Putty kidney

43 year old female came for USG evaluation of abdomen to rule out metastasis from carcinoma breast. This USG showing calcified mass in whole of the left kidney witch is maintaining the renal contour with posterior acoustic shadow suggestive of putty kidney.

Putty kidney is an end stage of infection with tuberculosis in the genitourinary tract, calcification may entirely outline a nonfunctional kidney.The radiologic appearance of this condition, completely calcified kidney which is associated with autonephrectomy, has been described as the putty kidney. It is very common to see the radiographic and CT appearance of putty kidney but unusual to see the USG features of putty kidney.

Cardiac hydatid cyst

CT scan of 58 year old male patient showing large well defined well capsulated hypodense lesion seen in the myocardium of the left ventricle with multiple daughter cysts within suggestive of hydatid cyst.

• Hydatid disease is a parasitic infection caused by larvae of Echinococcus granulosus, which is still endemic in many sheepraising countries.
• Hydatid cysts can be located in various tissues, although they are most common in the liver (50–70% of cases) and the lung (20–30% of cases) in humans.
• Cardiac involvement in hydatid disease is uncommon, constituting only 0.5–2% of all cases of hydatidosis.
• Heart involvement - LV – 60%, RV – 10%, pericardium – 7%, pulm Artery – 6%, left atrial appendage – 6%, and interventricular septum is rare – 4%.
• Cardiac involvement occurs by invasion of the myocardium - Through coronary circulation or pulmonary vein from rupture of pulm cysts in to vein.

• Signs and Symptoms •No symptoms due to its latency and slow growing nature unless it is situated in critical site. •Signs and symptoms are extremely variable and directly related to location and size of the cysts. •Precordial pain is the most common symptom and is most often vague and does not resemble angina pectoris. •Sudden rupture of intracardiac cysts is a frightful complication and can cause acute pericarditis or tamponade, acute pulmonary hypertension by embolization of several scolices, systemic arterial embolization, and severe anaphylactic shock can be life thretening.

• Imaging - Echocardiography, CT, and MRI can show the cystic nature of the mass and its relation to the cardiac chambers •CT best shows wall calcification. •MRI depicts the exact anatomic location and nature of the internal and external structures and is the technique used for posttreatment follow-up.
• The appearance of a hydatid cyst on MRI is usually a characteristic oval lesion that is hypointense on T1-weighted images and hyperintense on T2-weighted images. •A typical finding on T2-weighted images is a hypointense peripheral ring, which represents the pericyst (a dense fibrous capsule from the reactive host tissue). •A variety of tumors in the heart and a congenital pericardial cyst must be considered in the differential diagnosis; however, the multivesicular nature of the cystic mass and membrane detachment indicate the true diagnosis.
• The cysts may be single or multiple, uni or multiloculated, and thin or thick walled. •More specific signs are •Cyst wall calcification. •Presence of daughter cysts and Membrane detachment.
• •Surgery remains the treatment of choice in the management of hydatid disease. •Although antihelminthic drugs have been used in the preoperative and postoperative periods since 1977, extirpation of the lesion under cardiopulmonary bypass is recommended.
• To conclude CT and MRI are helpful for localizing and defining the morphologic features of hydatid cysts. •Specific signs include calcification of the cyst wall, presence of daughter cysts, and membrane detachment. •CT best shows wall calcification, whereas MRI depicts the exact anatomic location and nature of the internal and external structures.

Antenatal diagnosis Chiary II malformation - Fetal MRI

Gravida two female with previous history of abortion came for fetal MRI to ruleout congenital malformation showing lumbosacral myelomeningocele (arrow in first and third image), tonsillar herniation and corpus callosum dysgenesis (arrow in second image). features suggestive of Chiary 2 malformation.

The Austrian pathologist Hans Chiari in the late 1800s described seemingly related anomalies of the hindbrain, the so called Chiari malformations I, II and III. Later, other investigators added a fourth (Chiari IV) malformation.

Types include

Type I - Is generally asymptomatic during childhood, but often manifests with headaches and cerebellar symptoms. Herniation of cerebellar tonsils

Type II - Usually associated with myelomeningocele leading to partial or complete paralysis below the spinal defect. Abnormal development of the cerebellar vermis andmedulla oblongata occur, and they both descend into the foramen magnum. Hydrocephalus is frequently present.

Type III - Type II associated with with an encephalocele.

Type IV - Lack of cerebellar development.

The Chiari II malformation is a complex congenital malformation of the brain, nearly always associated withmyelomeningocele. This condition includes downward displacement of the medulla, fourth ventricle, and cerebellum into the cervical spinal canal, as well as elongation of the pons and fourth ventricle, probably due to a relatively small posterior fossa.

Occular Metallic Foreign body

17 year old male CT coronal, axial and coronal bone window showing metallinc foreign body in the right globe adherent to lateral wall.
Metallic foreign body in another patient in right orbit on radiograph (arrow). CT scan axial section of the same patient showing foreign body just posterior to the limbus which is extra occular.

Intraocular foreign bodies (IOFBs) are rather variable in presentation, outcome, and prognosis. With increased awareness and advanced surgical techniques, the outcome and the prognosis for these potentially devastating injuries have substantially improved.

CT scans are the imaging study of choice for IOFB localization. A helical CT scan is the most efficient method to establish a diagnosis. Helical CT scans have a very high identification rate. With conventional CT scans, cuts of 0.5 mm are advised. With the advent of MDCT the role of radiologist has become easier in identification and diagnosis of occular foreign body. Plain x-ray is useful if a metallic IOFB is present and a CT scan is unavailable. MRI is generally not recommended for metallic IOFBs. Ultrasound is a useful tool in localizing IOFBs, and its careful use is possible even if the globe is still open; alternatively, intraoperative use after wound closure can be attempted. The ultrasound biomicroscope may help with IOFBs in the anterior segment.

Focal Pyelonephritis

40 year old male patient came to emergency with history of right lumbar pain and fever, USG Doppler of right kidney shows focal hypoechoic area in upper pole with small anechoic area within. CT scan of the same patient showwed focal hypoenhancing lesion in upper pole of right kidney with small non enhancing area within. These features are suggestive of focal pyelonephritis with evolution of abscess.

Acute focal pyelonephritis (AFP) is a variant of pyelonephritis in which single or multiple discrete areas show changes of inflammation. The sonographic appearances of AFP are varied and can be echogenic, echopoor or of mixed echogenicity, but are typically described as being echopoor. CT typically shows focal hypoenhancing areas. Imaging is done mainly to identify the complications like intra renal and peri renal abscess.

Pericardial cyst

A 40-year-old man came for routine health checkup. Chest radiograph was found to be abnormal. He said he had no symptoms, and the results of a physical examination were normal. The chest radiograph (Fig 01) showed a smoothly marginated density in the region of the left cardiophrenic angle that partially obscured the left border of the heart and left dome of diaphragm. A computed tomographic scan (Fig 02) showed a homogeneous and smooth fluid attenuation lesion abutting the left ventricle. No septations or calcifications. The heart and great vessels were otherwise normal, and there was no adenopathy. Coronal and sagittal reformated images (fig03) depict the lesion better. The findings are consistent with pericardial cyst.

Pericardial cysts are an uncommon benign congenital anomaly in the middle mediastinum. They represent 6% of mediastinal masses, and 33% of mediastinal cysts. Other cysts in the mediastinum are bronchogenic – 34%, enteric – 12%, thymic and others – 21%. In the middle mediastinum 61% of presenting masses are cysts. Pericardial and bronchogenic cysts share the second most common etiology after lymphomas.

On CT scan pericardial cysts are thin-walled, sharply defined, oval homogeneous masses . Their attenuation is slightly higher than water density 30 to 40 HU. They fail to enhance with intravenous contrast. USG shows hypoechoic lesion with no calcification or septations. MRI is diagnostic, they appear hypointense on T1 and Hyperintense on T2 W images. They will not enhance on contrast study.

Cholesterol gallstones

Fig1: CT scan of 57 year old female shows multiple hypodense small lesions of fatty attenuation seen in the gall bladder suggestive of cholesterol gall stones. Fig 2: USG of gall bladder shows multiple calculi in the GB.

Gall stones are of two types: 1. Cholesterol stones and 2. Pigment stones.

Cholesterol stones are made primarily of cholesterol of 70-80%. Where as pigment stones contain only 20% of cholesterol. Ultrasound is the most sensitive and best investigation for the diagnosis of cholelithiasis. CT can pick up calcified gall stones and cholesterol stone which contain more amount of cholesterol. Cholesterol stones appear dark on the background of isoense bile on CT. CT can miss gallstones which are not calcified.

Carcinoma cervix with pyometra

CT scan of 52 year old female shows illdefined enhancing soft tissue lesion ( white arrow) in the region of cevix more on the right side with para metrial extnesion. The section through the body of uterus shows collection within the endometrial cavity. The findings are consistent with the carcinoma cervix with pyometra.

Invasive cervical cancer is the third most common gynecologic malignancy. The prognosis is based on the stage, size, and histologic grade of the primary tumor and the status of the lymph nodes. Assessment of the stage of disease is important in determining whether the patient may benefit from surgery or will receive radiation therapy. The official clinical staging system of the International Federation of Gynecology and Obstetrics has led to errors of 65%–90% in stage III and IV disease; the result has been unofficial extended staging with cross-sectional imaging modalities such as computed tomography (CT) and MRI. CT and MRI are useful in staging advanced disease and in monitoring patients for recurrence. The primary tumor is heterogeneous and hypoattenuating relative to normal stroma on contrast material–enhanced scans. Obliteration of the periureteral fat plane and a soft-tissue mass are the most reliable signs of parametrial extension. Less than 3 mm separation of the tumor from the pelvic muscles and vascular encasement are signs of pelvic side wall invasion. Lymphatic spread is along the external and internal iliac nodal chains and the presacral route to the paraaortic nodes. Distant metastases are seen with primary or recurrent disease and can involve the liver, lung, and bone.

Non Alcoholic Steatohepatitis (NASH)

15 year old male obese boy came with pain in abdomen with elevated liver enzymes. He is non alcoholic, not taking any medication and tests negetive for hepatitis. MRI abdomen T1 weighted image shows diffuse fatty infilteration in the liver which is confirmed by loss of signal on ooposed phase chemical shifgt image. Findings are consistent with Non Alcoholic Steatohepatitis (NASH).

Synonyms: Hepatic fatty metamorphosis , Hepatic fatty steatosis, NASH

Nonalcoholic steatohepatitis (NASH) is fat in the liver, with inflammation and damage. It resembles alcoholic liver disease, but occurs in people who drink little or no alcohol. The major feature in NASH is fat in the liver, along with inflammation and damage.Patients generally feel well in the early stages and only begin to have symptoms—such as fatigue, weight loss, and weakness—once the disease is more advanced or cirrhosis develops.

We have to differentiate "Fatty liver", NASH and nonalcoholic fatty liver disease (NAFLD). Fat in their liver, but no inflammation or liver damage, a condition called “fatty liver. If fat is suspected based on blood test results or scans of the liver, this problem is called nonalcoholic fatty liver disease (NAFLD). If a liver biopsy is performed in this case, it will show that some people have NASH while others have simple fatty liver. Main causes for the NASH are elevated blood lipids, such as cholesterol and triglycerides, and many have diabetes or pre-diabetes, obesity.

USG shows diffuse increase in echotexture. CT scan will show diffuse decrease in attenuation. MRI shows intracellular fatty infilteration which is diffusely hyperintense on T1 weighted image (in phase image) and shows loss of signal on opposed phase chemical shift image. These MRI findings in patient with elevated liver enzymes suggestive of NASH. Liver biopsy and histopathology are diagnostic.