Ovoid Lesion Research Articles

247 A Unique Presentation of Fibrosarcomatous Dermatofibrosarcoma Protuberans of Breast: A Case Report

Dermatofibrosarcoma protuberans (DFSP) is a rare metastasizing mesenchymal tumor of the deep dermis and subcutaneous tissue. While it frequently occurs in the trunk and extremities, breast involvement has rarely been reported. A preoperative diagnosis of DFSP is extremely difficult because it is a very rare entity, and its appearance is often similar to that of benign breast lesions. The patient is a 34-year-old African-American woman, who presented with a slow-growing mass in her left breast for the past 2 years with a rapid increase in size over the past 4 to 5 months. Physical examination revealed a cystic lesion with fluctuant center and peripheral induration at the inferior aspect of the left breast. The CT scan revealed a subcutaneous ovoid lesion with increased attenuation in the inferior aspect of the left breast measuring 7.1 cm, most consistent with a sebaceous cyst, abscess or breast mass. The entire mass was excised and submitted for histological diagnosis. Microscopic examination showed a well demarcated tumor involving the dermis and infiltrating the subcutaneous tissues forming a 7.5 cm mass consisting of spindle cells arranged in a storiform pattern and short fascicles. Fibrosarcomatous transformation was identified as hypercellular spindle cells in a herringbone pattern with marked nuclear atypia, necrosis, and mitotic activity (5 MF/10 hpf). Margins were extensively involved. The tumor cells were positive for CD34 and vimentin. The final diagnosis was fibrosarcomatous DFSP. FISH revealed rearrangement of PDGFB gene. Our present case highlights a rare presentation of DFSP in breast with fibrosarcomatous changes. Wide local excision remains the gold standard of treatment. This tumor has high recurrence rate, and if associated with fibrosarcomatous transformation, aggressive long-term follow-up is recommended. Tumors with rearrangement of PDGFB gene including t(17;22) have been shown to be sensitive to tyrosine kinase inhibitors.

Dementia Revealing Multiple Sclerosis

Cognitive abnormalities are frequently observed in advanced stages of Multiple Sclerosis (MS). Their frequency increases from clinically isolated syndromes, to relapsing-remitting and secondary progressive MS. The most frequently impaired functions are information processing speed, attention and memory. Dementia is uncommon but may reveal a MS. We reported a 47-year-old woman suffering since 8 months of headache with a progressive amnesia, temporospatial disorientation and behavioral disorders. On examination, we found dementia syndrome and a frontal syndrome. Brain MRI showed a T2 hyperintensity multifocal ovoid lesions with enhancement in the periventricular white matter and in the corpus callosum. Diagnostic hypotheses were ADEM or MS. Isoelectric focusing revealed oligoclonal bands and elevated IgG index. She was treated with intravenous methylprednisolone 1 g daily for five consecutive days. There was a regression of the symptomatology but 4 months after diagnosis, the patient presented with a postural instability, gait difficulty, terminal intention tremor and dysmetria. A diagnosis MS was considered and she was given interferon. The concept of MS being a dementing illness is not novel. Neurologists are well aware that patients with MS may present with cognitive impairment. But the fact that this disease is revealed by dementia is rare and new.

Desmoid Tumor of the Breast as a Manifestation of Gardner’s Syndrome in an Elderly Woman: A Case Report and Review of Literature

Desmoid tumor of the breast is an extremely rare entity. Histologically, it corresponds to a benign fibroblastic proliferation of a local evolution, with a high recurrence potential. We report the first case of elderly woman presented with desmoid-tumor of the breast as a manifestation of Gardner’s syndrome. A brief literature review was provided. We report the case of a 72-year-old woman who presented with five months history of painful and an exophytic mass of her left breast. She is known to have familial polyposis and had a total colectomy with Gardner’s syndrome. She had a history of osteomas of the maxilla. On clinical examination, there was an exophytic painless mass, on the upper medial quadrant of the breast. She had also lipoma in the left leg and pigmented skin lesions in legs. Her mammograms showed a suspicious stellar image. A computed tomography scan showed an ovoid lesion. Excision of the lesion was performed. Histopathology confirms a desmoid-tumor of the breast. Evolution was marked by lesion recurrence. In conclusion, desmoid tumor of the breast is rare, non-metastatic but locally aggressive. Clinical expression is often nonspecific. Treatment remains controversial; surgical excision is the treatment of choice.

Diversity of Neopestalotiopsis and Pestalotiopsis spp., Causal Agents of Guava Scab in Colombia.

Common guava (Psidium guajava L.) is a fruit tree of global economic importance. It is grown in Asia, South and Central America, and Hawaii for its exquisite aroma and flavor, and nutritional and medical properties. However, guava production is limited by guava scab, caused by fungi in the Pestalotiopsis genus. Characteristic symptoms of guava scab are corky, ovoid or round lesions on fruit surfaces. These lesions may thicken, affecting the flesh below and reducing fruit quality and commercial value. We characterized 81 isolates isolated from guava scab lesions on guava leaves and fruit in different regions of Colombia, and identified them as Pestalotiopsis and Neopestalotiopsis spp. We analyzed the morphology, pathogenicity, and genetic diversity of the isolates based on the sequences of the internal transcribed spacer, β-tubulin, and elongation factor genes. Isolates were morphologically, pathogenically, and genetically diverse but the diversity did not correlate with geographical origin, or guava cultivar or tissue from which the isolates were recovered. Selected monosporic isolates included in the multiple-gene analysis were identified as belonging to two genera: Neopestalotiopsis (65 isolates with versicolorous conidia) and Pestalotiopsis (4 isolates with concolorous conidia).

Distinct brain imaging characteristics of autoantibody-mediated CNS conditions and multiple sclerosis.

Brain imaging characteristics of MOG antibody disease are largely unknown and it is unclear whether they differ from those of multiple sclerosis and AQP4 antibody disease. The aim of this study was to identify brain imaging discriminators between those three inflammatory central nervous system diseases in adults and children to support diagnostic decisions, drive antibody testing and generate disease mechanism hypotheses. Clinical brain scans of 83 patients with brain lesions (67 in the training and 16 in the validation cohort, 65 adults and 18 children) with MOG antibody (n = 26), AQP4 antibody disease (n = 26) and multiple sclerosis (n = 31) recruited from Oxford neuromyelitis optica and multiple sclerosis clinical services were retrospectively and anonymously scored on a set of 29 predefined magnetic resonance imaging features by two independent raters. Principal component analysis was used to perform an overview of patients without a priori knowledge of the diagnosis. Orthogonal partial least squares discriminant analysis was used to build models separating diagnostic groups and identify best classifiers, which were then tested on an independent cohort set. Adults and children with MOG antibody disease frequently had fluffy brainstem lesions, often located in pons and/or adjacent to fourth ventricle. Children across all conditions showed more frequent bilateral, large, brainstem and deep grey matter lesions. MOG antibody disease spontaneously separated from multiple sclerosis but overlapped with AQP4 antibody disease. Multiple sclerosis was discriminated from MOG antibody disease and from AQP4 antibody disease with high predictive values, while MOG antibody disease could not be accurately discriminated from AQP4 antibody disease. Best classifiers between MOG antibody disease and multiple sclerosis were similar in adults and children, and included ovoid lesions adjacent to the body of lateral ventricles, Dawson's fingers, T1 hypointense lesions (multiple sclerosis), fluffy lesions and three lesions or less (MOG antibody). In the validation cohort patients with antibody-mediated conditions were differentiated from multiple sclerosis with high accuracy. Both antibody-mediated conditions can be clearly separated from multiple sclerosis on conventional brain imaging, both in adults and children. The overlap between MOG antibody oligodendrocytopathy and AQP4 antibody astrocytopathy suggests that the primary immune target is not the main substrate for brain lesion characteristics. This is also supported by the clear distinction between multiple sclerosis and MOG antibody disease both considered primary demyelinating conditions. We identify discriminatory features, which may be useful in classifying atypical multiple sclerosis, seronegative neuromyelitis optica spectrum disorders and relapsing acute disseminated encephalomyelitis, and characterizing cohorts for antibody discovery.

Man With Vision Loss and Eye Pain

A 51-year-old man presented to the emergency department, complaining of vision loss and ocular pain 10 days after he received vitrectomy for nonclearing vitreous hemorrhage in his left eye. On ophthalmology consultation, his visual acuity was hand motions and intraocular pressure was 40 mm Hg in the left eye. Slit-lamp biomicroscopic examination (Figure 1) and ocular ultrasonography (Figure 2) were conducted. Aqueous humor and vitreous cultures were performed.Figure 2Ocular ultrasonographic image showing an ovoid lesion (asterisk) with moderate internal reflectivity.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Phacoantigenic uveitis (phacoanaphylactic endophthalmitis) with glaucoma and dislocated lens. Slit-lamp biomicroscopic examination (Figure 1) showed ciliary congestion, corneal edema, and fluffy lenticular materials (white arrow) on the top of blood-tinged hypopyon (black arrow). Ocular ultrasonography (Figure 2) revealed vitreous opacity and dislocated lens (asterisk). Pars plana vitrectomy and lensectomy were performed. During the surgery, the dislocated lens was identified in the vitreous cavity, without obvious signs of infectious endophthalmitis. No growth of organisms was identified in vitreous and aqueous samples. Three months after surgery, his final vision was 4/200 because of myopic maculopathy. Phacoantigenic uveitis typically develops 1 to 14 days after traumatic or surgical perforation of the lens capsule and is characterized by a granulomatous antigenic reaction to lens protein.1Marak Jr., G.E. Phacoanaphylactic endophthalmitis.Surv Ophthalmol. 1992; 36: 325-339Abstract Full Text PDF PubMed Scopus (56) Google Scholar Clinically, phacoantigenic uveitis can be difficult to distinguish from other forms of postoperative uveitis or endophthalmitis. Findings can range from mild anterior uveitis to fulminant endophthalmitis with hypopyon. Initial therapy is to control the intraocular pressure with intraocular pressure-decreasing medications and to reduce the inflammation with topical steroids. When phacoantigenic uveitis follows lens trauma, as with our patient, surgery is required for definitive treatment.

A Review of Chile Pepper (Capsicum annuum) Stip: A Physiological Disorder of Peppers

Stip, a physiological disorder, which affects certain pepper (Capsicum annuum) cultivars and pod types, has received limited formal academic attention. The disorder, frequently noted for its appearance in bell peppers, but also present in pimento and New Mexican pod types, has been attributed in the literature to nutrient imbalances and/or temperature extremes. Symptoms of this disorder present on fully developed fruits as brown, black, and yellow ovoid subcutaneous chlorotic lesions ≈1.3 cm in length and 0.6 cm in width extending from the endocarp to the mesocarp, without apparent expression in the cuticle. Chile pepper has been significantly affected by stip for the past several decades leading to varying degrees of commercial losses. Due to the sporadic and seemingly spontaneous nature of the disorder, prolonged research interest has not been sustained. This review provides the reader a comprehensive synthesis of all available literature regarding this physiological disorder. Especially because research into this disorder is scarce, it is essential that any and all previous research be made available together in one document to interested scientists, breeders, and growers. To achieve this goal, all available stip-related publications were obtained and analyzed; additionally, searches were performed using all names associated with the disorder. The literature suggests that stip manifestation is a consequence of an interaction between a genetic component (open-pollinated cultivars being more susceptible to symptom expression than hybrids) and an environmental component (increased nitrogen application, shading, and soil applications of lime appear to increase both severity and incidence).

Mild encephalitis/encephalopathy with reversible splenial lesion (MERS) due to dengue virus

A 14-year-old girl presented with encephalopathy, delirium and ophthalmoplegia following a 3day history of high-grade fever. Brain MRI on day 6 of illness showed diffusion restricted ovoid lesion in the splenium of corpus callosum. Dengue virus encephalitis was diagnosed with positive PCR for dengue virus type-2 in both serum and cerebrospinal fluid. She made a complete recovery from day 10 of illness. Repeat brain MRI on day 12 of illness showed resolution of the splenial lesion. Serial diffusion tensor imaging (DTI) showed normal fractional anisotropy values on resolution of splenial lesion indicating that MERS was likely due to transient interstitial oedema with preservation of white matter tracts. This is the first reported case of MERS following dengue virus infection. It highlights the usefulness of performing serial DTI in understanding the underlying pathogenesis of MERS. Our case report widens the neurological manifestations associated with dengue infection and reiterates that patients with MERS should be managed supportively as the splenial white matter tracts are reversibly involved in MERS.

Epipericardial Fat Necrosis: Who Should Be a Candidate?

The objectives of the present study were to estimate the frequency of epipericardial fat necrosis among patients undergoing chest CT for chest pain and to compare the clinical and laboratory data between patients with epipericardial fat necrosis and control subjects. A retrospective review of 7463 chest CT studies performed in the emergency department from July 2011 to December 2014 was conducted to collect data regarding patient demographic characteristics and CT findings. Twenty patients who had epipericardial fat necrosis diagnosed were defined as the main patient group. An age- and sex-matched control group was selected from patients with chest pain who underwent chest CT during the same period. Linear regression models were used to assess data, and statistical significance was expressed as p values and 95% CIs. We found that the frequency of epipericardial fat necrosis was 2.15% among patients who underwent chest CT for chest pain. Epipericardial fat necrosis was statistically significantly associated with a lack of medication use (p = 0.01; 95% CI, -3.33 to -0.40) and the absence of other symptoms (p = 0.005; 95% CI, -5.83 to -1.27). Epipericardial fat necrosis was most often observed as an ovoid lesion with mixed fat attenuation with little stranding in the left paracardiac region accompanied by pleural effusion. Epipericardial fat necrosis is a significant clinical condition. For patients seen in the emergency department with isolated acute chest pain but no additional clinical history, no medication history, and normal laboratory results, chest CT is recommended to support a diagnosis of epipericardial fat necrosis.

The effect of venous anatomy on the morphology of multiple sclerosis lesions: a susceptibility-weighted imaging study

To investigate the cause of morphology in non-ovoid multiple sclerosis (MS) lesions lacking a radial course and typical shape. Non-ovoid atypical lesions without perpendicular extensions to the ventricle were investigated in 95MS patients by retrospective examination of T2-weighted and fluid-attenuated inversion recovery (FLAIR) images. The relationship between the morphology of these atypical lesions detected in 38 patients and central vein anatomy was examined using susceptibility-weighted imaging (SWI). A central venous structure was observed in 107 (65.6%) of 163 atypical lesions in 38 patients. The distribution of atypical lesions grouped by their shape was as follows: (1) V- or Y-shaped lesions (n=27, 48.6%) were observed where veins bifurcated; (2) crescent-shaped lesions (n=9, 8.4%) were observed where veins formed an arc; (3) patchy lesions comprised 48.6% (n=52) of the atypical lesions and involved multiple medullary veins or medullary veins showing a "caput medusae" distribution; (4) ovoid lesions with a non-radial course (n=19, 17.7%) were generally observed where medullary veins converged to form internal cerebral vein branches. Unlike typical MS plaques, non-ovoid atypical lesions make the differential diagnosis of MS challenging. Demonstration of the relationship between venous anatomy and lesion morphology in atypical lesions using SWI will aid in the differential diagnosis.

Implikacje diagnostyczne oraz skuteczne leczenie w przebiegu zespołu Susac’a z trombofilią

Susac syndrome is an uncommon autoimmune microangiopathy characterized by a combination of encephalopathy, branch retinal artery occlusions (BRAO), and hearing loss. In this report, we present a detailed history of a 31-year-old man with Susac syndrome with thrombophilia. The diagnosis was based on clinical signs and neurological, otolaryngological and ocular examination. Fluorescence retinal angiography showed right BRAO. A slight (30 dB) sensorineural lowering of the hearing level was observed in the audiogram. Numerous ovoid lesions in the corpus callosum were detected in magnetic resonance (MR). The applied treatment included glucocorticosteroids, disease-modifying antirheumatic drugs, anticoagulant treatment and immunoglobulin infusions. After treatment, ophthalmologic symptoms receded, the recanalization of BRAO was detected in angiography, and the lesions in the corpus callosum were reduced in control MR. To date, this is the first report showing the effective treatment of Susac syndrome, which was confirmed simultaneously in MR and fluorescein angiography in a case of Susac syndrome with thrombophilia.

Brain magnetic resonance imaging helps to differentiate atypical multiple sclerosis with cavitary lesions and vanishing white matter disease

Multiple sclerosis (MS) patients can present with atypical cavitary lesions mimicking vanishing white matter disease (VWMD). Our objective was to identify brain magnetic resonance imaging (MRI) findings that differentiate these two disorders. A cross-sectional study was performed including 14 patients with MS with cavitary lesions and 14 patients with VWMD. Two neuroradiologists retrospectively reviewed the MRI including at least T1-, T2- and fluid-attenuated inversion recovery weighted images. The main differences included ovoid lesions perpendicular to the lateral ventricle, punctate isolated juxtacortical lesions (both 100% in MS versus 0% in VWMD) and symmetrical infratentorial hyperintensities (0% in MS versus 50% in VWMD). Other statistically significant differences included midbrain (79% in MS versus 29% in VWMD) and thalamus lesions (71% vs. 7%) as well as extensive external capsule involvement (29% vs. 86%) and extensive corpus callosum lesions (64% vs. 100%). Cavitary lesions usually had periventricular predominance in MS (36% vs. 0%) whereas they were more frequently anterior in VWMD (0% in MS versus 57% in VWMD). Despite many similar MRI findings, our results suggest that a careful analysis of the morphology and the location of the lesions is helpful to differentiate these distinct disorders.

Transient Splenial Lesion of the Corpus Callosum Related to Migraine with Aura in a Pediatric Patient

Transient splenial lesions of the corpus callosum are rare radiological findings first described in association with epilepsy, antiepileptic drugs and viral encephalitis. However, subsequently more cases were described associated with diverse clinical conditions. We describe a 13-year-old girl suffering from migraine with aura presenting with headache, right-sided hemiparesis and encephalopathy. Brain magnetic resonance imaging revealed an ovoid lesion in the splenium of the corpus callosum. The patient's neurological symptoms resolved within 3 days without therapy and the lesion disappeared in follow up magnetic resonance images obtained 3 weeks after the onset of the symptoms. Migraine with aura was considered to be the cause of the lesion. To our knowledge the present case is the first report of a pediatric patient with a diagnosis of migraine with aura presenting with hemiparesis and encephalopathy. A diagnosis of transient lesion of the corpus callosum should be suspected in patients with migraine with aura presenting with hemiparesis and encephalopathy. A mild course and a good prognosis might be expected in the presence of a splenial lesion of the corpus callosum.

"Central vessel sign" on 3T FLAIR* MRI for the differentiation of multiple sclerosis from migraine.

The diagnosis of multiple sclerosis (MS) presently relies on radiographic assessments of imperfect specificity. Recent data using T2* methodology for the detection of the "central vessel sign" (CVS) in MS lesions suggests this novel MRI technique may distinguish MS from other disorders. Our aim was to determine if evaluation for CVS on 3T FLAIR* MRI differentiates MS from migraine. Patients with MS or migraine and a prior brain MRI demonstrating at least two hyperintense lesions ≥3mm were recruited. Exclusion criteria included any additional comorbidity known to cause brain MRI abnormalities. 3T MRI was performed in each participant with administration of gadopentetate dimeglumine, and FLAIR* images were generated in postprocessing. The total number of discrete ovoid lesions ≥3mm were counted on FLAIR, per participant, and subsequently evaluated for presence of CVS on FLAIR*. An exploratory method evaluating for CVS in a maximum of 12 lesions per subject was also completed. Ten participants with MS and 10 with migraine completed the study. The median percentage (quartiles) of lesions in MS participants with CVS was 84 (79, 94) compared to 22 (15, 54) in migraine (P=0.008). In a subanalysis by brain region, in the subcortical and deep white matter, the median percentage (quartiles) of lesions in MS participants with CVS was 88 (81, 100) compared to 19 (11, 54) in migraine (P=0.004). This difference was not identified in juxtacortical, periventricular, or infratentorial regions. Identification of CVS using FLAIR* on 3T MRI helps differentiate MS from migraine, particularly in the subcortical and deep white matter.

P104 – 2363: Transient splenial lesion of the corpus callosum related to migraine with aura in a pediatric patient

Objective Transient splenial lesions of the corpus callosum are described in association with many diverse clinical conditions including various infections, use or withdrawal of antiepileptic drugs, and hypoglycemia. The lesion appears as a well-defined hyperintense ovoid lesion in the center of the splenium of the corpus callosum best observed in diffusion weighted brain magnetic resonance images. Generally, the condition is associated with a mild clinical course and a favorable prognosis. We present a pediatric case with a transient splenial lesion of the corpus callosum related to migraine with aura. Methods A 13-year old girl was admitted to our emergency room with a severe headache, confusion, violent behavior, slurred speech, and right-sided hemiparesis. She first experienced a similar but milder attack with numbness in the face and lips not complicated with hemiparesis, 3 weeks before. At the time, her brain magnetic resonance imaging (MRI), electroencephalography (EEG) were unremarkable. After 3 more attacks the diagnosis of migraine with aura was made 1 week before. Her brain MRI conducted on admission revealed well-circumscribed hyperintense ovoid lesion in the splenium of corpus callosum in diffusion-weighted images. Her EEG revealed generalized, high amplitude intermittent slow delta waves prominent on frontal areas, which is consistent with encephalopathy. Her follow-up EEG on day 3 showed significant improvement. She was discharged 4 days after admission with a completely normal neurological examination. Her follow-up MRI 3 weeks after the first MRI, revealed a complete disappearance of the lesion. Results To our knowledge our patient is the first pediatric case of transient splenial lesion of the corpus callosum related to migraine with aura presenting with encephalopathy. Conclusions Transient lesion of splenium is caused by a heterogenous etiology and a mild course and a good prognosis might be expected in the presence of a splenial lesion in the corpus callosum.

Endometriosis as an Epiphenomenon in a Patient with Nonobstructive Primary Amenorrhea: A Case Report

Introduction The pathophysiology of endometriosis is not well established. Different theories have been proposed to explain endometriosis, but none alone is able to explain all of the cases described. Case presentation We report a case of a woman with a congenital polymalformative syndrome, early puberty and primary amenorrhea, in whom an asymptomatic right adnexal nodule was detected at 14 years of age. When she was 18 years old, a laparoscopy was performed, and an ovoid lesion in the right uterine tube was identified and salpingectomy was performed. The pathological examination revealed endometriosis in the muscular layer of the tube. Conclusions Endometriosis can start early in puberty, even before menarche and in the absence of an obstructive disorder.

Criteria improving multiple sclerosis diagnosis at the first MRI.

The introduction of the McDonald criteria has enabled earlier diagnosis of multiple sclerosis (MS). However, even with the 2010 revised criteria, nearly 50% of patients remain classified as "possible MS" following the first MRI. The present study aimed to demonstrate that time to MS diagnosis could be shorter than 2010 revised criteria, and established after a single early MRI in most patients with the association of the symptomatic lesion and at least one suggestive asymptomatic lesion. We also evaluated the short-term predictive capacity of an individual suggestive lesion on disease activity. We analyzed initial MRI results from 146 patients with MS from a multicenter retrospective study. Visualization of the symptomatic lesion was used as a primary criterion. Secondary criteria included one suggestive lesion (SL) aspect or topography on MRI, or one non-specific lesion associated with positive CSF. The proposed criteria led to a positive diagnosis of MS in 100% of cases, from information available from the time of the first MRI for 145 patients (99.3%). At least one SL was observed for 143 patients (97.9%), and positive CSF for the 3 others. Compared to the McDonald criteria, the proposed criteria had 100% sensitivity, with a significantly shorter mean time to reach a positive diagnosis. Furthermore, the simultaneous presence of corpus callosum, temporal horn, and ovoid lesions was associated with radiological or clinical activity after a year of follow-up. The proposed diagnostic criteria are easy to apply, have a good sensitivity, and allow an earlier diagnosis than the 2010 McDonald criteria. Nevertheless, prospective studies are needed to establish specificity and to confirm these findings.

Thalamic lesions in multiple sclerosis by 7T MRI: Clinical implications and relationship to cortical pathology

Objective: Pathology in both cortex and deep gray matter contribute to disability in multiple sclerosis (MS). We used the increased signal-to-noise ratio of 7-tesla (7T) MRI to visualize small lesions within the thalamus and to relate this to clinical information and cortical lesions. Methods: We obtained 7T MRI scans on 34 MS cases and 15 healthy volunteers. Thalamic lesion number and volume were related to demographic data, clinical disability measures, and lesions in cortical gray matter. Results: Thalamic lesions were found in 24/34 of MS cases. Two lesion subtypes were noted: discrete, ovoid lesions, and more diffuse lesional areas lining the periventricular surface. The number of thalamic lesions was greater in progressive MS compared to relapsing–remitting (mean ±SD, 10.7 ±0.7 vs. 3.0 ±0.7, respectively, p < 0.001). Thalamic lesion burden (count and volume) correlated with EDSS score and measures of cortical lesion burden, but not with white matter lesion burden or white matter volume. Conclusions: Using 7T MRI allows identification of thalamic lesions in MS, which are associated with disability, progressive disease, and cortical lesions. Thalamic lesion analysis may be a simpler, more rapid estimate of overall gray matter lesion burden in MS.

Retrorectal cystic hamartoma (Tailgut cyst)

CASE SUMMARY A 30-year-old asymptomatic female presented for IUD placement 5 months after an uncomplicated C-section. Ultrasound confirmed correct IUD placement but revealed a “complex pelvic mass” in the posterior cul-de-sac. Rectovaginal exam revealed a nontender soft tissue mass, 6-7cm in size, just to the right of the rectum and vaginal apex. Pelvic MRI showed a 7 cm mass deep in the right hemipelvis, felt to possibly represent an endometrioma, which remained unchanged on a 3-month follow-up study. Colonoscopy revealed extrinsic bowel compression but no mucosal changes. Due to recent pelvic surgery, the imaging characteristics of the mass, and the normal appearance of both ovaries, a gossypiboma was considered. Exploratory laparotomy revealed a right perirectal retroperitoneal mass containing copious amounts of keratin. The mass was excised and the patient had an uneventful recovery. IMAGING FINDINGS The initial and follow-up pelvic MR images demonstrated a well-defined, non-enhancing, ovoid lesion within the cul-de-sac which exerted mass effect on the uterus (Figure 1) and was distinct from both ovaries. The lesion exhibited high T2 and low T1 signal as well as several areas of linear low T2 signal internally with a somewhat “whorled” appearance (Figure 2). In addition, there was no signal loss on fat saturated images (Figure 3). Given these findings and the patient’s clinical history, the differential diagnosis included gossypiboma, retrorectal cystic hamartoma, epidermal inclusion cyst and endometrioma.

Paraspinal hydatid cyst with unusual presentation: a case report

Hydatid disease is a zoonotic infection most commonly caused by Echinococcus granulosis. Primary hydatid cysts of the skeletal muscles are extremely rare. In this paper, we present a case in which a patient had a hydatid cyst in the paraspinal muscle. A 19 years old female patient presented with a painless swelling over the left side on the back for the last two months. On local examination, a solitary, firm, non tender well defined, non movable, oval swelling was present over the left paraspinal region from T12 -L3. Provisional diagnosis of hydatid cyst was made on ultrasonography. Magnetic Resonance imaging revealed a well defined ovoid lesion measuring 4.3 × 4.54 × 2.3cm within the left erector spinae muscle. Operative intervention was planned and preoperative albendazole therapy (15 mg/kg/day) was given for two weeks. Hydatid disease is caused by the larval form of Echinococcus granulosus, It is most frequently located in the liver (75%) and lungs (15%). Musculo-skeletal involvement is secondary and uncommon. Spinal and paraspinal involvement is rare, with an incidence of less than 1%. Investigations for diagnosis include Ultrasonography, Computed tomography, Magnetic Resonance Imaging and Serologic tests. Surgical removal is the most effective treatment of hydatid cyst. Therapy with nontoxic scolocidal agents or combination chemotherapy with mebendazole is of therapeutic value. Albendazole is suggested to be given post operatively. Primary paraspinal echinococcosis must be considered in the preoperative differential diagnosis of the atypical presentation of paraspinal lesions in countries where Echinococcus infestation is endemic. Early diagnosis and radical surgery combined with antihelminthic therapy of sufficient duration are mandatory for the treatment of this disease.