Hypoattenuating Lesions Research Articles

Fulminant Liver Failure From Infiltrative Carcinomatosis

Introduction: Malignancy is a rare cause of fulminant liver failure. We report a case of infiltrative carcinomatosis of unknown origin, presenting as acute liver failure (ALF) and progressing to fulminant liver failure (FLF). Case Presentation: 58—year—old Caucasian male presented with worsening encephalopathy along with abdominal pain, distension and peripheral edema for three months. Physical exam was significant for icterus, ascites and hepatomegaly. Computed tomography of abdomen revealed a nodular liver with small hypo attenuating lesions. Initial work up was significant for serum ammonia of 227 ug/dl, INR of 3.6, total bilirubin of 13.1, AST >10,000, and ALT of 4900, Factor VII levels of 7%, qualifying as ALF; associated with refractory hyperkalemia requiring emergent dialysis. His hospital course was complicated by hematemesis and worsening ascites requiring therapeutic paracentesis. In the interim, biochemical parameters worsened further with Factor V and VII levels at 12% and 7%, INR of 9.5 and lactate dehydrogenase of 7000 U/L, lactic acidosis, hypoglycemia and Grade IV encephalopathy, reflective of FLF. Patient subsequently required mechanical ventilation and vasopressor support. Furthermore, he developed abdominal compartment syndrome, at which point, patient was made comfort care as per wishes of next of kin. A limited abdominal autopsy revealed near total hepatic necrosis, associated with infiltrating pancytokeratin positive carcinoma cells. A primary could not be determined due to lack of examination of other organs.3028_A.tif Figure 1: H&E staining of liver specimen showing massive hepatic necrosis secondary to extensive tumor thrombus3028_B.tif Figure 2: Liver biopsy staining as pancytokeratin positive, supportive of the primary tumor being of epithelial subtype.3028_C.tif Figure 3: Liver specimen with Hep PAR Immunohistochemical staining positiveDiscussion: Liver is one of the most common sites for metastasis of various cancers. FLF due to metastasis has been rarely reported. Imaging findings are non—specific and diagnosis is mostly confirmed by autopsy. A loss of adhesion molecules in the primary tumor allows migration of cells to organs including liver, with an intra—sinusoidal pattern of invasion rather than parenchymal mass formation. The occlusion of blood vessels results in massive parenchymal necrosis. Liver transplantation is contra—indicated in these cases, with most chemotherapy agents not being viable options due to severe liver dysfunction. The prognosis is dismal with death occurring between 3 days to 6 months. In conclusion, we report a rare case of FLF secondary to infiltrative carcinomatosis. Physicians should have a high index of suspicion to consider this etiology when approaching a case of ALF so as to avoid inappropriate listing for transplantation.

Characterization of Small Incidental Indeterminate Hypoattenuating Hepatic Lesions: Added Value of Single-Phase Contrast-Enhanced Dual-Energy CT Material Attenuation Analysis.

The objective of this study is to determine whether single-phase contrast-enhanced dual-energy CT (DECT) material attenuation analysis improves the characterization of small (< 2.0 cm) incidental indeterminate hypoattenuating hepatic lesions, compared with conventional single-energy CT evaluation. This retrospective study involved 55 patients (24 men and 31 women; mean [± SD] age, 63.9 ± 15.3 years) with 77 incidental hypoattenuating hepatic lesions (59 benign and 18 malignant lesions) measuring 0.5-2.0 cm who underwent single-phase contrast-enhanced DECT of the abdomen for pain. For each lesion, attenuation measurements were obtained using blended 120-kVp-equivalent images and contrast map images. DECT material attenuation images were used for iodine quantification. Optimal lesion attenuation and iodine concentration threshold values that best distinguished benign lesions from malignant lesions were generated using smooth bootstrapping. The diagnostic accuracy of the optimized thresholds was compared using the Wilcox rank sum test. The optimal mean (± standard error) attenuation threshold values that best differentiated benign and malignant lesions were 50.2 ± 5.2 HU and 11.5 ± 2.0 HU when blended 120-kVp and contrast map images, respectively, were used. The iodine concentration (expressed as milligrams of iodine per milliliter) differed significantly (p < 0.0001) between benign lesions (0.6 ± 0.4 mg I/mL) and malignant lesions (1.7 ± 0.4 mg I/mL). The optimal iodine concentration that best distinguished between benign and malignant lesions was 1.2 ± 0.1 mg I/mL. The sensitivity, specificity, and AUC value were highest for iodine concentration (0.94, 0.93, and 0.97, respectively), compared with blended images (0.89, 0.70, and 0.81, respectively) and contrast map images (0.94, 0.64, 0.77, respectively). Iodine quantification performed using single-phase contrast-enhanced DECT material attenuation images improves the characterization of small (< 2 cm) incidental indeterminate hypoattenuating hepatic lesions, compared with conventional attenuation measurements.

Retropharyngeal tendinitis: Hydroxyapatite deposition driven headache and nuchal rigidity resolves with prednisone

We present a case of a 42-year-old woman who presented with sudden onset severe headache, neck pain, and nuchal rigidity associated with dysphagia. The initial differential in this patient included meningitis or retropharyngeal abscess, and an extracranial neck CT showed an ill-defined hypo-attenuated lesion within the retropharyngeal space. However, the neck pain and dysphagia were unresponsive to empirical antibiotic treatment and pain management. Further CT with contrast identified acute calcific tendonitis of the longus colli tendon, also known as retropharyngeal tendonitis (RCT). Although RCT is already known as a rare, self-limiting inflammatory condition, we present a new case of RCT, with the uncommon features of headache and nuchal rigidity in an aseptic patient, while providing a diagnostic flow chart to guide the clinical work-up of similar presentations to also include RCT.

Disseminated Endobronchial Nocardiosis Masquerading as a Bronchogenic Tumor

SESSION TITLE: Lung Pathology 1 SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Nocardia is a weak gram positive, partial acid fast branching filamentous organism. Pulmonary Nocardiosis is infrequently reported in immunocompetent patients and delay in diagnosis occurs due to non-specific clinical symptoms and radiological signs [1]. Our case highlights an unusual presentation of disseminated endobronchial Nocardiosis, initially mistaken for metastatic lung cancer. CASE PRESENTATION: A previously healthy 61-year-old male presented with a worsening right occipital headache. He denied any changes in vision. No fever, chills, anorexia, cough or shortness of breath were reported. His physical examination was unremarkable. Laboratory work up was unrevealing. A Computed Tomography (CT) of the head showed three hypoattenuating lesions in the right cerebral convexity (figure 1). A PET/CT of the body was obtained for concerns of metastatic disease and showed two infrahilar nodules and a right sided subcarinal lymph node with high FDG avidity suspicious for malignancy. These findings prompted a diagnostic bronchoscopy with EBUS-FNA of an endobronchial lesion found in the bronchus intermedius (figure 2). The pathology was negative for malignancy but cultures grew Nocardia. Speciation later showed Nocardia wallacei. A biopsy of the right occipital brain lesion was also consistent with Nocardia. The patient was started on trimethoprim-sulfamethoxazole and imipenem. His follow up visit with repeat CT imaging showed an interval decrease in the size of the right infrahilar mass. DISCUSSION: Pulmonary Nocardiosis has been rarely reported in immunocompetent individuals. Risk factors for this opportunistic infection include solid organ transplant, leukemia, steroid use and HIV [2]. Diagnosis of pulmonary Nocardiosis is usually heralded by the insidious onset of fever, anorexia, cough or shortness of breath. Our patient had a unique presentation with symptoms related to brain dissemination but had absent pulmonary symptomatology [2]. Radiological features of Nocardia in lungs include lobar infiltrates, nodules or cavitary lesions. Treatment consists of a combination of sulfonamides and Imipenem [3]. CONCLUSIONS: We hereby present a rare case of pulmonary Nocardiosis with dissemination to brain in an immunocompetent host. The presentation mimicked malignancy. Our case highlighted the importance of including pulmonary Nocardia in the differential diagnosis of lung nodules with brain lesions even in the absence of respiratory symptoms or known factors of immunosuppression. Reference #1: Ramana KV, Sabitha K, Venkata Bharatkumar P, Sharada CHV, Ratna Rao, Ratna Mani, Sanjeev DR: Invasive Fungal Infections: A Comprehensive Review. American Journal of Infectious Diseases and Microbiology. 2013, 1:64-69 Reference #2: Martínez Tomas R, Menéndez Villanueva R, Reyes Calzada S, et al: Pulmonary nocardiosis: risk factors and outcomes. Respirology. 2007, 12:394-400 Reference #3: Shariff M, Gunasekaran J: Pulmonary Nocardiosis: Review of cases and an update. Canadian Respiratory Journal. 2016:749202 DISCLOSURE: The following authors have nothing to disclose: Sara Assaf, Pujan Patel, David Stoeckel No Product/Research Disclosure Information

Bilateral adrenal myelolipoma: A case report

Myelolipoma is a relatively rare benign tumor composed of mature adipose tissue with variable amounts of hematopoietic element of both the myeloid and the erythroid series. It is usually asymptomatic, and bilateral tumors are unusual. The case is reported of a 62-yr-old male who presented with an ill-defined firm, non-tender, bimanually palpable mass in the right lumbar region, encroaching into right hypochondrium. It showed slight movement with respiration and was intraperitoneal. Contrast enhanced computed tomography (CECT) scan of the abdomen showed bilateral, heterogenous, hypoattenuating lesions with an enhancing rim of soft tissue in the adrenal fossae. At surgery the right sided tumor was treated by adrenalectomy and the left by enucleation of the tumor. Conclusion: Bilateral myelolipoma of adrenal gland is a very rare entity and warrants careful evaluation, by abdominal CECT scan and fat suppressing magnetic resonance imaging (MRI).

Subclinical leaflet thrombosis in surgical and transcatheter bioprosthetic aortic valves: an observational study

Subclinical leaflet thrombosis of bioprosthetic aortic valves after transcatheter valve replacement (TAVR) and surgical aortic valve replacement (SAVR) has been found with CT imaging. The objective of this study was to report the prevalence of subclinical leaflet thrombosis in surgical and transcatheter aortic valves and the effect of novel oral anticoagulants (NOACs) on the subclinical leaflet thrombosis and subsequent valve haemodynamics and clinical outcomes on the basis of two registries of patients who had CT imaging done after TAVR or SAVR. Patients enrolled between Dec 22, 2014, and Jan 18, 2017, in the RESOLVE registry, and between June 2, 2014, and Sept 28, 2016, in the SAVORY registry, had CT imaging done with a dedicated four-dimensional volume-rendered imaging protocol at varying intervals after TAVR and SAVR. We defined subclinical leaflet thrombosis as the presence of reduced leaflet motion, along with corresponding hypoattenuating lesions shown with CT. We collected data for baseline demographics, antithrombotic therapy, and clinical outcomes. We analysed all CT scans, echocardiograms, and neurological events in a masked fashion. Of the 931 patients who had CT imaging done (657 [71%] in the RESOLVE registry and 274 [29%] in the SAVORY registry), 890 [96%] had interpretable CT scans (626 [70%] in the RESOLVE registry and 264 [30%] in the SAVORY registry). 106 (12%) of 890 patients had subclinical leaflet thrombosis, including five (4%) of 138 with thrombosis of surgical valves versus 101 (13%) of 752 with thrombosis of transcatheter valves (p=0·001). The median time from aortic valve replacement to CT for the entire cohort was 83 days (IQR 33-281). Subclinical leaflet thrombosis was less frequent among patients receiving anticoagulants (eight [4%] of 224) than among those receiving dual antiplatelet therapy (31 [15%] of 208; p<0·0001); NOACs were equally as effective as warfarin (three [3%] of 107 vs five [4%] of 117; p=0·72). Subclinical leaflet thrombosis resolved in 36 (100%) of 36 patients (warfarin 24 [67%]; NOACs 12 [33%]) receiving anticoagulants, whereas it persisted in 20 (91%) of 22 patients not receiving anticoagulants (p<0·0001). A greater proportion of patients with subclinical leaflet thrombosis had aortic valve gradients of more than 20 mm Hg and increases in aortic valve gradients of more than 10 mm Hg (12 [14%] of 88) than did those with normal leaflet motion (seven [1%] of 632; p<0·0001). Although stroke rates were not different between those with (4·12 strokes per 100 person-years) or without (1·92 strokes per 100 person-years) reduced leaflet motion (p=0·10), subclinical leaflet thrombosis was associated with increased rates of transient ischaemic attacks (TIAs; 4·18 TIAs per 100 person-years vs 0·60 TIAs per 100 person-years; p=0·0005) and all strokes or TIAs (7·85 vs 2·36 per 100 person-years; p=0·001). Subclinical leaflet thrombosis occurred frequently in bioprosthetic aortic valves, more commonly in transcatheter than in surgical valves. Anticoagulation (both NOACs and warfarin), but not dual antiplatelet therapy, was effective in prevention or treatment of subclinical leaflet thrombosis. Subclinical leaflet thrombosis was associated with increased rates of TIAs and strokes or TIAs. Despite excellent outcomes after TAVR with the new-generation valves, prevention and treatment of subclinical leaflet thrombosis might offer a potential opportunity for further improvement in valve haemodynamics and clinical outcomes. RESOLVE (Cedars-Sinai Heart Institute) and SAVORY (Rigshospitalet).

Effect of Radiation Dose Reduction and Reconstruction Algorithm on Image Noise, Contrast, Resolution, and Detectability of Subtle Hypoattenuating Liver Lesions at Multidetector CT: Filtered Back Projection versus a Commercial Model-based Iterative Reconstruction Algorithm.

Purpose To determine the effect of radiation dose and iterative reconstruction (IR) on noise, contrast, resolution, and observer-based detectability of subtle hypoattenuating liver lesions and to estimate the dose reduction potential of the IR algorithm in question. Materials and Methods This prospective, single-center, HIPAA-compliant study was approved by the institutional review board. A dual-source computed tomography (CT) system was used to reconstruct CT projection data from 21 patients into six radiation dose levels (12.5%, 25%, 37.5%, 50%, 75%, and 100%) on the basis of two CT acquisitions. A series of virtual liver lesions (five per patient, 105 total, lesion-to-liver prereconstruction contrast of -15 HU, 12-mm diameter) were inserted into the raw CT projection data and images were reconstructed with filtered back projection (FBP) (B31f kernel) and sinogram-affirmed IR (SAFIRE) (I31f-5 kernel). Image noise (pixel standard deviation), lesion contrast (after reconstruction), lesion boundary sharpness (average normalized gradient at lesion boundary), and contrast-to-noise ratio (CNR) were compared. Next, a two-alternative forced choice perception experiment was performed (16 readers [six radiologists, 10 medical physicists]). A linear mixed-effects statistical model was used to compare detection accuracy between FBP and SAFIRE and to estimate the radiation dose reduction potential of SAFIRE. Results Compared with FBP, SAFIRE reduced noise by a mean of 53% ± 5, lesion contrast by 12% ± 4, and lesion sharpness by 13% ± 10 but increased CNR by 89% ± 19. Detection accuracy was 2% higher on average with SAFIRE than with FBP (P = .03), which translated into an estimated radiation dose reduction potential (±95% confidence interval) of 16% ± 13. Conclusion SAFIRE increases detectability at a given radiation dose (approximately 2% increase in detection accuracy) and allows for imaging at reduced radiation dose (16% ± 13), while maintaining low-contrast detectability of subtle hypoattenuating focal liver lesions. This estimated dose reduction is somewhat smaller than that suggested by past studies. © RSNA, 2017 Online supplemental material is available for this article.

Multifocal Hepatic Angiosarcoma: Unusual Synchronous Presentation with Pancreatic Acinar Cell Carcinoma, Mimicking Metastatic Liver Disease

Hepatic angiosarcoma is a rare malignancy that accounts for 0.5 to 2 % of primary hepatic tumors. Diagnosis of this neoplasm could be challenging because of nonspecific liver biopsy findings and variable clinical and radiological manifestations. We report a case of unusual occurrence of 2 synchronous primary tumors: Acinar cell carcinoma of pancreas and primary multifocal hepatic angiosarcoma that was originally thought to be metastatic disease. 42 year old female presented with vague abdominal pain and significant weight loss of 2months duration. Computed tomography of abdomen showed a 4.8 cm pancreatic head mass and bilobar hypoattenuating hepatic lesions. Endoscopic ultrasound guided biopsy of the pancreatic mass revealed poorly differentiated adenocarcinoma and a PET scan disclosed no extrapancreatic tumor uptake. Therefore, a CT guided biopsy of liver lesions was done to rule out metastatic disease but was inconclusive. An exploratory laparotomy revealed multiple liver lesions. Wedge liver biopsies were taken from segments III and VIII to disclose high grade hepatic angiosarcoma (fig 1) with positive CD31, CD34, vimentin and factor VIII on immunohistochemistry (fig 2). Patient underwent pancreaticoduodenectomy (Whipple's procedure) followed by chemotherapy for the multiple hepatic angiosarcoma lesions.Figure 1Figure 2Primary hepatic angiosarcoma is a rare aggressive vascular neoplasm with high propensity for local recurrence and distant metastasis. This tumor carries an unfavorable prognosis and a median survival of 6 months after diagnosis. All hepatic malignant vascular tumors share histologic characteristics, grow around and into the vessels, and are grossly multifocal. They lack specific clinical presentations and radiological features which makes their diagnosis challenging. They may be misdiagnosed histologically, particularly if only a percutaneous biopsy sample is available, as in our case. Hence, heightened awareness is warranted in such circumstances in order to pursue investigation and prevent delayed detection. Surgical wedge liver biopsy should be obtained for an accurate diagnosis which will require confirmation by immunohistochemical staining. Because hepatic angiosarcomas are often multiple, the main differential diagnosis is metastatic disease. Optimal management of these rare tumors is not well defined but the standard recommended treatment still remains surgical resection for confined liver lesions, followed by radiation and/or chemotherapy.

Hepatitis C and Numerous Disappearing Hepatic Nodules: No-dule C It, No-dule Don’t

Question: A 52-year-old Caucasian male with a past medical history of hypertension underwent evaluation for chronic, intermittent abdominal discomfort. He drank an average of 48 ounces of beer daily and had a remote history of intravenous drug use. He was referred to our center when a contrast-enhanced computed tomography (CT) scan of the abdomen, obtained during late arterial phase, showed numerous discrete hypoattenuating hepatic lesions concerning for malignancy (Figure A). Physical examination showed normal vital signs with a body mass index of 29 kg/m. There were blisters and erosions on the dorsum of his hands bilaterally with no lymphadenopathy, hepatosplenomegaly, or stigmata of chronic liver disease. Liver tests were mildly elevated and remaining basic bloodwork was within normal limits. Viral hepatitis studies demonstrated negative HIV, immunity to hepatitis B, with core antibody positivity, and hepatitis C antibody positivity with a subsequent viral load of 14 million and genotype 1a. Iron percent saturation was 54 with a ferritin of 1099 ng/mL; genetic testing showed heterozygosity for p.H63D. Tumor markers ɑ-fetoprotein, carcinoembryonic antigen, and carbohydrate antigen 19-9 were normal. Abdominal magnetic resonance imaging (MRI) with Multihance was completed on initial referral, demonstrating a noncirrhotic liver with no evidence of portal hypertension. In-phase and opposed-phase gradient echo T1-weighted MRI

Virtual unenhanced imaging of the liver with third-generation dual-source dual-energy CT and advanced modeled iterative reconstruction

ObjectivesTo compare image quality and diagnostic accuracy for the detection of liver lesions of virtual unenhanced (VU) images based on third-generation dual-source dual- energy computed tomography (DECT) compared to conventional unenhanced (CU) images. MethodsThirty patients underwent triphasic abdominal CT consisting of single-energy CU (120kV, 147 ref.mAs) and dual-energy CT arterial and portal-venous phase acquisitions (100/Sn150kV, 180/90 ref.mAs). VU images were generated from arterial (AVU) and portal venous (PVU) phases. CU, AVU and PVU datasets were reconstructed. Quantitative image quality analysis was performed and two abdominal radiologists independently analyzed all datasets to evaluate image quality and identify liver lesions. Radiation dose was recorded and potential radiation dose reduction was estimated. ResultsImage quality was rated diagnostic in 100% of the VU datasets. The mean subjective image quality of the CU datasets was higher than that of VU images (p<0.0001). No significant difference was observed in the mean attenuation values of the liver parenchyma (p>0.99) and hypoattenuating liver lesions (p≥0.21) between CU, AVU and PVU. However, a significant reduction in the attenuation values of calcified lesions (p<0.0001), metallic clips (p<0.0001) and gallstones (p≤0.047) was observed in the AVU and PVU images compared with CU images. A total of 122 liver lesions were found in 25 patients. VU images were more sensitive than CU images for detection of small hypoattenuating liver lesions (≤1cm). However, CU images were more sensitive than VU for calcified liver lesions. The mean radiation dose reduction achievable by avoiding the unenhanced acquisition was 32.9%±1.1% (p<0.01). ConclusionsThird-generation DSCT VU images of the liver provide diagnostic image quality and improve small (≤1cm) liver lesion detection; however calcified liver lesions can be missed due to complete subtraction.

Splenorenal Manifestations of Bartonella henselae Infection in a Pediatric Patient.

Bartonella henselae is a bacterium which can cause a wide range of clinical manifestations, ranging from fever of unknown origin to a potentially fatal endocarditis. We report a case of Bartonella henselae infection in a pediatric-aged patient following a scratch from a kitten. The patient initially presented with a prolonged fever of unknown origin which was unresponsive to antibiotic treatment. The patient was hospitalized with worsening fevers and night sweat. Subsequent ultrasound imaging demonstrated multiple hypoechoic foci within the spleen. A contrast-enhanced CT of the abdomen and pelvis was also obtained which showed hypoattenuating lesions in the spleen and bilateral kidneys. Bartonella henselae IgG and IgM titers were positive, consistent with an acute Bartonella henselae infection. The patient was discharged with a course of oral rifampin and trimethoprim-sulfamethoxazole, and all symptoms had resolved following two weeks of therapy.

Littoral cell angioma mimicking metastatic tumors

Abstract Littoral cell angioma is a rare primary, vascular tumor thought to originate from the endothelial cells lining the sinuses of the splenic red pulp (the “littoral cells”). It is a benign, usually asymptomatic lesion diagnosed incidentally. Ultrasound and tomography appearance is not characteristic and histopathological examination is required. This work provides a case-study of littoral cell angioma which was seen in a 55-year-old female who complained of non-specific upper abdominal pain. Computed tomography revealed multiple hypo-attenuated splenic lesions suggestive for metastasis. A splenectomy was performed and routine microscopic examination supported by immunohistochemistry reactions with CD68, CD34 and CD31 showed littoral cell angioma.

Disseminated Tuberculosis on an Otherwise Healthy Pediatric Patient

SESSION TITLE: Tuberculosis Global Case Reports SESSION TYPE: Global Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Disseminated tuberculosis (TB) can involve several organs and clinically presents itself with multiple signs and symptoms. Pulmonary infection is generally the primary focus. The development of TB disease depends on inherent immunologic status of the host. Miliary disease and tubercular (TB) meningitis are the earliest and most deadly complications of primary TB. Genitourinary TB (GU TB) is the second most common form of extrapulmonary disease after peripheral lymphadenopathy. Despite it comprises 20% of nonpulmonary TB form, it is still misdiagnosed. CASE PRESENTATION: We report a case of an otherwise healthy, 11-year-old boy with disseminated tuberculosis who exhibited a wide spectrum of extrapulmonary involvement. He had nonspecific symptoms such as fever, weight loss (10 kg), fatigue, malaise, asthenia, anorexia, headache, and recurrent urinary infections for 4 months. Thereafter, a painful swelling appeared in his left scrotum and treated as a nonspecific abscess with drainage and antibiotics before admission at the tertiary hospital. His physical examination showed an extremely thin boy, palpable masses on left hypochondrium and flank, and a painful and erythematous scrotal mass ipsilateral. Urine analysis revealed hematuria and sterile pyuria but the urine was positive for acid-fast bacilli (AFB) on the third sample. Cerebrospinal fluid (CSF) yielded normal results. Bronchoalveolar lavage (BAL) smear produced a negative response for AFB.. Tuberculin Skin Test (TST) was anergic. There were no associated systemic disorders and HIV infection was not detected. A Chest Computed Tomography (CT) scan displayed well-defined randomly distributed nodules. Head CT scan showed hypoattenuating lesions on white matter. On a contrast, enhanced abdominal CT scans revealed intraluminal calcifications in the left kidney, hydronephrosis degree V, and a heterogeneous mass adjacent to left testis. A treatment with standard fixed-dose-combination tablets containing 4 drugs (RHZE) was initiated during the intensive care phase (2 months), R 150/H75/Z400/E275and 2 drugs (RH) during the continued treatment (7 months) and an oral corticosteroid (prednisone at a dose of 1mg/kg/day for 4 weeks). The patient showed marked recovery after initiation of anti-TB therapy and the scrotal mass had gradually subsided. DISCUSSION: Miliary tuberculosis (TB) is the widespread dissemination of Mycobacterium tuberculosis via hematogenous spread. It is estimated that it accounts for approximately less than 2% of all cases of TB in immunocompetent patients. In addition, miliary TB may mimic many diseases. GU TB comprises approximately 15-20% of extrapulmonary cases of TB in some developing countries, which is roughly twice that in developed areas. It is very uncommon in children. Persistent sterile pyuria and hematuria are the most classical findings in GU TB. In the case of epididymal TB, pain swelling, heaviness or mass lesion in the scrotum are the common presenting complaints, as observed in our case. Serial early-morning urine cultures (at least 3) for acid-fast bacilli (AFB) are still considered the criterion standard for evidence of active tubercular (TB) disease with a sensitivity of 65% and a specificity of 100%. Although microbiologic staining has a low sensitivity, our case presented AFB positive in the urine smear. Nonspecific clinical presentations may mimic other pathologic lesions. In this case, the patient was initially treated for the scrotal mass as a nonspecific abscess with drainage and usual antibiotics. Therefore, a high index of clinical suspicion for TB on a severely debilitated patient allowed prompting initiation of empirical therapy anti-TB. CONCLUSIONS: Tuberculosis (TB) is the most common cause of infection-related death worldwide. Therefore, a high index of clinical suspicion is important to obtain an early diagnosis and to ensure improved clinical outcomes. Early empirical treatment for possible but not yet definitive miliary TB increases the likelihood of survival and should never be withheld while test results are pending. Reference #1: Manual de Recomendações para o controle da tuberculose no Brasil. Ministério da saúde, 2010. Reference #2: Wise GJ, Marella VK. Genitourinary manifestation of tuberculosis.Urol Clin North Am 2003, 30:111-121 Reference #3: Klaus-Dieter Lessnau: Miliary Tuberculosis. Updated: Sep 13, 2013 http://emedicine.medscape.com/article/221777-overview#aw2aab6b2 (accessed in March 22, 2015) DISCLOSURE: The following authors have nothing to disclose: Lilian Pereira, Erica Cavalcante, Bernadete Silva, Waldonio Vieira, Roseana Sovano No Product/Research Disclosure Information

Association of morphologic response with progression free survival in patients with metastatic colorectal cancer treated with bevacizumab-based chemotherapy: HGCSG0802.

743 Background: It was reported that an optimal morphologic response to preoperative chemotherapy was associated with better overall survival (OS) in patients (pts) with colorectal liver metastases (CLM). We investigated association of morphologic response with progression free survival (PFS) in pts with unresectable CLM from HGCSG0802 observational cohort study in pts with mCRC treated with first-line bevacizumab (BV)-based chemotherapy. Methods: The objective of HGCSG0802 was to evaluate PFS, OS, time to treatment failure (TTF), response rate (RR), safety, etc. The key eligibility criteria were evaluable lesions, older than 20 years old, ECOG PS 0-2. Pts with CLM underwent contrast-enhanced CT at the start and every 8-weeks of BV-based chemotherapy. In this analysis, three blinded, independent radiologists evaluated images for morphologic response, based on metastases changing from heterogeneous masses with ill-defined margins into homogeneous hypoattenuating lesions with sharp borders. Association of morphologic response and pts characteristics, RR, and PFS were evaluated. PFS was analyzed with Kaplan-Meier method, log-rank test, and Cox proportional hazards model. Results: Of 108 pts (the full analysis set), 73 pts with CLM were evaluable for morphologic criteria. Eighteen pts (24.7%) had optimal morphologic response (OR), 31 (42.5%) had incomplete (IR), and 24 (32.9%) had no response (NR). The pts characteristics between those with OR, IR and NR were generally balanced. The median TTF was 7.2 months in NR versus 7.2 months in IR versus 6.8 months in OR (HR (OR/NR) = 0.91, HR (OR/IR) = 0.90; p = 0.93). RR was 77.8% in OR versus 64.5% in IR and 58.3% in NR (p = 0.528). The median PFS was 8.3 months in NR versus 8.5 months in IR versus 9.1 months in OR (HR (OR/NR) = 0.72, HR (OR/IR) = 1.04; p = 0.420). Conclusions: In this analysis, morphologic response might not be a prognostic marker in first-line BV-based chemotherapy in pts with CLM.

Webino syndrome caused by meningovascular syphilis. A rare entity with an unexpected cause

Case reportThe patient is a 57-year-old obese and hypertensive male. His chief complaints were double vision and dizziness, with mild exodeviation in both eyes in primary gaze position in the ocular motility examination, but more predominant in the left eye. The exotropia was noticeably more evident on the attempted upgaze. On horizontal gaze, the abducting eye deviated fully, but the adducting eye did not cross the midline. Nystagmus in the abducting eye and convergence impairment were found. Pupil size and testing were normal. Ataxia and areflexia were also present. Bilateral internuclear ophthalmoplegia was suspected and imaging and laboratory tests were performed. The CAT scan showed a right occipital hypo-attenuated lesion. In the MRI scan, a mesencephalic subacute ischemic lesion was found, involving the medial rectus subnuclei. Blood and cerebrospinal fluid test for syphilis were positive. DiscussionBilateral internuclear ophthalmoplegia is a very uncommon–and difficult to diagnose–condition. In the reported case the lesion involved the medial rectus subnuclei. This fact could explain the exotropia in the primary gaze position, and supports that it is not possible to exclude the involvement of the medial rectus subnuclei in the webino syndrome. The rapid identification of the pathology contributed to the better prognosis of the patient.

Littoral Cell Angiomatosis: Splenic Lesions in a Patient with Follicular Non Hodgkin Lymphoma

A 67 year old patient was diagnosed with grade I extranodal follicular lymphoma of the parotid gland. She suffered from a painless swelling of the right parotid gland. No other symptoms, especially no B-symptoms were present on admission. The physical examination as well as the laboratory study was all normal. Histological, immunhistochemical and molecular genetic workup of the parotid gland showed an infiltration by a population of small CD20and CD10-positive clonal B-cells, consistent with an extranodal follicular Non Hodgkin Lymphoma (FL), grade I. The staging examinations (CAT scan, bone marrow trephine) showed no further lymphoma involvement apart from multiple hypoattenuating lesions in the spleen suspicious of a splenic infiltration of the lymphoma (Figure 1, white arrow). Since the treatment approach for a limited stage IEA (FLIPI 1) FL is curative, whereas a more extensive Ann Arbor stage [1] IIIEA (FLIPI 2) with spleen involvement is palliative, splenectomy was performed to define the exact stage of the disease. The histological workup showed multiple anastomosing neovascular channels lined by cells which have endothelial and histocytic (CD 68) properties, indicative of a littoral cell angioma (LCA) of the spleen (Figure 2 white arrow) beneath physiological lymphoid follicles (Figure 2, black arrow). The LCA is a rare splenic vascular tumor that derives from littoral cells which cover the splenic sinus channels of the red pulp. It was first described in 1991, normally shows a benign behavior and can be associated with solid and haematological neoplasias. Characteristic, but not specific CAT-findings are multiple defects in the spleen with low contrast. To exclude malignant primary splenic entities such as an angiosarcoma, splenic metastases, or, as suspected here, a lymphoma infiltration, a splenectomy is advisable in most cases [2]. In our patient, a splenic involvement of the spleen could be ruled out, and she underwent an involved field radiation and is still in remission 5 years later.

A Classic Case of Diarrhea in a Severely Immune-compromised Patient

Purpose: A classic presentation of an exceedingly rare entity. Case Report: A 28-year-old African-American female with HIV/AIDS most recent CD4 1, VL 600,000 copies/mL who is non-compliant with HAART therapy presented to the emergency department with complaints of profuse watery non-bloody diarrhea for three weeks associated with abdominal cramping and night sweats. She also had 10-pound unintentional weight loss over the three weeks. She denied nausea and vomiting. She denied sick contacts and recent travel. Her past medical history also includes: oral/esophageal candidiasis, pneumocystis jirovecii pneumonia and molluscum contagiosum. On examination, she was found to have a fever of 103.8F, hypotension and tachycardia. She appeared severely cachectic and listless. Her abdomen was scaphoid with hyperactive but normo-pitched bowel sounds, soft and non-tender. The stool was liquid, brown mixed with mucous; there was no bright red blood or melena. Labs were significant for profound iron deficiency anemia, thrombocytosis and electrolytes disturbance. The liver function tests were within normal limits. Stool studies and culture were negative. Rectal swab viral culture was also negative. CAT scan of the abdomen and pelvis revealed hepatomegaly, splenomegaly with multiple hypoattenuated lesions in the spleen and multiple mesenteric lymph nodes. Flexible- sigmoidoscopy was normal and the pathology on random biopsies showed chronic non-specific inflammation. Esophagogastroduodenoscopy revealed thickening pale nodular duodenal folds interdigitated with atrophic friable mucosa (Figure 1). Pathology was significant for numerous histiocytes within the lamina propria with PAS and AFB stain positive revealing numerous intracellular organisms morphologically consistent with Mycobacterium avium-intracellulare complex. Subsequently, blood cultures returned positive for Mycobacterium avium-intracellular complex as well. She was started on ethambutol, clarithromycin, and rifabutin, and her symptoms resolved.Figure

POLYCYSTIC KIDNEYS IN THE RED PANDA (AILURUS FULGENS)

An intact adult male 14.3-yr-old red panda (Ailurus fulgens) presented for health examination with a history of slowly progressing loss of body condition. Abdominal radiographs revealed a truncated abdomen with poor serosal abdominal detail and multiple areas of spondylosis with some collapsed intervertebral disc spaces. On computed tomography, multiple ovoid hypoattenuating lesions were seen in the left and right kidneys. Gross pathology and histopathology revealed multiple cystic lesions in the kidneys concurrent with pancreatic cysts on histopathology. To the best of the authors' knowledge, polycystic kidneys have not been reported in this species.

Abstract No. 377 - CT findings after irreversible electroporation ablation in a porcine model: Radiologic-pathologic correlation

Purpose To characterize computed tomography (CT) findings after irreversible electroporation (IRE) in a porcine model Materials and Methods Twenty two CT-guided IRE lesions were created in livers of 12 pigs. Energy was delivered at 2250-3000 V (pulse length, 90-100 μsec; pulse repetition, 70-90) by using two 18-gauge electrodes with 2-2.5 cm active tip, 1.5-2.0 cm distance between electrodes and a Nanoknife generator (Angiodynamics, Fremont, CA). Triple-phase multi-detector CT imaging was performed prior to IRE application and immediately before euthanasia (2 hours after ablation). Multiple CT imaging features were studied, including: dimensions; coagulation zone attenuation; and presence, as well as characteristics of post ablation enhancement. Zones of ablation were evaluated at gross and histopathologic examination, correlated with CT findings, and subjected to statistical analysis. Results The mean ablation volume measured by CT imaging and gross pathology was 31.8 cm 3 [95% CI: (14.3, 49.4)] and 15.2 cm 3 [95% CI: (12.8,17.6)]. Using a mixed-effects regression model, the two volume means are significantly different (p=0.04) with the size of the ablation zone on the CT appearing larger than the gross size (p=0.0416). Two hours after IRE energy application, the ablation zone appeared as a well demarcated hypoattenuating area. Mean pre, arterial and portal HU for the zone of ablation was 79.6 [95% CI: (73.1, 87.2), 64.3 [95% CI: (57.3, 72.0)], and 73.9 [95% CI: (61.8, 86.1). An incomplete rim of enhancement was observed surrounding the zone of ablation in both the arterial and portal phase with a median thickness of 2.5 mm. Histologic examination revealed a clear demarcation between the ablated liver and adjacent unaffected parenchyma. Coagulation zone was characterized by hepatocellular dissociation often associated with hemorrhage and sinusoidal dilatation. Conclusion CT imaging in the acute period after IRE depicts the ablation zone as a hypoattenuating lesion with a surrounding rim of enhancement. However, it appears to overestimate the dimensions of the ablative injury.

A Case ofClostridiumLiver Abscess with Sepsis

Clostridial septicemia usually occurrs in patients with immunocompromised diseases such as diabetes and malignancy. Clostridial liver abscess is very rare but highly fatal. We experienced a case of Clostridial septicemia due to liver abscess in a 73-year-old man. He was presented with fever and chills. On admission, abdominal CT scan showed about 35 mm sized hypoattenuated lesion with multiple central air-bubbles. After the diagnosis of liver abscess, the patient underwent prompt empirical antimicrobial therapy and percutaneous drainage. In spite of early therapy, the patient had gone into shock and death.