Smooth Thickening Research Articles

Drug-Induced Interstitial Lung Disease in a patient treated with a combination of palbociclib and fulvestrant

A 59-year-old patient without a history of pulmonary disease presented with episodes of hemoptysis and acute respiratory failure after being treated for metastatic breast cancer with fulvestrant and palbociclib. The high-resolution chest CT revealed diffuse ground glass opacities and diffuse smooth thickening of the interlobular septa and peribronchovascular interstitium, consistent with drug-induced interstitial lung disease (DIILD). A few days of high-dose steroid treatment increased the patient's PaO2/FiO2 from 75 to 200. Following hospital discharge, the oncologist resumed fulvestrant therapy, with no further adverse events occurring during subsequent follow-up.

Drug-Induced Interstitial Lung Disease in a patient treated with a combination of palbociclib and fulvestrant

A 59-year-old patient without a history of pulmonary disease presented with episodes of hemoptysis and acute respiratory failure after receiving fulvestrant and palbociclib for metastatic breast cancer. The High-Resolution chest CT demonstrated diffuse ground glass opacities, as well as diffuse smooth thickening of the interlobular septa and peribronchovascular interstitium, which are consistent with Drug-Induced Interstitial Lung Disease (DIILD). A few days of high-dose steroid therapy improved the patient's gas exchange from PaO2/FiO2 of 75 to 200. After hospital discharge, the oncologist resumed fulvestrant therapy, with no additional adverse events occurring during the subsequent follow-up.

CT Differentiation of Diffuse Malignant Peritoneal Mesothelioma, Tuberculous Peritonitis, and Peritoneal Carcinomatosis

Objective: To investigate the significance of computed tomography findings in diffuse malignant peritoneal mesothelioma (DMPeM), tuberculous peritonitis (TBP), and peritoneal carcinomatosis (PC) to differentiate the three diseases. Methods: The clinical manifestation and computed tomography scans of 147 patients with diffuse malignant peritoneal mesothelioma (n = 60), tuberculous peritonitis (n = 32), and peritoneal carcinomatosis (n = 55) were retrospectively reviewed, while taking into account of ascites, pleural plaques, viscera infiltration; abnormalities in the peritoneum; involvement of the mesentery and omentum; as well as the presence and location of enlarged lymph nodes. Results: There was no significant difference among all three groups in terms of clinical manifestation, peritoneum, omentum, and mesentery involvement, ascites, as well as the presence and location of enlarged lymph nodes. The study found that 95% of DMPeM patients had been exposed to asbestos in the past. The patients showed significant differences in the following aspects: (1) irregular peritoneum thickening, caked omentum thickening, pleural plaques, visceral infiltration, and asbestos exposure were more common in peritoneal mesothelioma patients; (2) nodular peritoneum thickening and visceral metastasis were more common in patients with peritoneal carcinomatosis; (3) smooth peritoneal thickening, pleural effusion, and extraperitoneal tuberculosis were more common in patients with tuberculous peritonitis. Conclusion: A combination of computed tomography findings could improve our ability in differentiating the three diseases.

Isolated IgG4-related cholecystitis with localized gallbladder wall thickening mimicking gallbladder cancer: a case report and literature review

BackgroundIgG4-related cholecystitis, which is a manifestation of IgG4-related disease in the gallbladder, is associated with autoimmune pancreatitis or IgG4-related sclerosing cholangitis in most cases; isolated gallbladder lesions without systemic manifestations are very rare. Gallbladder wall thickening is often diffuse, but sometimes localized, in which case, differentiation from gallbladder cancer becomes difficult. The characteristic features of IgG4-related cholecystitis on imaging that would enable differentiation from gallbladder cancer remain poorly described.Case presentationWe present a rare case of isolated IgG4-related cholecystitis with localized gallbladder wall thickening that was clinically difficult to distinguish from malignancy before resection. An 82-year-old man was referred to our hospital because of gallbladder wall thickening on abdominal ultrasonography without any symptoms. Dynamic computed tomography of the abdomen showed localized wall thickening from the body to the fundus of the gallbladder that was enhanced from an early stage with a prolonged contrast effect. There were no other findings, such as pancreatic enlargement and bile duct dilatation. Magnetic resonance cholangiopancreatography revealed neither dilatation nor stenosis of the bile duct and pancreatic duct. Endoscopic ultrasonography (EUS) showed a smooth layered thickening of the gallbladder wall with a maximum thickness of 6 mm and a well-preserved outermost hyperechoic layer in the same area. Laparoscopic cholecystectomy was performed because malignancy could not be completely ruled out. Pathological examination of a resected specimen revealed IgG4-positive plasma cell infiltration, fibrosis, and phlebitis. Although the serum IgG4 level measured after resection was normal, the condition was ultimately diagnosed as probable IgG4-related cholecystitis according to the 2020 revised comprehensive diagnostic criteria for IgG4-related disease. The EUS images reflected the pathological findings, in which lymphocytic infiltration was distributed in a laminar fashion in the gallbladder wall.ConclusionsAlthough rare, isolated IgG4-related cholecystitis with localized wall thickening mimicking gallbladder cancer remains a clinical problem. A smooth laminar thickening of the gallbladder wall on EUS imaging could be one of the most informative characteristics for differentiating IgG4-related cholecystitis from gallbladder cancer.

Diffuse Intense Pleural FDG Uptake with Smooth Thickening: A MARKER of Tuberculosis in Isolated Pleural Effusion

Tuberculosis is a great mimicker of malignancy and both can present with isolated pleural effusion. Herein we present the characteristic PET/CT features of tuberculosis pleural effusion. Careful attention to these findings could direct the management towards tuberculosis in such scenarios, where demonstration of Acid Fast Bacilli and necrotizing granulomas would be difficult due to absence of nodal disease and/or technically challenging pleural biopsy

A Rare Case of Peritoneal Tuberculosis in a 21 Years Old Male Patient

Tuberculosis is among the top 5 causes of death from infectious disease caused by Mycobacterium tuberculosis, it most frequently affects the lungs, although it can compromise the digestive tract, genitourinary, peritoneum, pleura, bones, lymph nodes and meninges, composing the group of extrapulmonary tuberculosis. Peritoneal involvement is the most common form of abdominal type representing 0.1 to 0.7% of all tuberculosis cases. With nonspecific symptoms, without of laboratory findings that would guide the search for Mycobacteria and imaging tests that overlap common in other pathologies, the diagnosis is difficult. In Abdominal Computed Tomography, ascites, smooth peritoneal thickening, densification of the mesentery root, lymphadenomegaly with central necrosis or calcification are observed. Laparoscopy with the biopsy and collection of ascitic fluid is used as a method for diagnosis. The mortality of abdominal tuberculosis can reach 15% and perforation of intestinal loops, malnutrition, anemia, hypoalbuminemia are the main complications. We present the case of a patient presenting recurrent umbilical hernia, whose diagnosis of peritoneal tuberculosis was made during surgery.

LEUKEMIC PULMONARY INFILTRATION: A RARE COMPLICATION OF ACUTE LYMPHOBLASTIC LEUKEMIA

TOPIC: Pulmonary Manifestations of Systemic Disease TYPE: Fellow Case Reports INTRODUCTION: We report a rare case of pulmonary leukemic infiltration that posed a diagnostic dilemma. CASE PRESENTATION: A 61 year old female presented with weeks of weakness, nausea, vomiting, diarrhea. Initial laboratory evaluation revealed hyperleukocytosis of >100,000 cells/microliter with 86% blasts and thrombocytopenia. A bone marrow biopsy revealed B cell type ALL. Hydroxyurea was initiated for cytoreduction. On hospitalization day 3 she developed hypoxemia requiring 2-3 L supplemental oxygen. Chest radiograph revealed mild patchy airspace opacities. Extensive non-invasive infectious work up was negative. Over next week she developed worsening dyspnea and hypoxemia, with near tandem progression of radiographic airspace disease, despite antibiotics and stabilization of blood count. CT chest revealed diffuse patchy ground glass opacities, small pleural effusion and adjacent atelectasis. Bronchoscopy showed bloody secretions, with BAL differential showing abundant atypical cells with irregular nuclear contours, fine chromatin and prominent nucleoli, consistent with lymphoblastic leukemic blast cells. Concern was for pulmonary leukemic infiltration vs DAH with peripheral blood blast spillage. High dose corticosteroids were initiated. Her clinical condition deteriorated requiring endotracheal intubation and ICU admission. Due to her critically ill status, she was treated dose reduced, moderate intensity Cyclophosphamide and Vincristine chemotherapy. A repeat BAL revealed similar findings of ~30% blasts on differential. Subsequently her respiratory status improved, she was extubated and discharged on low supplemental oxygen. Bone marrow restaging 4 weeks after initial treatment showed persistent B acute lymphoblastic leukemia in the bone marrow. Her oncology team is planning for mini-HOP induction with Larson consolidation. DISCUSSION: Thoracic involvement of leukemia is varied, from leukemic pulmonary infiltration, hyperleukocytopathic reaction, leukostasis, DAH, lymphadenopathy, pleural effusion etc. CT findings of leukemic pulmonary infiltration are nonspecific, however leukemic cells have a tendency to involve the perilymphatic interstitium, producing smooth or nodular thickening of the bronchovascular bundles and interlobular septa. Nodules are also common and may be peribronchovascular, centrilobular, or random in distribution. Ground-glass and consolidative opacities are less common, predominately in peribronchial regions, by infiltration of the parenchyma adjacent to the perilymphatic interstitium. Accurate diagnosis usually requires bronchoalveolar lavage or lung biopsy to rule out other common etiologies. Response to primary chemotherapy usually depends on primary leukemia and patient's clinical status, but usually portends a poor prognosis. CONCLUSIONS: Clinicians need to thoroughly investigate pulmonary infiltrates in a leukemic patient in order to ensure appropriate therapy. REFERENCE #1: Shroff, G. S., et al (2019). Leukemic involvement in the thorax. Radiographics, 39(1), 44-61. DISCLOSURES: No relevant relationships by Jyotirmayee Lenka, source=Web Response No relevant relationships by Naman Sharma, source=Web Response

Spontaneous cholecystocutaneous fistula as the presenting manifestation of IgG4-related disease

A 79-year-old woman with an unremarkable past medical history presented to the outpatient surgery clinic with a 30-day history of dull abdominal pain. She had noticed a skin orifice in the supraumbilical region discharging a yellowish serous material. Ultrasound showed findings of chronic cholelithiasis. An x-ray fistulogram disclosed a 3.9-inch-long fistulous tract from the skin to the gallbladder (Fig 1) confirming the diagnosis of spontaneous cholecystocutaneous fistula. An abdominal CT showed diffuse and smooth thickening of the gallbladder wall with multiple calcified gallstones.

Exogenous lipoid pneumonia: when radiologist makes the difference.

To report high-resolution CT (HRCT) findings in our group of patients with exogenous lipoid pneumonia (ELP), confirmed with histopathological findings and clinical-anamnestic data, in order to describe the most common radiological patterns of this rare disorder. In this retrospective study, HRCT of 10 patients with ELP were evaluated by three radiologists. Diagnosis of ELP was made through CT, bronchiolo-alveolar lavage (BAL) and a pneumological examination associated with an accurate medical anamnesis. Five patients had a histologically proven ELP, through lung biopsy. All patients had a chronic exposition to substances made of animal fat or mineral/vegetable oils. In our cohort of patients with ELP, the following parenchymal patterns were observed: 8/10 patients had lung consolidation with adipose density (attenuation values < - 40 HU); 10/10 patients had multiple areas of ground glass opacity; 6/10 patients had smooth thickening of interlobular septa and ground glass opacities ("crazy-paving" pattern); 2/10 patients presented nodules > 2.5cm with spiculated margins (tumor-like); 5/10 patients showed reactive lymph nodes enlargement. The oldest lesions were characterized by bronchiectasis and fibrosis around the lipidic consolidations. Pulmonary alterations found in HRCT exams can be confused with other lung diseases (especially lung tumors) and they are always a challenge even for the most experienced radiologist. In our experience, although non-specific, consolidation areas with low HU values and crazy-paving pattern are frequently associated in ELP. These characteristics should alert the radiologist to consider ELP among the possible differential diagnoses, always correlating the results of CT examination with appropriate clinical-laboratory evaluations and an accurate anamnesis.

Peritoneal tuberculosis mimicking carcinomatous ascites in a child living in a low prevalence country: a case report

BackgroundAscites can develop as a consequence of a number of diseases in childhood. Despite chronic liver disease is the most common cause, several conditions can lead to ascites also in the absence of liver dysfunction. As non-cirrhotic ascites shows a high degree of overlapping sign and symptoms it is still a challenge for physicians.Case presentationA 8-year-old Caucasian girl was referred for fever, vomit and diarrhea occurred over the past few weeks. Physical examination showed timpanitic distension of the abdomen with marked tenderness and increased abdominal wall rigidity. Abdominal imaging showed diffuse ascites and thickened omentum and bowel wall. Blood tests showed increased C- reactive protein levels and decreased lymphocyte count. Specific treatment for inflammatory bowel disease was started. Persisting of ascites required additional investigations. Positive tuberculin skin test and Interferon Gamma release assay (IGRA) as well as increased Ca125 serum concentrations were found. Computed tomography scan showed mediastinal and mesenteric adenopathies and diffuse smooth thickening of the omentum with significant enhancement (omental cake-like). Ascitic fluid analysis revealed high leucocytes and protein levels. Presumptive diagnosis of peritoneal tuberculosis (PTB) was made. Antituberculous treatment resulted in the resolution of ascites and normalization of lymphocyte count and Ca125 serum concentrations.ConclusionsPTB is still possible in low-prevalence countries. As it is a great mimicker of other abdominal pathology whose treatment might worsen tuberculosis progression, clinical suspicion and adequate screening are required to avoid unnecessary interventions and delayed treatment. Ca125 is a non-specific marker of peritoneal inflammation but it might be helpful in monitoring the treatment response.

Diagnostic performance of CT for differentiating peritoneal tuberculosis from peritoneal carcinomatosis: a systematic review and meta-analysis

To undertake a systematic review and meta-analysis of the diagnostic performance of CT for differentiating peritoneal tuberculosis (PTB) from peritoneal carcinomatosis (PC). PubMed, Embase, the Web of Science, and the Cochrane Library were searched for papers published before 23 July 2019. The methodological quality of the studies was analysed. Overlapping descriptors used in different studies to denote the same image finding were subsumed under a single CT feature. Sensitivity, specificity, and positive and negative likelihood ratios were pooled. A summary receiver operating characteristic curve (sROC) was constructed and the area under the curve (AUC) of the included studies was calculated when possible. Six studies were included and 17 CT features were analysed. The pooled sensitivity and specificity of smooth peritoneal thickening were 59% (95% CI: 52-66%) and 84% (95% CI: 79-88%), respectively. The AUC of smooth peritoneal thickening was 0.83. Omentum line/rim, lymph node necrosis or calcification, and mesenteric macro nodules had a pooled specificity ranging from 95% to 100% and a pooled sensitivity ranging from 12% to 67%. The other 12 signs had a pooled sensitivity ranging from 21% to 79% and a pooled specificity ranging from 19% to 81%. Omentum involvement (cake-like pattern) showed a threshold-effect, so only the AUC (=0.70) was calculated. Smooth peritoneal thickening shows fairly good diagnostic accuracy, while omentum rim/line, lymph nodes necrosis or calcification, mesenteric macro nodules have good specificity but limited sensitivity. The informative features summarised in this study may aid clinical practice and future studies.

Computed tomography features of local pleural recurrence in patients with malignant pleural mesothelioma treated with intensity-modulated pleural radiation therapy.

This study was conducted in order to describe the computed tomography (CT) features of local pleural recurrence in patients with malignant pleural mesothelioma undergoing intensity-modulated pleural radiation therapy (IMPRINT) as part of multimodality treatment. In this observational study, 58 patients treated with IMPRINT between September 21, 2004, and December 1, 2014 were included. Baseline and follow-up CT scans were qualitatively assessed. On follow-up scans, pleural thickening was categorized as unchanged, decreased, or new/increased. New/increased pleural abnormality was subcategorized as diffuse smooth pleural thickening, diffuse nodular pleural thickening, focal pleural nodule, or multiple pleural nodules. To identify features more frequently present at the time of local recurrence, follow-up scans with local recurrence were matched to four control scans; exact conditional logistic regression was performed. Twenty-one (36%) patients had local pleural recurrence and 20 (34%) patients had nonpleural recurrence; 3 patients had both types of recurrence. The 1-year cumulative incidence rate of local recurrence was 27% (95% confidence interval 15, 39). On follow-up scans, three patterns of pleural abnormality were significantly associated with local recurrence: new/increased multiple pleural nodules (10 (48%) positive scans vs 0 control scans), new/increased diffuse nodular pleural thickening (7 (33%) positive scans vs 1 (1%) control scans), and new/increased focal pleural nodule (3 (14%) positive scans vs 1 (1%) control scan) (p < 0.001 for all). Multiple new/increased pleural nodules are the feature most commonly present at local recurrence following IMPRINT; however, any pattern of increased nodular pleural thickening is suspicious. • In patients with mesothelioma receiving intensity-modulated pleural radiation as part of multimodality therapy, increasing multiple pleural nodules is the computed tomography feature most commonly present at local recurrence. • In these patients, any CT pattern of increased nodular pleural thickening should be considered suspicious for local recurrence. • The most common sites of nonpleural recurrence were lung parenchyma, thoracic lymph nodes, and peritoneum.

Computed tomographic features of abdominal tuberculosis: unmask the impersonator!

Abdominal tuberculosis (ATB) mimics various infectious, inflammatory, and neoplastic conditions and hence requires a high index of suspicion for accurate diagnosis, especially in low prevalence areas. It is difficult to consistently establish a histopathological diagnosis of ATB which underlines the importance of supportive evidences for institution of prompt empirical therapy to prevent associated morbidity and mortality. We retrospectively evaluated clinical and imaging features of 105 ATB cases and classified their CT findings based on peritoneal, lymph node, bowel, and solid organ involvement. Concomitant pulmonary and extra-pulmonary involvement was assessed. Abdominal pain (78.1%) followed by fever (42.9%) were the commonest presenting symptoms. Peritoneal TB (77.14%) most commonly presented with a mix of ascites (49.38%), peritoneal (28.40%), and omental involvement (27.16%). Lymphadenopathy (57.1%) most commonly presented as necrotic nodes (81.67%) at mesenteric, peripancreatic, periportal, and upper paraaortic regions. Commonest site of bowel involvement (cumulative of 62.85%) was ileocecal region, with the commonest pattern of involvement being circumferential bowel wall thickening without bowel stratification with mild luminal narrowing. Hepatic (13.33%) and splenic (16.2%) involvement predominantly presented as multiple microabscesses. Adrenal and pancreatic involvement was noted in 4.7% and 1.9% of patients, respectively. 38.1% patients showed concomitant pulmonary and extra-pulmonary TB. ATB has varied radiological features; however, peritoneal involvement in the form of mild ascites, smooth peritoneal thickening, smudgy omentum, multi-focal bowel involvement, necrotic nodes, and multiple visceral microabscesses point towards a diagnosis of ATB in appropriate clinical setting.

Pulmonary &amp;lt;i&amp;gt;In Situ&amp;lt;/i&amp;gt; Adenocarcinoma with Mosaic Paving Pattern

CONTEXT: Adenocarcinoma already comprises half the cases of lung cancer. Its insidious clinical evolution contributes to the fact that, in absolute numbers, lung tumor is the cancer with the highest mortality in the world. When still in situ, the adenocarcinoma is even quieter, making its typical presentation on the computerized tomography of an irregular semisolid nodule smaller than 3.0 cm. It is often diagnosed in a finding of examination in an asymptomatic patient. The prevalence of in situ adenocarcinoma (ISA) is less than 5% of pulmonary malignancies and its radiological presentation with a diffuse mosaic paving pattern is even more unusual, mimicking other conditions more frequent to this finding. CASE REPORT: We describe the case of a 44-year-old male patient with a history of chronic smoking admitted to the emergency room at a referral hospital in Sao Paulo on 12/16/2016 with a complaint of progressive dyspnea associated with dry cough for 3 months, intermittent fever and weight loss of 8 kg in 2 months. A chest X-ray and computed tomography showed discrete focal points of peribroncovascular consolidation, predominantly central, areas with frosted glass attenuation associated with smooth thickening of the interlobular septa, sometimes interspersed with areas of preserved parenchyma, giving an aspect of “crazing paving” with diffuse distribution by the pulmonary parenchyma. The patient underwent a biopsy with the anatomicopathological diagnosis of primary Adenocarcinoma in situ of the lung. CONCLUSION: We emphasize that the “crazing paving” of adenocarcinoma in situ pulmonary should be considered and known by the radiologist, because although isolated it is a rare condition, its early distrust in cases of atypical evolution of the most common injuries can avoid a diagnosis in phases more advanced and higher mortality.

Radiological spectrum of anthracofibrosis: A series of 40 patients with computed tomography, bronchoscopy, and biopsy.

Introduction:Anthracofibrosis is a lesser known clinical entity. Patients present with chronic symptoms of cough and breathlessness with a history of biofuel/wood fire smoke exposure. There are distinct computed tomography (CT) imaging features of anthracofibrosis that can differentiate it from more common conditions such as tuberculosis (TB) and bronchogenic carcinoma. Findings include multifocal noncontiguous stenosis of bronchial tree, calcified enlarged mediastinal or hilar nodes, and secondary lung parenchymal changes. However, in TB, bronchostenosis usually involves a single lobar bronchus in a contiguous manner with trachea and/or major bronchi also being affected. In this study, we highlight the imaging characteristics of anthracofibrosis.Context:The CT findings of anthracofibrosis closely mimic TB and bronchogenic carcinoma, hence we highlight the key imaging features of anthracofibrosis.Aims and Objectives:To identify and describe the CT imaging features of anthracofibrosis and correlate it with bronchoscopic findings.Setting and Design:Retrospective study.Materials and Methods:Retrospectively, 40 patients were selected who were diagnosed with anthracofibrosis on bronchoscopy and biopsy. However, CT scan records of only 14 patients were available for review. Two radiologists reviewed the scans independently.Results:Most common CT finding was multisegmental noncontiguous bronchostenosis seen in 93% patients mostly involving the right middle lobe. 85% of the cases showed lymph node enlargement involving hilar, peribronchial, and mediastinal nodes. The nodes were calcified in 91.7% of the cases, with 58% showing pressure effect on adjacent bronchi due to nodal enlargement. The next common findings were peribronchial cuffing and bronchial obstruction seen in 57 and 28% of the cases, respectively.Conclusion:The key imaging features of anthracofibrosis on CT are multifocal involvement of bronchi with smooth peribronchial thickening and enlarged calcified lymph nodes.

CT differentiation of diffuse malignant peritoneal mesothelioma and peritoneal carcinomatosis

Diffuse malignant peritoneal mesothelioma (DMPM) and peritoneal carcinomatosis (PC) have similar imaging in computer tomography (CT). We aimed to distinguish them. Computer tomography findings were evaluated in 48 DMPM and 47 PC for the peritoneal, mesenteric, omentum, lymph nodes, viscera infiltration, ascites and pleural plaques. Two groups had no difference in terms of thickness, clinical manifestation, diameter of lymph nodes, ascites, and viscera infiltration. But they showed differences in the following: Ratio of asbestos exposure in DMPM group was higher. Smooth and irregular peritoneal thickening were more seen in DMPM group; peritoneal nodules were more commonly detected in PC group. Forty-eight cases of peritoneum in DMPM showed mild enhanced, while 14 patients in PC showed severe enhanced. Nodular type of omentum was more common in PC group than in DMPM group; omental cake was more commonly detected in DMPM group. Mesentery involvement was more commonly seen in DMPM group. Location of enlarged lymph nodes in cardiophrenic region was more frequently identified in DMPM, whereas location of enlarged lymph nodes in retroperitoneal region was more frequently identified in PC. Lymph nodes fusion was more frequently visualized in PC. Fixation of the intestinal wall was more common in DMPM. Pleural plaque was more common in DMPM. PC had distant metastasis except primary foci and peritoneum. In PC, tumor origins were ovary in 10, digestive system in 21, breast in one. Using a combination of CT findings may increase our ability to distinguish PC from DMPM.

A man with abdominal fullness

A 64-year-old man presented with abdominal fullness and intermittent night fever for 1 month. His medical history included hemodialysis for 1 year and hypertension. He did not drink alcohol and had no history of chronic hepatitis B or hepatitis C virus infection. There was no body weight loss, cough, or bowel habit change. His physical examination revealed abdominal distension and shifting dullness on percussion. Laboratory workup revealed anemia (hemoglobin, 8.4 g/dL) and hypoalbuminemia (albumin, 2.8 g/ dL). The chest radiograph was normal. An abdominal computed tomography with contrast showed ascites, smooth uniform thickening of the peritoneum (arrowhead), omental cakes (arrow; Fig. 1), and soft tissue strands with crowded vascular bundles in the small bowel mesentery (Fig. 2). The ascitic fluid was cloudy yellow; the analysis revealed a white blood cell count of 950 cells/mm with 67% lymphocytes and a total protein level of 4.73 g/dL. Ascitic fluid culture, cytology, cell block, and acid-fast stain yielded negative results.

Computed tomographic features of pregnant women with pandemic H1N1 virus infection

ObjectiveThe aim of this study was to review the chest CT findings at presentation and on follow-up in pregnant women with confirmed S-OIV. Materials and methodsWe reviewed the CT findings at presentation (n = 16) and after hospital admission (n = 10) of 18 pregnant women diagnosed with Influenza A (H1N1) in our hospital between Nov 5, 2009 to Dec 12, 2009. CT manifestations were reviewed independently by 3 observers who reached a consensus decision. Chest CT findings were analyzed with regard to the patterns and distributions of pulmonary abnormalities. ResultsThe predominant CT findings at presentation consisted of unilateral (n = 6) or bilateral (n = 10) ground-glass opacities or focal unilateral (n = 3) or bilateral (n = 9) areas of consolidation. 4 of the 16 patients had associated mild thickening of the interlobular septa. The predominant follow-up abnormalities consisted of unilateral (n = 3) or bilateral (n = 7) ground-glass opacities or unilateral (n = 1) or bilateral (n = 1) consolidation. 8 of the 10 patients had interstitial opacity findings, including smooth thickening of the interlobular septa (n = 5), reticulation (n = 2) and honeycombing (n = 1). 3 patients had irregular lines (n = 3) and traction bronchiectasis (n = 1). ConclusionThe most common CT manifestations of pregnant women with confirmed S-OIV are unilateral or bilateral ground-glass opacities or focal unilateral or bilateral areas of consolidation. In pregnant women, the abnormalities seem to more extensive than general patients. Some pregnant women patients may develop interstitial opacity and traction bronchiectasis due to fibrosis.

Idiopathic Pachymeningitis Presenting with Progressive Sensorineural Hearing Loss, Tinnitus and Confusion

The patient was a 74-year-old female who presented with progressive left hearing loss, nonpulsatile tinnitus, and confusion. She denied headache, visual symptoms, and vertigo. She had a normal neurotologic examination. Pure tone audiometry showed left low frequency sensorineural hearing loss (SNHL) and a bilateral symmetric high frequency SNHL, with word recognition of 100% right, 46% left (Fig. 1). Serologic studies revealed a nonspecific monoclonal gammopathy. Other serologic tests were negative, including CBC, ANA, Lyme titer, syphilis, angiotensin converting enzyme, anti-double stranded DNA and ANCA antibodies. Cerebrospinal fluid testing revealed normal cytology with a mild increase in protein. Computed tomography of the abdomen and chest was normal, as was bone marrow biopsy. Magnetic resonance imaging (MRI) demonstrated diffuse smooth dural thickening and enhancement consistent with idiopathic hypertrophic pachymeningitis (IHP) (Fig. 2). Figure 1 Pure tone audiograms from 2009 through 2012, demonstrating progressive hearing loss in the left (A) and right (B) ears. At baseline (solid black line), the patient had a left 30 dB SRT and 100% WR, and a right SRT of 20 dB and WR 100%. After onset of ... Figure 2 Axial T1-weighted contrast-enhanced MRI of brain from prior to treatment (A) demonstrating initial enhancement of dura of the internal auditory canals left > right (arrowheads) prior to treatment. Following pulse steroid treatment (B), a significant ... The patient was initially treated with oral prednisone with minimal improvement. She then received IV methylprednisolone infusions every two weeks for two months with improvement in left hearing, tinnitus, mental status, and dural enhancement on MRI. Six months following initial presentation, she showed no further progression of her symptoms while off steroid therapy.

Peritoneal tuberculosis mimicking advanced ovarian carcinoma: an important differential diagnosis to consider

BackgroundFemale patients who present with ascites, adnexal masses and elevated CA125 levels are typically presumed to have advanced ovarian carcinoma. This can lead to radical surgery with its associated morbidity. An important differential diagnosis to consider is tuberculous peritonitis which can present in a similar manner and responds well to medical treatment.Case presentationA 44 year old female presented with abdominal distension, weight loss and low grade fever. Her CA125 level was 909 U/ml. Imaging studies revealed an adnexal lesion and ascites. The lungs appeared normal and a Mantoux test was negative. Ovarian malignancy was highly suspected. Cytology of ascites was negative for malignant cells. The patient subsequently developed a large pleural effusion which was drained and negative for malignant cells and acid fast bacilli. Repeat imaging revealed a ‘tree in bud’ appearance of the lung parenchyma and dense ascites. Histology from diagnostic laparotomy revealed caseating granulomas with epithelioid cells and Langhan’s type giant cells. The patient responded well to antituberculosis therapy with normalization of CA125 levels, confirming the diagnosis of peritoneal tuberculosis.ConclusionCA125 levels lack specificity, with elevated levels encountered in many benign and malignant conditions, including tuberculosis. There are a few discriminating features that suggest a diagnosis of tuberculous peritonitis rather than ovarian carcinoma. Apart from chest findings which may not always be present, smooth peritoneal thickening and a dirty omentum on CT favours a diagnosis of peritoneal tuberculosis compared with nodular thickening of the peritoneum and omentum in peritoneal carcinomatosis. PCR and ADA testing of ascitic fluid can also be helpful. When these tests are negative or unavailable then diagnostic laparoscopy or laparotomy should be performed with the aid of frozen section to avoid unnecessary radical surgery in cases of peritoneal tuberculosis.