Clinico-radiological Diagnosis Research Articles

Jejunal strongyloidiasis mimicking crohn's colitis: A diagnostic dilemma!

We report an unusual case of jejunal strongyloidiasis presenting as chronic malabsorption and intractable small bowel diarrhea in an immunocompetent adolescent boy who posed a diagnostic challenge for pathologists, radiologists, and gastroenterologists. Histopathology revealed chronic active colitis and was consistent with the clinicoradiological diagnosis of Crohn's colitis but nonresponse to immunomodulators warranted full-thickness jejunal biopsy through laparotomy which showed numerous larvae and eggs of Strongyloides. There is a need to increase the awareness of Strongyloides colitis given its high rate of misdiagnosis and mortality as the correct diagnosis can avoid a fatal outcome of this curable disease.

Functional Disability Due to Chronic Low Back Pain in the Geriatric Population of a Tertiary Care Hospital in North India: A Cross-Sectional Study.

Background Chronic low back pain (CLBP) is one of the painful and disabling conditions affecting the young as well as the geriatric population. There is a limited body of research to find out the impact of CLBP and functional disability on geriatric adults in the Indian region. Aim This study aims to determine the prevalence of functional disability due to CLBP in the geriatric population and to investigate the correlation between functional disability due to CLBP and other sociodemographic factors. Methodology A total of 157 geriatric adults were enrolled in the study, fulfilling the inclusion and exclusion criteria. Basic sociodemographic data, along with a clinical-radiological examination, was recorded. The Numeric Pain Rating Scale (NPRS), the Roland and Morris Disability Questionnaire, and the Quebec Back Pain Disability Scale were used as study tools. Summary measures (frequency, mean, median, etc.) are calculated according to the level of measurement of variables. The point prevalence of functional disability due to CLBP in the geriatric population, along with 95% confidence intervals, has been calculated. The prevalence estimates were estimated and calculated with SD variables using a t-test, chi-square test, or Fisher's exact test under bivariate analysis. The linear/logistic regression analysis was used to control for the effects of covariates. A significance level of 5% was set for all analyses due to the exploratory nature of the study. Statistical significance was considered at p < 0.05. Results According to the Roland and Morris Disability Questionnaire, 29% (N = 46) of the study geriatric participants had a severe disability, 45% (N = 70) had a moderate disability, and 26% (N = 41) had a mild disability. According to the Quebec Back Pain Disability Scale, 34% (N = 53) had scored more than 50, and 66% (N = 104) had scored less than 50. Statistically significant correlations have been found between the level of functional disability and intensity of pain (NPRS score), gender, associated illness, current and past occupation, and clinical diagnosis of CLBP (p < 0.05). Conclusion The prevalence of functional disability due to CLBP is higher in the geriatric population. It is associated with many influencing sociodemographic factors like gender, occupation, associated musculoskeletal illness, the intensity of low back pain, and clinico-radiological diagnosis. Early identification and timely interventions to reduce functional disability due to CLBP and associated risk factors are the need of the hour. Regular back muscle exercises, ergonomic modifications, and modification of activities of daily life are recommended to prevent functional disability due to CLBP.

Prevalence and Characteristics of Pathological Fractures in Patients Referred to Specialist Palliative Care: A Retrospective Study From India.

Background: Prevalence of pathological fractures in palliative care is less studied. This study aimed to determine the annual prevalence of pathological fractures and describe the characteristics and treatments in patients with pathological fractures referred to a specialist palliative care clinic in a tertiary care cancer center in India. Methods: Data of adult cancer patients newly referred to the specialist palliative care clinic over 1year with a clinico-radiological diagnosis of pathological fracture was included. Key outcomes of interest were annual prevalence, clinical characteristics, symptoms and treatments offered. Results: 75 out of 5800 (1.29%) patients newly referred to the clinic over 1year had pathological fractures. Lung cancer was the most common primary diagnosis (n = 23).Dorsal spine (n = 25) was the most common site of fracture. Pain was the predominant symptom. Mean pain score was 7.04(SD = 1.75) and 42 patients (56%) required strong opioids for analgesia. Only 11 (16%) patients underwent surgical fixation. Median duration from diagnosis of cancer to occurrence of fracture was found to be 329days. Treatment goals changed to best supportive care in 33 patients (44%) post fracture. Patients with bone and soft tissue neoplasms and those who received only chemotherapy previously had a higher risk of occurrence of fractures. Conclusion: Annual prevalence of pathological fractures in patients referred to the specialist palliative care clinic was 1.29%. It was associated with significant symptom burden and affected oncological treatments. Close monitoring of patients with bone metastases is crucial and proactive implementation of prophylactic measures to prevent such skeletal related events is warranted.

Diagnostic accuracy of Lipoarabinomannan detection by lateral flow assay in pleural tuberculosis

BackgroundLipoarabinomannan (LAM) antigen serves as an attractive biomarker to diagnose Tuberculosis (TB). Given the limitations of current diagnostic modalities for Pleural TB, current study evaluated LAM’s potential to serve as a point-of-care test to diagnose pleural TB.MethodsA cross sectional, diagnostic accuracy study was conducted during February to November 2021 in a tertiary care hospital in India. LAM antigen detection was performed on pleural fluid as well as early morning urine specimen of suspected pleural TB patients by “Alere/ Abott Determine TB LAM” lateral flow assay (LAM-LFA). The results were compared to microbiological reference standards/MRS (Mycobacterial culture or NAAT) and Composite reference standards/CRS (MRS plus Clinico-radiological diagnosis).ResultsA total of 170 subjects were included in the analysis, including 26 with Definite TB, 22 with Probable TB, and 122 with No TB. Compared to MRS and CRS, the sensitivity (61.54% & 45.83%) and positive predictive value (PPV) (57.14 & 78.57%) of Pleural LAM-LFA testing were found to be suboptimal, whereas the specificity (91.67% & 95.08%) and negative predictive value (NPV) (92.96% & 81.69%) of the assay were found to be good. Urinary LAM-LFA performed even worse than pleural LAM-LFA, except for its higher specificity against MRS and CRS (97.2% and 98.3%, respectively). Specificity and PPV of pleural LAM detection increased to 100% when analysed in a subgroup of patients with elevated ADA levels (receiver operating curve analysis-derived cut off value > 40 IU/ml).ConclusionDetection of LAM antigen by LFA directly from pleural fluid was found to be a useful test to predict absence of the disease if the test is negative rather than using as a POCT for diagnosis.

The discriminative role of PROX-1 immunohistochemistry between venous malformation and lymphatic malformation of the deep type with no visible diagnostic surface skin lesion.

Venous malformations (VMs) are distinguished from lymphatic malformations (LMs) when specific diagnostic skin lesions are present. In the deep type, this is difficult by clinico-radiologic evaluation alone. We aimed to investigate the usefulness of lymphatic vessel endothelial cell (LEC) markers for the differential diagnosis of the deep VMs and LMs. A retrospective study was conducted based on the medical records of patients with VMs and LMs who underwent biopsy with both D2-40 and PROX-1 immunohistochemistry. We compared the initial clinico-radiological diagnosis with the final pathological diagnosis and identified which ones showed a difference. From 261 patients who had VMs and LMs, 111 remained after the exclusion of those who showed definite surface diagnostic features. After pathological diagnosis with the expressions of D2-40 and PROX-1, 38 of 111 (34.2%) patients' final diagnoses were changed. Among these 38 cases, diagnosis was not changed by D2-40 positivity alone, but changed by PROX-1 positivity alone (52.6%) or by both (47.4%). The diagnostic changes were more frequent in the deep category (43.7%) than in the superficial category. Identifying the expression of D2-40, and especially PROX-1, in the differential diagnosis of VMs and LMs may provide important treatment guidelines and understanding their natural course.

Outcome of neutropenic enteropathy during induction phase of treatment of childhood acute lymphoblastic leukemia

BackgroundNeutropenic enteropathy is one of the important causes of death during intensive phase of chemotherapy in children with acute lymphoblastic leukemia (ALL). It follows a prolonged course of neutropenia and carries a mortality rate up to 30%. The study aimed to find out the outcomes of typhlitis during induction phase of treatment of childhood ALL. Material and methodsThis prospective case control study was conducted in the Department of Pediatric Hematology and Oncology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from November 2018 to January 2021. Children (<19 years) with ALL who developed neutropenic enteropathy during induction phase of chemotherapy without any comorbid condition were included in this study. The clinico-radiological diagnosis of neutropenic enteropathy was based on a standard diagnostic criteria. Complete blood count, serum electrolytes, albumin, blood culture, stool culture, abdominal X-ray and ultrasonogram were performed in all the cases. ResultsThirty-six patients developed neutropenic enteropathy. 8 (22.2%) died. Thrombocytopenia (p = 0.001), hypoalbuminemia (Odd ratio 21.0, p < 0.001), positive blood culture (Odds ratio 6.11, p = 0.026). ConclusionThis study found a mortality rate of 22.2% amongst the pediatric patients with ALL who developed neutropenic enteropathy during induction chemotherapy. Thrombocytopenia, hypoalbuminemia, and a positive blood culture predicted mortality.

Rare Location of Ewing Sarcome: A Case Study

Introduction: Ewing's sarcoma is also known as a primary peripheral neuroectodermal tumour and is a primary malignancy accounting for 5-15% of all malignancies. It can involve all skeletal bones and more rarely soft tissue. The area of predilection of this tumour is the long bones 50-60%; the flat bones mainly the pelvis 20%, while the bones of the foot and the hand constitute an exceptional localization (1), hence the interest to report our case. Clinical presentation: We report the case of an 18-year-old girl who presented with a painful swelling of the right heel evolving for 14 months in a febrile context. The diagnosis of Ewing's sarcoma of the calcaneus was suspected by radiological assessment and confirmed by a histological study after a biopsy. We discuss the clinico-radiological and histological diagnosis of this tumour and its management. Discussion: Ewing's sarcoma described by James Ewing in 1921(2), since then Cook reports only 29 cases of Ewing's sarcoma of the calcaneus in the literature (3), which shows the paucity of the literature concerning this type of calcaneal lesions, and therefore clinicians are unfamiliar with these tumours and therefore a delay in diagnosis, morbidity and amputations unnecessary. It is a tumour with a rapid potential for metastasis, particularly in the lungs, which determines the prognosis of this lesion. Conclusion: Ewing's sarcoma remains a rare disease (4) of which the calcaneus is an exceptional location. It may be misdiagnosed with other lesions, notably calcaneal osteomyelitis.

Overcoming the challenges of a misdiagnosed rare lung disease - Idiopathic pleuroparenchymal fibroelastosis.

Pleuroparenchymal fibroelastosis (PPFE) is a rare condition characterized by pleural and subpleural lung fibroelastosis with an upper lobe predominance. We present the third case of idiopathic pleuroparenchymal fibroelastosis (IPPFE) from India, as well as the second antemortem diagnosis. A 27-year-old man presented with a one-year history of mMRC class II dry cough and shortness of breath. He described a fifteen-kilogram weight loss. After a clinico-radiological diagnosis, he was given anti-tubercular treatment and referred because he showed no improvement. A high-resolution computed tomography of the chest revealed bilateral upper lobe bullae, parenchymal and subpleural fibrosis, and irregular pleural thickening. PPFE was found in surgical lung and pleural biopsies. He was given systemic glucocorticoids but did not respond clinically or radiologically. Pirfenidone and a lung transplant were out of reach for him. He died nine months after being diagnosed with his condition. Finally, IPPFE is an extremely rare entity, with only three cases reported from our subcontinent. As a result, it is easily underdiagnosed or misdiagnosed; clinician awareness of this condition is critical for better diagnosis and management.

Invasive cerebral aspergillosis in non-neutropenic patients: A case series from Western India.

Invasive cerebral aspergillosis (ICA) is a rare but fatal infection affecting neutropenic immunocompromised patients. Recently cases have been reported in non-neutropenic settings also. We hereby present a series of ICA cases in non-neutropenic patients diagnosed at our tertiary care centre in Western India between March to October 2021. All patients with clinico-radiological suspicion of CNS infections were analysed. Data regarding Clinico-radiological features, diagnosis, treatment and outcome were collected. After ruling out bacterial, viral and mycobacterial causes, appropriate samples were sent for KOH (potassium hydroxide) wet mount, fungal culture, histopathology and serum/CSF galactomannan. A total of four patients were diagnosed with ICA with a mean age of 43.5 years. Three patients had significant comorbidities; Diabetes mellitus, chronic liver disease and COVID-19 pneumonia treated with dexamethasone, respectively. One patient had no known predisposing factor. Radiologically, one patient presented with a frontal brain abscess and two patients had multiple subcortical hyperintensities. Three patients were diagnosed based on CSF galactomannan (Platelia™ Aspergillus antigen, Bio-Rad, France) with OD >1 and one patient had high serum galactomannan (OD >2). CSF culture grew Aspergillus species in two patients. All patients were treated with Voriconazole. One patient recovered, and the remaining three succumbed due to delayed presentation and extensive cerebral involvement. Even in non-neutropenic patients, a high index of suspicion is warranted for cerebral aspergillosis. CSF galactomannan can be considered a reliable marker for diagnosing ICA in non-neutropenic settings. Early diagnosis allows timely antifungal therapy, which could be a key to improving the outcomes.

Teaching Neuro Images : Nonfluent variant primary progressive aphasia

A 66-year-old woman presented with 4 years of progressive speech difficulty. She had nonfluent speech with phonemic errors but intact single-word comprehension and object knowledge. Her grammar was impaired in both speech and writing, and she exhibited orofacial apraxia. A clinico-radiologic (see figure) diagnosis of nonfluent variant primary progressive aphasia was made.

Posterior Reversible Encephalopathy Syndrome: A Rare Side Effect of Nivolumab

Introduction: Posterior reversible encephalopathy syndrome (PRES) is a novel clinico-radiological syndrome which is characterized by variable symptoms including visual disturbances, headache, vomiting, seizures and altered consciousness, usually accompanied by hypertension. Several cases of immunotherapy-related PRES have been reported as a rare cause of PRES. We present a case of a 52-year-old male who was started on the immunotherapy nivolumab for his esophageal cancer. He came to the hospital with progressive vision loss and was diagnosed with PRES along with optic neuritis. Case Presentation: A 52-year-old male with no significant past medical history presented to the hospital with left sided numbness and spatial recognition issues. A computed tomography (CT) of the head revealed a 3 cm right parietal mass with vasogenic edema later confirmed with a magnetic resonance imaging (MRI) of the brain. He was started on steroids along with 500 mg Keppra twice a day. CT of the chest, abdomen, and pelvis showed multiple hepatic masses and retroperitoneal lymphadenopathy. He had a colonoscopy about a year prior that was unremarkable. He underwent right frontal parietal craniotomy for single brain metastatic lesion. The biopsy of both the brain and liver mass revealed metastatic adenocarcinoma. He was discharged and started on Fluorouracil, Folinic Acid, Oxaliplatin (FOLFOX) chemotherapy as outpatient for possible upper gastrointestinal (GI) cancer. After two cycles of chemotherapy, a positron emission tomography (PET) scan revealed suspected primary esophageal cancer. Though patient had zero PDL-1 biomarker, nivolumab was added to cycle 3 of FOLFOX with the expectation of having a better response early in the disease. He continued to have stereotactic radiosurgery (SRS) along with steroid taper for local control of brain metastasis. Nivolumab was held after cycle 2 as he developed mild headache, fever and elevated lipases. He was found to be hypertensive to 144/85 mmHg. MRI brain showed improving post-surgical changes. On improvement of symptoms, Nivolumab was reintroduced to cycle 6 of FOLFOX. Unfortunately, a week later he developed progressive vision loss more on right eye. He was sent to optometrist who referred patient to emergency room (ER) because of concern for bilateral papilledema. On admission to ER, he was hypertensive to 182/104 and tachycardic to 107 beats per minute. Physical exam was significant for left inferior quadrantanopia more prominent in right eye. CT head was unrevealing for any infarct. MRI of the orbit and brain showed increased patchy T 2 signal in bilateral parieto-occipital lobes without enhancement suggestive of posterior reversible encephalopathy syndrome (PRES) along with right optic neuritis. These findings were attributed to the immunotherapy nivolumab. He was started on a high dose of prednisone, 1mg/kg/day along with 20 mg lisinopril for strict blood pressure control with a goal of 120/80 mmHg. He was discharged with tapering steroids dose and his symptoms improved within 1 week of treatment. Discussion: Posterior reversible encephalopathy syndrome is a clinico-radiological diagnosis. The underlying pathophysiology involves hypertension and endothelial dysfunction. Hypertension leads to cerebral hyper-perfusion which may cause vascular damage and vasogenic edema leading to blood brain barrier dysfunction. The posterior circulation is the most susceptible to blood pressure changes, thus it is the most common imaging abnormality. PRES frequently develops in the context of cytotoxic medication, immunotherapy, (pre)eclampsia, sepsis, renal disease or autoimmune disorders. MRI is an important diagnostic tool and displays hyperintense lesions in T2-weighted or FLAIR sequences in the parietal-occipital lobes in about 70% of cases but other parts can also be involved. Electroencephalogram (EEG) and lumbar puncture (LP) can be done to rule out other causes. Differentiation is important from an ischemic event as management is different in both cases. Treatment of PRES is symptomatic. Recommendations are to avoid fluctuations in blood pressure with a goal of 130-150/80-100mmHg. If any triggering factor or condition is identified like immunotherapy, it should be avoided or treated accordingly. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

ODP261 Non-Ketotic Hyperosmolar Hyperglycemia Induced Hemichorea-Dystonia Syndrome, Without Radiologic Striatopathy

Abstract Background Movement disorder is an uncommon complication of Hyperglycemic crisis. It is often associated with diabetic striatopathy which is a clinico-radiologic entity that is associated with acute changes of the contralateral basal ganglia. Isolated dyskinetic-dystonic disorder without obvious radiologic lesion is a rare clinical entity. Case Report A 42-years-old woman with a history of type 2 diabetes mellitus was admitted with a 1-week history of involuntary right arm and face movements and 3 weeks of polyuria. She had recurrent choreiform right arm movements without athetosis or hemiballismus lasting about 2. Additionally, she experiences right cervicofacial dystonia. There was no involvement of the lower extremities, no loss of consciousness and no other neurologic deficit between attacks. Physical examination was essentially unveiling with no focal neurologic deficits or tremors. Initial work up showed elevated; blood glucose to 620mg/dl (65–110), serum sodium of 148mEq/L (135–145) and serum osmolality of 330mmol/kg (275–295). Work up was negative for acidosis, with pH of 7.39 (7.32–7.42), bicarbonate of 23mEq/L (23–31) and no ketones on urinalysis. Other relevant test including serum bilirubin, transaminases, ammonia level, calcium, ceruloplasmin and cupper were normal. An initial non-contrast CT scan of the brain was negative for acute pathology and MRI did not show any lesions in basal ganglia. E. E. G was also normal. Movements recurred twice in hospital, and she received IV lorazepam without much response. She was diagnosed with non-Ketotic hyperosmolar hyperglycemic chorea- dystonia syndrome. She received IV normal saline and started on insulin therapy resulting in improvement in serum glucose to 255 by the next morning. She was discharge after 72 hours with no recurrence at 2 weeks follow up visit. Discussion Hyperglycemic crisis may rarely be associated with dyskinetic syndromes, often due to the development of diabetic striatopathy and about 80% are without ketosis. The mechanism is believed to be due to impaired GABA synthesis in the basal ganglia. Prevalence of hyperglycemia induced striatopathy stands at 1 per 100,000. The commonest manifestation is that of hemiballismus and chorea. Very few cases of dystonia have been reported. It is a clinico-radiologic diagnosis with basal ganglia abnormalities on imaging stemming from edema, microhemorrhages or calcific changes. There are very few case reports of hyperglycemic dyskinetic syndromes without CNS changes on MRI. The average time for resolution of MRI changes is 60 days thus we believe our patient had no radiologic striatopathy. In majority of cases, resolution of hyperglycemia leads to clinical resolution of dyskinetic spells. Occasionally, some patients may require medications such as antipsychotics including haloperidol, or benzodiazepines such as clonazepam to control movements. In conclusion, movement disorder related to hyperglycemia though rare, can be disabling. Prognosis is excellent if a timely clinical diagnosis is made. Presentation: No date and time listed

P15.14.B Radionecrosis versus progression in brain tumors: results of a promising MRI tools

Abstract Background Distinguish between radiation necrosis (RN) and tumor progression, in patients with irradiated primary or metastatic brain tumors, is a diagnostic challenge. Also the use of new MRI sequences, like diffusion, perfusion-weighted and spectroscopy, or PET with new amino acid tracers, is not always able to differentiate these two entities.To overcome this crucial problem, encouraging results have been obtained using the analysis of delayed contrast extravasation MRI to calculate high resolution maps, called “treatment response assessment maps” (TRAMs). Aim of this exploratory analysis is to assess TRAM ability in differentiate between radiation effect and tumor progression in a small cohort of brain tumor patients treated with radiation therapy (RT). Material and Methods Thirty-four patients irradiated for primary and metastatic brain tumors were evaluated. 12 patients have primary brain tumors, 22 patients have brain metastases from different solid tumors. Distinguish by histological subtypes and type of treatment, the 12 patients with primary brain tumors were: 8 glioblastoma, 2 anaplastic astrocitoma, 1 pleomorphic xanthoastrocytoma WHO grade II, and 1 anaplastic xanthoastrocytoma WHO grade III, treated with surgery followed by RT and concomitant and\or adjuvant chemotherapy with temozolomide. Among brain metastatic patients, primary tumor was: 18 non-small cell lung cancer, 2 malignant melanoma, 1 breast cancer and 1 renal cell carcinoma. All of them were treated with stereotactic radiosurgery at the dose of 20-24Gy in 1fraction, or with hypofractionated stereotactic radiotherapy at the dose of 27-30Gy in 3fractions. All images were uploaded and elaborate into the image workstation ([Brainlab AG, Olof-Palme-Straße 9, 81829 Munich]). TRAMs were calculated by subtracting T1 MRI images acquired 5 minutes after contrast injection from the T1 MRI images acquired 60-105 minutes later. On TRAMs, radiation effects appeared as red areas whereas persistent tumoral lesion appeared as blue areas. Results From February 2021, 34 patients have been evaluated, in a prospective study, with this novel MRI modality. During their follow-up, 13patients (38%) showed a clinicoradiologic suspicion of a persistent tumoral lesion or progressive disease, and 21 (62%) a suspicion of RN. For 14patients a brain MET-PET has been performed. TRAMs analysis have shown a fair agreement with clinicoradiologic diagnosis, perfusion-weighted MRI, and PET imaging. Moreover, 7 patients underwent surgical resection, with histopathological confirm of persistent disease in 4 and radionecrosis in 3. Conclusion These preliminary results show the ability of TRAMs evaluation in distinguish between RN and progressive disease. The recruitment of new patients continues, and further evaluations are ongoing to evaluate sensitivity and positive predictive value of TRAMs analysis.

Osteonecrosis of the Femoral Head: A Multidisciplinary Approach in Diagnostic Accuracy.

Osteonecrosis of the Femoral Head (ONFH) is a disabling disease affecting up to 30,000 people yearly in the United States alone. Diagnosis and staging of this pathology are both technically and logistically challenging, usually relying on imaging studies. Even anatomopathological studies, considered the gold standard for identifying ONFH, are not exempt from problems. In addition, the diagnosis is often made by different healthcare specialists, including orthopedic surgeons and radiologists, using different imaging modes, macroscopic features, and stages. Therefore, it is not infrequent to find disagreements between different specialists. The aim of this paper is to clarify the association and accuracy of ONFH diagnosis between healthcare professionals. To this end, femoral head specimens from patients with a diagnosis of ONFH were collected from patients undergoing hip replacement surgery. These samples were later histologically analyzed to establish an ONFH diagnosis. We found that clinico-radiological diagnosis of ONFH evidences a high degree of histological confirmation, thus showing an acceptable diagnostic accuracy. However, when the diagnoses of radiologists and orthopedic surgeons are compared with each other, there is only a moderate agreement. Our results underscore the need to develop an effective diagnosis based on a multidisciplinary approach to enhance currently limited accuracy and reliability.

Pneumothorax in Critically Ill COVID-19 Patients in the Indian Subcontinent.

To explore the incidence and risk factors, as well as mortality, in critically ill COVID-19 patients who developed pneumothorax (PTX) and/or pneumomediastinum (PNM). A retrospective cohort study was undertaken to analyse data of all patients with moderate to severe COVID-19 disease who were either RTPCR positive or had a clinico-radiological diagnosis. The exposure group consisted of COVID-19 patients who presented with PTX/PNM, whereas the non-exposure group consisted of patients who did not develop PTX and/or PNM during the stay. Incidence of PTX/PNM was observed to be 1.9% among critically ill COVID-19 patients. 94.4% (17/18) of patients in the PTX group received positive pressure ventilation (PPV); the majority of these patients were on non-invasive ventilation when they developed PTX/PNM; only one patient was receiving conventional oxygen therapy. COVID-19 patients who developed PTX/PNM had 2.7 times higher mortality. A mortality rate of 72.2% was observed in COVID-19 patients who developed PTX/PNM. Development of PTX/PNM in critically ill COVID-19 patients is associated with more severe disease involvement, and institution of PPV is an additional risk factor. Significantly high mortality was observed following PTX/PNM in critically ill COVID-19 patients and is an independent marker of poor prognosis in COVID-19 disease.

Diagnostic Performance of High-Resolution Vessel Wall Magnetic Resonance Imaging and Digital Subtraction Angiography in Intracranial Vertebral Artery Dissection.

Purpose: Intracranial vertebral artery dissection (VAD) is being increasingly recognized as a leading cause of Wallenberg syndrome and subarachnoid hemorrhage. Conventional angiography is considered the standard diagnostic modality, but the diagnosis of VAD remains challenging. This study aimed to compare the diagnostic performance of high-resolution vessel wall imaging (HR-VWI) with digital subtraction angiography (DSA) for intracranial VAD. Materials and methods: Twenty-four patients with 27 VADs, who underwent both HR-VWI and DSA within 2 weeks, were consecutively enrolled in the study from March 2016 to September 2020. HR-VWI and DSA were performed to diagnose VAD and to categorize its angiographic features as either definite dissection or suspicious dissection. Features of HR-VWI were used to evaluate direct arterial wall imaging. The reference standard was set from the clinicoradiologic diagnosis. Two independent raters evaluated the angiographic features, dissection signs, and interrater agreement. Each subject was also dichotomized into two groups (suspicious or definite VAD) in each modality, and diagnosis from HR-VWI and DSA was compared with the final diagnosis by consensus. Results: HR-VWI had higher agreement (90.6% vs. 53.1%) with the final diagnosis and better interrater reliability (kappa value (κ) = 0.91; 95% confidence interval (CI) = 0.64–1.00) compared with DSA (κ = 0.58; 95% CI = 0.35–1.00). HR-VWI provided a more detailed identification of dissection signs (77.7% vs. 22.2%) and better reliability (κ = 0.88; 95% CI = 0.58–1.00 vs. κ = 0.75; 95% CI = 0.36–1.00), compared to DSA. HR-VWI was comparable to DSA for the depiction of angiographic features for VAD. Conclusions: HR-VWI may be useful to evaluate VAD, with better diagnostic confidence compared to DSA.

Diagnosis of diffuse parenchymal lung diseases using transbronchial cryobiopsy guided by endobronchial ultrasound compared to clinicoradiological diagnosis.

This study aimed to evaluate the safety and effect of transbronchial cryobiopsy guided by radial probe endobronchial ultrasound (RP-EBUS) compared with clinicoradiological diagnoses in diffuse parenchymal lung diseases (DPLDs). A total of 60 patients with DPLDs confirmed by chest computed tomography (CT) who underwent transbronchial lung cryobiopsy guided by RP-EBUS were enrolled. The ultrasound images were obtained and identified together with corresponding chest CT characteristics. The cryobiopsy samples were evaluated histopathologically and compared with CT imaging, and the complications were analyzed. The multidisciplinary diagnosis was clear in 51 (85%) participants but unclear in the remaining 9 (15%) participants. In transbronchial cryobiopsy guided by RP-EBUS, 36 (60%) participants had the biopsy in 1 lobe while 24 (40%) had a biopsy in 2 different lobes, with a mean biopsy specimen size of 43.17±15.25 mm2. The histopathologic diagnosis based on biopsy confirmed the preprocedural clinicoradiological diagnosis in 51 (85%) patients and clarified the diagnosis in the other 9 patients with unclear clinicoradiological diagnosis, including alveolated lung parenchyma with interstitial chronic inflammation in 4 (6.7%) cases and chronic bronchiolitis and interstitial lymphocytic infiltrates in the other 5 (8.3%). Intraprocedural complications occurred in 57 (95%) patients, including pneumothorax in 9 (15%), bleeding in 47 (78.3%), and hypoxemia in 1 (1.7%). The ultrasound images of DPLDs were normal, mesh (n=24), nodular (n=9), and alveolar type (n=27). Transbronchial cryobiopsy guided by RP-EBUS is safe and effective and can supply additional information to the clinicoradiological approach for correct diagnosis of DPLDs.

Clinico-radiological diagnosis of silent Choroid plexus papilloma in a child

Background: Choroid plexus papillomas (CPPs) are benign slow-growing tumors with the most common site as the choroid plexus of the lateral ventricle in children. These are highly vascular solid tumors which have classical diagnosis in contrast-enhanced computerized tomography (CECT) and contrast-enhanced magnetic resonance imaging (CEMRI). These require early management because of their secondary symptoms related to hydrocephalus and others due to tumoral compression. Case Report: We present a 10-month-old male child with abnormal eye movements and fever following head trauma seventeen days before. Ultrasound of the brain revealed the hyperechoic mass in the right lateral ventricle. CECT and CEMRI diagnosed as a case of choroid plexus papilloma with gross hydrocephalus. This was a silent CPP which came to limelight following head trauma. Ventriculoperitoneal shunt was placed for the decompression of the ventricular system and was advised for subsequent surgical management. Conclusion: Atypical presentations of CPP can confuse in making the diagnosis and this delay can be harmful to the patient. Early diagnosis of CPP is very important as these are slow-growing tumors which can lead to various complications if late diagnosis is made. Cross-sectional modalities such as CECT and CEMRI are the most valuable diagnostic modality tools for the early diagnosis

Lung ultrasound (LUS) in pre-term neonates with respiratory distress: A prospective observational study.

To find out the diagnostic use of lung ultrasound (LUS) in respiratory distress in neonates by taking clinico-radiological (clinical plus X-ray) diagnosis as the gold standard. Secondary objectives were to find out if modified LUS score can predict the need for surfactant therapy. A prospective observational study was done in a tertiary care neonatal intensive care unit over a period of 1 year (January-December 2018). All pre-term infants with respiratory distress were screened with LUS and CXR within 2 h of admission and modified LUS score was calculated to find out the lung water content and its correlation with the severity of respiratory distress syndrome (RDS). In total, 92 neonates were screened during the study period, and 61 were finally diagnosed as RDS. The Kappa statistic between the clinico-radiological diagnosis and LUS diagnosis was 0.639. LUS diagnosis and CXR diagnosis had a Kappa correlation value of 0.786 (95% CI: 0.678-0.983). The most common LUS feature in RDS was pleural line thickening (100%), followed by whiteout lungs (75.4%). The modified LUS score was higher in babies who needed surfactant therapy (median (IQR): 49 (44, 53.5) vs. 29.5 (21, 46)) (P < 0.0001). Our study shows that LUS in neonatal RDS can predict the severity of the disease, need for surfactant therapy and has good agreement with clinical and Xray diagnosis.

Clinico-Radiological assesment of lumbar spinal canal stenosis and evaluation of its surgical treatment

Objective: This study aimed to predict the absolute criteria for surgical intervention and study the outcome of surgical intervention.Materials and Methods: A prospective study was conducted from June 2002 to July 2003. A total of 35 patients were included in the study. Pre- and postoperative Oswestry Disability Index (ODI) scores were evaluated for all the patients. All patients underwent magnetic resonance imaging (MRI). The surgical indications were disabling backache with radicular pain, limited walking capacity, and neurological deficits leading to a poor ODI score. Surgical procedures done were discectomy and laminectomy with or without fixation with pedicle screws on a case-to-case basis. Follow-up was done for up to 1 year at three-monthly intervals. The final ODI score was taken at the last follow-up and was compared with preoperative scores.Results: A 50 ± 10 years was the average age of patients included in the study. The average walking capacity was 40 m; the average duration of symptoms was 41 months. ODI improved from average score of 71% ± 4% preoperatively to 22% ± 6% postoperatively. L4–L5 was the level most severely narrowed, with a mean cross-sectional area of 75 mm2. The most common surgical interventions done were discectomy and laminectomy, which were performed in 54% of the cases. We had good-to-excellent results in all our cases. None of the cases deteriorated after surgery.Conclusion: The findings in this study have important implications in clinical practice. The radiological findings in the MRI correlated well with the clinical signs and symptoms of the patients, i.e., patients with significant findings in the MRI had profound clinical symptoms and neurological deficits.Clinical Significance: Lumbar canal stenosis is a clinicoradiological diagnosis. ODI score is related to canal narrowing on MRI. Clinical improvement is related to preoperative disability and canal narrowing on MRI.