Radiological Quiz

By

DR. AZIAN BT. ABD. AZIZ

Department of Radiology, Kulliyyah of Medicine, IIUM

CASE 1

History

A 79-year-old Malay man was referred from a district hospital for further investigations. He was complaining of difficulty in swallowing both solid food and liquid, which was progressive over the past 1 month and noted a remarkable loss of weight over that period. There is no other significant medical or surgical history obtained.

On physical examination, he is emaciated but otherwise conscious, alert and the vital signs were stable.

Laboratory investigations do not reveal any remarkable findings.

Radiological investigations:

Figure 1a: Barium swallow examination.

Figure 1b: CXR (zoomed at the left lower aspect).

Questions:

1)     What is the most likely diagnosis?

2)     What intervention you think has taken place based on figure 1b?

CASE 2

History

A 30-year-old man who is an intravenous drug user was referred to the surgical unit with a complaint of abdominal mass for further investigations.  On examination, he was conscious, alert and the vital signs were stable. Multiple needle puncture marks are seen over the upper and lower limbs. On abdominal examination, a pulsatile mass was palpable. An abdominal ultrasound was initially performed and following that an abdominal CT was done to further characterize the abnormality seen on ultrasound. A central venous catheter was inserted via the subclavian vein for the purpose of administration of contrast agent for the abdominal CT examination since attempts to get the peripheral venous access failed.  The central venous catheter was also inserted with difficulties .A day after the CT examination patient developed sudden onset of shortness of breath. A chest radiograph was ordered. At this point all the laboratory investigation results were pending.

Radiological investigations:

Figure 2a: axial CT abdomen

Figure 2b: axial CT abdomen

Figure 2c: MPR coronal CT abdomen

Figure 2d: MPE sagittal CT abdomen

Figure 2e: CXR

Figure 2a & 2b: Axial CT of the lower abdomen and pelvis following administration of intravenous contrast agent.
Fig. 2c & 2d:  CT abdomen with coronal and sagittal reconstruction. Contrast agent was administered intravenously
Figure 2e: CXR taken one day after the abdominal CT examination was performed

Questions:

1)     What is the abnormality seen on CT abdomen and what is the diagnosis?

2)     Based on the CXR, why do you think patient developed shortness of breath?

CASE 3

This is a case of a 16-year-old Malay boy with the problem of recurrent epistaxis for the past 2-3 years. The epistaxis occurs spontaneously and only from the left nostril. It is sometimes associated with left nasal blockage, mucoidal rhinorrhea and hyposmia. There is no generalized bleeding tendency. Over the past 2-3 years, he had been admitted 3 times for this problem and treated with nasal packing. However blood transfusion was required for the most recent admission.  On physical examination, he is in satisfactory general condition and his vital signs were stable. The laboratory results were unremarkable. The ORL surgeon performed a nasoendoscopy and found a fleshy mass occupying the posterior part of the left nasal cavity, which appear pink to red in colour. This mass is seen to arise from the lateral nasal wall and it bleeds upon contact.

Radiological investigations:

Figure 3a: Axial non-contrasted CT at the level of nasopharynx.

Figure 3b: Axial CT at the level of nasopharynx following administration of intravenous contrast agent.

Figure 3c: Axial CT with bone window.

Figure 3a: Axial non-contrasted CT at the level of nasopharynx	Figure 3b: Axial CT at the level of nasopharynx following administration of intravenous contrast agent
Figure 3c: Axial CT with bone window

Questions:

1)     What is the most likely diagnosis?

2)     What is the next radiological investigations that you would do and why?