is not indicated

Patient 3) On colonoscopy, they found and removed a 12mm pedunculated polyp that was a tubular adenoma with a focus of high-grade dysplasia away from the biopsy margin on histology. Would you repeat the procedure in:

A) 6 months

B) 1 year

C) 3 years

D) 5 years

E) 10 years

F) Repeat is not indicated

Patient 4) On colonoscopy, they found and removed a 12mm pedunculated polyp that was a tubulvilllous adenoma on histology. Would you repeat the procedure in:

A) 6 months

B) 1 year

C) 3 years

D) 5 years

E) 10 years

F) Repeat is not indicated

Patient 5) On colonoscopy, they found and removed two 6mm polyps that were both tubular adenomas on histology. Would you repeat the procedure in:

A) 6 months

B) 1 year

C) 3 years

D) 5 years

E) 10 years

F) Repeat is not indicated

 

So, now you can see how you did: Read more »

Mystery Quiz #1-The Answer…

December 20, 2006

Before you read the answer you will probably want to review the original post of the mystery quiz from last week.

The Answer:

The chest film shows a probable mass in the area of the left hilum and associated complete collapse of the left upper lobe.  The key findings are loss of volume of the left hemithorax indicated by elevation of the left hemidiaphragm and shift of the mediastinum to the left side.  Additionally, the arrows indicate the major fissure, ordinarily not visible, but now bordering the left upper lobe because it has shifted upward. The increased density seen at the left hilum (A)suggests the presence of a mass.  Click on the thumbnails below.

 

All of the above findings are more easily seen on the two CT  images below.  Note the cutoff of the left upper lobe bronchus by an intraluminal mass (arrow), and the airlessness of the collapsed left upper lobe (B).

This patient subsequently developed hoarseness related to involvement of the left recurrent laryngeal nerve which was invaded by tumor thus indicating non-resectability of this lesion.  The biopsy of the endobronchial lesion at the left upper lobe revealed non-small cell carcinoma.

Although a peanut or foreign body was not responsible for these findings, several respondents correctly identified the volume loss and implied collapse of the left upper lobe.

Mystery Quiz-Radiology

December 13, 2006

Posted By Robert Smith, MD Associate Professor of Medicine, Division Pulmonary and Critical Care Medicine 

62 year old male smoker with past medical history notable for hypertension, copd, comes to clinic complaining of chronic cough x 6 months with minimal sputum, no wheezing.  Lung exam shows decreased breath sounds throughout.  Pt had the following CXR performed:

    

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What's your diagnosis and the next step in his evaluation?  Please submit your answers by clicking on the "comments" link below this post.  For those of you who are unwilling to attach your name, you can post your comments anonymously.  Responses will be posted for 1 week when the answer will be revealed…