Total Body CT Scan Research Articles

Case Report: Kikuchi disease and lupus erythematosus in a schizophrenic patient with extreme anorexia

Kikuchi-Fujimoto Disease (KFD) is a rare benign condition of necrotizing histiocytic lymphadenitis. The manifestations include localized lymphadenopathy, fever and weight loss. KFD has been described in association with systemic lupus erythematosus (SLE). This case describes a patient whose anorexia and deterioration were first interpreted as a manifestation of her schizophrenia. Diagnosis of a rare organic treatable disease resulted in improvement in her life threatening condition. A 36-year-old woman with schizophrenia treated with depot haloperidol experienced a general deterioration, extreme anorexia and fever up to 38°C for few months. On examination she was cachectic weighing 33kg and confined to bed. She had malar rash, cough, fever, and enlarged axillary lymph nodes. Primary laboratory tests revealed pancytopenia and LDH 1254U/L. For suspected atypical pneumonia, therapy with ceftriaxone and azithromycin was started with no improvement. Cotrimoxazole was initiated and appropriate tests ruled out PCP, TB and HIV. Her condition deteriorated further demonstrating neutropenia 600mm 3 , and coombs positive hemolytic anemia with hemoglobin 8g/L. Further lab tests revealed: positive ANA with titer of 1:60, elevated anti-smith, anti-RNP levels more than 200U. Anti-double stranded DNA was negative, C3: 62mg/dL, 24 hour protein urine collection showed 3.8g with no casts in urinary sediment. A total body CT scan revealed pleural effusion, enlarged axillary and mediastinal lymph nodes. A biopsy form a right axillary lymph node revealed histiocytic necrotizing lymphadenitis. The diagnosis of KFD associated with SLE was made based on a malar rash, pleural and pericardial effusion, nephrotic range proteinuria, positive ANA, Anti-Smith, Anti-RNP, pancytopenia and a positive coombs test. The pathology result was consistent with KFD. A follow up cardiac echocardiogram showed a new large pericardial effusion with right atrial compression and tachycardia. Parallel to high dose IV methylprednisolone treatment, a pericardiocentesis was performed and only 250ml were aspirated because of septations. A sternotomy with a pericardial window was performed. Following this procedure the patient's condition improved. Therapy with azathioprine 75mg/day and Prednisone 40mg/day was started. A second CT scan showed that the previously shown lymph nodes disappeared. Physiotherapy was started on admission and continued ongoing. Five months after admission the patient maintains a significant improvement in her daily function and activity. She gained 15kg. There was a decrease in her proteinuria and increase in the C3 level to 93 with a normal blood count. To conclude, we describe a case of KFD, a rare disease evolving in a SLE patient. Both diagnoses were made relatively late in the course of a chronic schizophrenic patient, leading to the appropriate therapy and saving her life.

Disseminated and late metastatic disease from nasal pit leiomyosarcoma after radical surgical resection. Case report of a singular presentation of a rare disease

BackgroundLeiomyosarcoma of the head and neck is a rare cancer with high local aggressiveness. Radical surgery and adjuvant treatment offer the best chance for cure, nonetheless 5-years recurrence rate remains high. Despite international guidelines are available for soft tissue sarcomas, no recommendations are specifically endorsed for leiomyosarcoma of the head and neck, due to the rarity of its presentation and consequently scarcity of data on long-term outcome.Case presentationA 50-year old woman, operated 10 years before for leiomyosarcoma of the nasal pit and with negative 5-years follow-up, was admitted to our ward for impairment of the hepatic function. Total-body CT scan detected multiple localizations at lungs, kidneys, pancreas, bones, muscles, lymph nodes and thyroid. The pathologic report after lung biopsy confirmed the diagnosis of metastasis from leiomyosarcoma and the patients was scheduled for first line chemo-radiotherapy.ConclusionsDespite adequate primary treatment, distant and disseminated metastatic disease may be not excluded in leiomyosarcoma of the head and neck.

Laparoscopic treatment of abdominal unicentric castleman\u2019s disease: a case report and literature review

BackgroundCastleman’s disease is a rare lymphoproliferative disorder of unknown etiology that most commonly presents as a mediastinal nodal mass. It is exceptionally uncommon for Castleman’s disease to present in the mesentery and, only 53 cases have ever been described in the literature. Standard treatment for this lymphoproliferative disorder involving a single node is a complete “en bloc” surgical resection which has proven to be a curative approach in almost all cases without recurrence after 20 years of follow up. All 53 reported cases of mesenteric Castleman’s disease, except one, were treated with laparotomy.Case presentationWe report on a case of mesenteric Castleman’s disease localized in the mesentery which is the second reported case if its kind and was treated by a laparoscopic-assisted procedure. Our female patient had an uneventful postoperative course and was discharged in the 5th post-operative day. No signs of recurrence were present as evidenced by physical examination and total body CT scan 24 months after the operation. We compare our case with the other reported cases in which Castleman’s disease presented as an isolated mass in the abdomen.ConclusionAlthough a rare disease, Unicentric Castleman’s disease should always be considered when a solid asymptomatic abdominal mass is occasionally presented. The laparoscopic approach (LA) allows for the achievement of better results than open surgery, including a reduction in postoperative pain and length of hospital stay. In cases of masses of an uncertain nature, LA must be considered the last diagnostic tool and the first treatment one.

Phase II Study of Neoadjuvant Chemotherapy With S-1 and CDDP in Patients With Lymph Node Metastatic Stage II or III Gastric Cancer

We conducted a phase II trial to investigate the efficacy and safety of neoadjuvant chemotherapy (NAC) comprising S-1 and cisplatin (CDDP) followed by extensive resection in the management of resectable locally advanced gastric cancer with lymph node (LN) metastases. Patients with LN metastases from stage II or III gastric cancer received S-1 and CDDP, as NAC criteria for LN metastases were the involvement of ≥4 nodes <2 cm or ≥1 nodes ≥2 cm as confirmed by a total body computed tomography scan. All patients underwent extensive resection including D2 gastrectomy. The primary endpoint was complete resection rate and the secondary endpoints were 3-year relapse-free and overall survival. Fifty patients were assessable for the analysis. The complete resection rate was 87.8%. Three-year relapse-free survival was 44.9% and 3-year overall survival rate was 48.0%. NAC with S-1 and CDDP is safe and may improve the complete resection rate in patients with metastatic LN gastric cancer. This suggests that LN metastases would provide good target lesions in future clinical trials of NAC.

Videoscopic Iliac-Obturator and Inguinal Lymph Node Dissection

Abstract Introduction: An extended iliac-obturator–inguinal lymph node dissection is required for positive inguinal sentinel lymph nodes to rule out regional metastases. This surgery may result in lower limb lymphedema, infections, or cutaneous necrosis. A minimally invasive technique to dissect the iliac-obturator–inguinal nodes reduces the complications associated with an open procedure. This video shows a minimally invasive technique for the iliac-obturator and inguinal dissection. Materials and Methods: A 33-year-old man presented status post a resection for a right foot malignant melanoma. Histologic examination revealed a pT2a melanoma, a Breslow depth of 1.34 mm with 2 mitoses/mm2, and a Clark's level II of invasion with a positive right inguinal sentinel node. Total body CT scan was negative. A minimally invasive iliac-obturator–inguinal dissection was performed as shown in the video. Results: Histologic evaluation revealed 15 iliac-obturator lymph nodes that were negative for metastatic disease. ...

Salvage Surgery After Definitive Chemoradiotherapy for Non–small Cell Lung Cancer

Following definitive chemoradiation therapy, 24%-35% of patients with locally advanced non-small cell lung cancer have recurrence. We aimed to evaluate the feasibility of salvage surgery after definitive chemoradiotherapy and perioperative morbidity and mortality rates to determine long-term survival. From June 2003 to June 2013, 35 patients were eligible for lung cancer resection owing to relapse after definitive chemoradiation therapy. All patients received cisplatin-based chemotherapy and definitive radiotherapy (mean Gy: 58) with curative intent and all underwent total body computed tomography scan and 18-fluoro-deoxyglucose positron emission tomography scan after the end of medical treatment and before surgery. Cyto-histologic confirmation was attempted in 20 (57%) patients. Six patients had exploratory thoracotomies. Twenty-nine patients underwent lung cancer resection: 11 lobectomies, 1 bilobectomy, and 17 pneumonectomies (7 right, 10 left). Complete resection was obtained in 27 of 35 (77%) patients. Thirteen (45%) patients underwent extended resection: intrapericardial pneumonectomy in 5 patients, vascular or bronchial sleeve resection in 2, atrial resection in 1, tracheal sleeve in 1, superior vena cava resection and reconstruction in 2 (1 with tracheal-sleeve resection), and chest wall resection in 2. Median time from chemoradiation therapy to resection was 7 months (range: 1-39). Viable tumor was found in 26 of 29 (89.6%) patients. Major complications occurred in 9 patients (25.7%). There were 2 (5.7%) perioperative deaths within 30 days. With a median follow-up of 13 months, postoperative 2- and 3-year survival rates after complete resection were 46% and 37%, respectively. Salvage lung resection after definitive chemoradiation therapy is feasible, with acceptable postoperative survival and complication rates.

Erratum to: High rates of clinically relevant incidental findings by total-body CT scanning in trauma patients: Results of the REACT-2 trial.

A technical error led to incorrect rendering of the author group in this article. The correct authorship is as follows: K. Treskes1, S.A. Bos1, L.F.M. Beenen2, J.C. Sierink1, M.J.R. Edwards3, B.J.A. Beuker4 , G.S.R. Muradin5, J. Hohmann6, J.S.K. Luitse1, M.W. Hollmann7, M.G.W. Dijkgraaf8, J.C. Goslings1, on behalf of the REACT-2 study group The collaborators are: T.P. Saltzherr, T. Schepers, V.M. de Jong, R. van Vugt, M. Brink, J. Peters, M. El Moumni, J.S. Harbers, K.W. Wendt, E.M.M. van Lieshout, M.J. Elzinga, E.H. Jansen, C. Zahringer, N. Bless, R. Bingisser The original publication has been corrected.

High rates of clinically relevant incidental findings by total-body CT scanning in trauma patients; results of the REACT-2 trial

ObjectivesTo determine whether there is a difference in frequency and clinical relevance of incidental findings detected by total-body computed tomography scanning (TBCT) compared to those by the standard work-up (STWU) with selective computed tomography (CT) scanning.MethodsTrauma patients from five trauma centres were randomized between April 2011 and January 2014 to TBCT imaging or STWU consisting of conventional imaging with selective CT scanning. Incidental findings were divided into three categories: 1) major finding, may cause mortality; 2) moderate finding, may cause morbidity; and 3) minor finding, hardly relevant. Generalized estimating equations were applied to assess differences in incidental findings.ResultsIn total, 1083 patients were enrolled, of which 541 patients (49.9 %) were randomized for TBCT and 542 patients (50.1 %) for STWU. Major findings were detected in 23 patients (4.3 %) in the TBCT group compared to 9 patients (1.7 %) in the STWU group (adjusted rate ratio 2.851; 95%CI 1.337–6.077; p < 0.007). Findings of moderate relevance were detected in 120 patients (22.2 %) in the TBCT group compared to 86 patients (15.9 %) in the STWU group (adjusted rate ratio 1.421; 95%CI 1.088–1.854; p < 0.010).ConclusionsCompared to selective CT scanning, more patients with clinically relevant incidental findings can be expected by TBCT scanning.Key points• Total-body CT scanning in trauma results in 1.5 times more incidental findings.• Evaluation by TBCT in trauma results in more patients with incidental findings.• In every category of clinical relevance, TBCT detects more incidental findings.

Ocular Onset of Paraneoplastic Pemphigus Presenting as Hyperemic Conjunctivitis and Massive Bilateral Eyelid Ulceration: A Case Report and Literature Review

ABSTRACTIntroduction: Paraneoplastic clinical signs are characterized by a large and heterogeneous variety of manifestations due to several possible underlying neoplasms. Paraneoplastic pemphigus (PNP) is a particular paraneoplastic variety that usually primarily affects the dermic and/or oral mucosa and is characterized by a high rate of mortality (90%). Therefore, it is important to recognize its possible signs early. This report describes a case of ocular paraneoplastic pemphigus (PNP) presenting with recalcitrant eyelid ulceration and hyperemic conjunctivitis caused by an undiagnosed prostate cancer.Methods: A 77-year-old man was admitted to our department because of recalcitrant hyperemic conjunctivitis in both eyes, complicated with large ulceration of both upper eyelids in spite of topical therapy. After 3 weeks, oral mucositis and bullous dermatitis on the chest and arms developed.Results: Complete slit lamp ocular study, conjunctival swabs, routine hematologic tests, serum neoplasm markers, indirect immunofluorescence study, immunoblotting, and oral mucose biopsy with direct immunofluorescence were performed under the hypothesis of a paraneoplastic sign. Total body computed tomography scan and ultrasound-guided needle prostate biopsy completed the diagnostic process and confirmed the diagnosis of prostate PNP. Complete remission of ocular clinical signs was achieved by treatment of the prostate malignancy with systemic immunosuppressive therapy and chemotherapy.

Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial

Published work suggests a survival benefit for patients with trauma who undergo total-body CT scanning during the initial trauma assessment; however, level 1 evidence is absent. We aimed to assess the effect of total-body CT scanning compared with the standard work-up on in-hospital mortality in patients with trauma. We undertook an international, multicentre, randomised controlled trial at four hospitals in the Netherlands and one in Switzerland. Patients aged 18 years or older with trauma with compromised vital parameters, clinical suspicion of life-threatening injuries, or severe injury were randomly assigned (1:1) by ALEA randomisation to immediate total-body CT scanning or to a standard work-up with conventional imaging supplemented with selective CT scanning. Neither doctors nor patients were masked to treatment allocation. The primary endpoint was in-hospital mortality, analysed in the intention-to-treat population and in subgroups of patients with polytrauma and those with traumatic brain injury. The χ(2) test was used to assess differences in mortality. This trial is registered with ClinicalTrials.gov, number NCT01523626. Between April 22, 2011, and Jan 1, 2014, 5475 patients were assessed for eligibility, 1403 of whom were randomly assigned: 702 to immediate total-body CT scanning and 701 to the standard work-up. 541 patients in the immediate total-body CT scanning group and 542 in the standard work-up group were included in the primary analysis. In-hospital mortality did not differ between groups (total-body CT 86 [16%] of 541 vs standard work-up 85 [16%] of 542; p=0.92). In-hospital mortality also did not differ between groups in subgroup analyses in patients with polytrauma (total-body CT 81 [22%] of 362 vs standard work-up 82 [25%] of 331; p=0.46) and traumatic brain injury (68 [38%] of 178 vs 66 [44%] of 151; p=0.31). Three serious adverse events were reported in patients in the total-body CT group (1%), one in the standard work-up group (<1%), and one in a patient who was excluded after random allocation. All five patients died. Diagnosing patients with an immediate total-body CT scan does not reduce in-hospital mortality compared with the standard radiological work-up. Because of the increased radiation dose, future research should focus on the selection of patients who will benefit from immediate total-body CT. ZonMw, the Netherlands Organisation for Health Research and Development.

A Rare Case of Chin Cutaneous Metastases from Transitional Cell Carcinoma of Bladder in a Patient Who Underwent Radical Cystectomy

Facial cutaneous metastases from primary bladder cancers are very rare and usually they are associated with poor prognosis. In literature, very few cases of cutaneous metastases from urothelial malignancies are reported but we did not find any case of bladder cancer metastases localised to chin; usually cutaneous metastases from bladder are localised in chest or scrotal skin. We report a 66 year-old patient affected by muscle-invasive transitional cell carcinoma of bladder who underwent radical cystectomy and who developed in two months after operation a skin lesion localised to chin. Clinical stage of bladder cancer was cT2 N0 M0; the patient was studied before operation through total body CT-scan, TB bone-scan negative for metastases. The patient was totally asymptomatic and he had a good performance status. We discuss the need to have suspicion in presence of cutaneous lesions, apparently benign, in a patient affected by malignancy in order to start quickly a proper treatment.

Long term efficacy and safety of Fludarabine, Cyclophosphamide and Rituximab regimen followed by (90)Y-ibritumomab tiuxetan consolidation for the treatment of relapsed grades 1 and 2 follicular lymphoma.

BackgroundIn this retrospective study, we investigated the efficacy and safety of radioimmunotherapy with 90Yttrium- ibritumomab tiuxetan (90Y-RIT) in 9 patients with recurrent follicular lymphoma (FL) who were treated in a consolidation setting after having achieved complete (CR) or partial remission (PR) with Fludarabine, Cyclophosphamide and Rituximab (FCR).MethodsThe median age was 63 years (range 46–77). All patients were relapsed with histologically confirmed CD20-positive (grade 1 or 2) FL, at relapse they received FCR every 28 days: F (25 mg/m2x 3 days), C (1 gr/m2 day 1) and R (375 mg/m2 day 4) for 4 cycles. Those who achieved at least a PR with <25 % bone marrow involvement were treated with 90Y-RIT 11.1 or 14.8 MBq/Kg, at 3 months after completing FCR. Patients underwent a further restaging at 12 weeks after 90Y-RIT with a total body CT scan, FDG-PET/CT and bilateral bone marrow biopsy.ResultsNine patients completed the treatment: FCR followed by 90Y-RIT (6 patients at 14.8 MBq/Kg, 3 patients at 11.1 MBq/Kg). After FCR, 7 patients obtained CR and 2 PR; after 90Y-RIT 2 patients in PR converted to CR 12 weeks later. With a median follow up of 95 months (range 20–114) since FCR and 88 months (range 13–104) since 90Y-RIT 3 deaths were not related to lymphoma; all 3 deceased patients obtained CR before 90Y-RIT and died still in CR. The median overall (OS) and progression free survival (PFS) have not been reached, in this analysis both OS or PFS are 67 % at 7.5 year. The most common grade 3 or 4 adverse events were hematologic.ConclusionsThese results confirm the long term efficacy and safety of 4 cycles of FCR followed by 90Y-RIT in relapsed grades 1 and 2 FL and suggest that this regimen could be a therapeutic option for this setting of patients, specially at age of 60–75 with no unexpected toxicities.

Cervical Spine Metastases: Our Experience

Introduction Metastases are the most frequent malignant lesions of the spine. Around 5 to 10% of the patients with a systemic tumor have got spinal metastases. More than 95% of spinal metastases are extradural lesions. The residual cases are intradural extramedullary lesions and only 0.5% are intramedullary lesions. Prostate, lung, breast, clear cell kidney tumors, lymphoma, myeloma, and gastric carcinoma are the most frequent primitive neoplasms to cause secondary lesions to the spine. The cervical spine is involved in 10% of the cases. In 80% of the cases, metastases are found to be in the lower cervical tract. Life expectancy in patients with lung carcinoma metastasis is approximately 6 months, 1.5/2 years in patients affected by breast, kidney, and prostate cancers. We reviewed our series of patients with spinal metastases operated between 1997 and 2013 with the aim to analyze the efficacy of the surgical treatment to recover the function and biomechanics of the vertebral column. We evaluated the prognosis in terms of duration and quality of residual life. Materials and Methods We included 36 patients (mean age 65 years). The patients were evaluated according to neurological status, Karnofsky score for the quality of life, and Denis score for pain. Indications for surgery were: pain resistant to pharmacological therapy, medullary compression, neurological deficits, and vertebral instability. Patients underwent CT and MR scan examinations of the cervical spine. In all patients, a total body CT scan was performed. All surgical procedures were performed with microsurgical techniques. In 25 cases, the surgical treatment contemplated an anterior approach: single corpectomy in 16 cases and double in 11 cases. In these cases, the vertebral body was replaced by an expandable titanium cage with PMMA filling and plating. In 6 cases, the treatment consisted of a 360-degree reconstruction. In the residual 5 cases, where the lesion was located in the superior cervical tract of the spine, we performed an occipital–cervical fusion through a posterior approach. Postoperative follow-up controls were run at 1, 3, 6, and 12 months. A cervical orthosis was worn by the patient for 40 days. Results During the follow-up time, 18 patients died because of the progression of the primitive tumor. In 36 patients treated with surgery, the histological examination documented a primitive lesion of the breast in 12 cases, of the lung in 10 cases, of the prostate in 5, of the kidney in 4, of the thyroid in 2, and of the testicle in 2. One patient affected by plasmacytoma was also observed. No intra- and perioperative complications arose. The neurological status was preserved intact in all cases with a sensible improvement in those patients affected by severe tetraparesis. We noticed a rise in the Karnofsky score, on an average from 70 to 85. Postoperative neuroimaging controls documented that the instrumentation was in the correct place. Conclusion Surgical treatment of spine metastases allows pain control, management of neurological conditions, and an overall improvement in the quality of residual life.

Fatal retroperitoneal bleeding caused by neurofibromatosis: a case report and review of the literature.

A young female was brought into the emergency department with pulseless electrical activity (PEA) after local resection of neurofibromateous lesions. Chest ultrasonography was normal. Abdominal ultrasonography was not performed. After successful resuscitation a total body CT-scan was performed to rule out potential bleeding sources. However, haemodynamic instability reoccurred and the scan had to be aborted at the thoracoabdominal level. No thoracic abnormalities were found. Resuscitation was reinitiated and abdominal ultrasonography was performed, showing a large amount of abdominal fluid. A progressive fall in haemoglobin was noted. Emergency laparotomy was performed, revealing a large retroperitoneal haematoma. Despite ligation and packing, bleeding continued. Postoperative angiography showed active bleeding from a branch of the left internal iliac artery, which could be successfully coiled. Unfortunately, the patient died five days later due to irreversible brain damage. Revision of an MRI scan made one year earlier showed a 10 cm large retroperitoneal neurofibromatous lesion exactly at the location of the current bleeding. This case shows that patients with neurofibromatosis might develop spontaneous life-threatening bleeding from retroperitoneal located lesions. Furthermore, it points out the necessity of focused assessment with ultrasonography of the abdomen in all patients with PEA of unknown origin.

FCR (Fludarabine, Cyclophosphamide, Rituximab) Followed By 90yttrium Ibritumomab Tiuxetan for the Treatment of Relapsed Grades 1 and 2 Follicular Lymphoma. Long Term Efficacy and Safety Results of 9 Cases

Background: This retrospective analysis is focused on the efficacy and safety of radioimmunotherapy (RIT) with Zevalin® in nine patients with recurrent follicular lymphoma (FL) who were treated in a consolidation setting after having achieved complete remission or partial remission with FCR.Methods: The median age was 63 years (range 46-77), all patients were relapsed with histologically confirmed CD20-positive (grade 1 or 2) FL, at relapse they received FCR every 28 days: F (25mg/m2x 3 days), C (1gr/m2 day 1) and R (375mg/m2 day 4) for 4 cycles. Who achieved at least a partial remission, with<25% bone marrow involvement, was treated with 90Yttrium Ibritumomab Tiuxetan 11.1 or 14.8 MBq/Kg up to a maximum dose 1184 MBq, at 3 months after the completion of FCR. The patients underwent a further restaging at 12 weeks after 90Y-RIT with total body CT scan, FDG-PET/CT and bilateral bone marrow biopsy.Results: Nine patients have completed the treatment: FCR followed by 90Y-RIT (6 patients at 14.8 MBq/Kg, 3 patients at 11.1 MBq/Kg). After FCR 7 patients obtained CR and 2 PR; after 90Y-RIT two patients in PR converted to CR 12 weeks later. With median follow up of 86 months (range 20-107) since FCR and 79 months (range13-97) since RIT, 3 deaths were observed not related to lymphoma: one for acute renal failure, one for ictus cerebri and one for sepsis; all three deceased patients obtained CR before 90Y-RIT and died still in CR. The median overall survival (OS) and progression free survival (PFS) have not been reached , current analysis has shown that either OS or PFS are 67% at 7 year. The most common grade 3 or 4 adverse events were hematologic, one patient developed herpes zoster infection after 8 months following valacyclovir discontinuation; another patient developed fungal infection.Conclusions: These results confirm the long term efficacy and safety of 4 cycles of FCR followed by consolidation with 90Y-RIT in patients relapsed with grades 1 and 2 FL and suggest that this regimen could be an option to be used for treatment in this setting of patients, specially at age of 60-75 with no unexpected toxicities. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Current controversies in emergency room CT: could trauma total-body CT scanning improve clinical outcome?

In trauma patients who have sustained multiple injuries, every second counts: time is life. Immediate total-body computed tomography (TBCT) can give quick and complete radiological diagnoses for these critically ill patients. Hence, direct scanning can result in increased survival and a reduction in emergency department time. Several, mostly retrospective studies, have shown the potential of TBCT scanning in trauma patients. In these studies, TBCT appears to be associated with reduced evaluation times and decreased mortality. On the other hand, concerns have risen concerning the amount of radiation exposure in this overall relatively young population. Therefore, the need for prospective studies has been stressed recently by several authors. If immediate TBCT scanning is found to be the best imaging strategy in severely injured trauma patients, it could replace conventional imaging with selective CT in this specific group.

Imaging Assessment of Gunshot Wounds

Gunshot injuries occur when someone is shot by a bullet or other sort of projectile from a firearm. Wounds are generally classified as low velocity (less than 609.6m/s) or high velocity (more than 609.6m/s). Those with higher velocity may be expected, on this basis, to dissipate more energy into surrounding tissue as they are slow and cause more tissue damage, but this is only a very approximate guide. However, these terms can be misleading; more important than velocity is the efficiency of energy transfer, which is dependent on the physical characteristics of the projectile, as well as the kinetic energy, stability, entrance profile and path traveled through the body, and the biological characteristics of the tissues injured. Hemodynamically stable patients and patients who stabilized after simple immediate resuscitation were evaluated with a careful history and physical examination. A routine x-ray is performed in patients with gunshot wounds. Indication for total body computed tomography (CT) is based on the presence of signs and symptoms of vascular damage at clinical examination. Patients are immediately transferred in the operating room for surgery if more serious injuries that require immediate surgical care are not diagnosed, or hemostasis may be preliminary reached in the emergency room. Hemodynamically stable patients with no history and clinical examination showing suspected vascular damage are allowed in the radiology department for obtaining a total body CT scan with intravenous contrast medium and then transferred to the surgical ward trauma for observation. After 24 hours without the complications, patient can be discharged. CT is the procedure of choice to identify hemorrhage, air, bullet, bone fragments, hemothorax, nerve lesion, musculoskeletal lesions, and vessels injuries and is useful for assessing medicolegal aspects as trajectory and the anatomical structures at risk.

A rare case of DRESS (Drug Reaction With Eosinophilia And Systemic Symptoms) with important involvement of heart, liver, central nervous system and bone marrow

A 46 year old woman from Sri Lanka, underwent blood examination after her return to Italy and found high titers of uric acid (8.2 mg/dl), thus her family physician prescribed allopurinol 300 mg once daily. After 3 weeks she presented to the ER with fever and esantematic rash on the thorax and limbs, therefore allopurinol was stopped and began prednisone 25 mg/day. A week later she returned to the ER for a worsening of the cutaneous eruption, high fever and marked weakness. The admitting physician excluded an adverse drug reaction and was admitted to the Infectious diseases ward with altered liver function tests, high inflammation indices and eosinophilia. All the tests for infectious disease workup resulted negative, but her general condition worsened with high fever, anasarcatic status and neurological weakness. The total body CT scan showed lung and abdominal lymphadenopathy and pleural effusion. The bone marrow biopsy excluded a lympho myeloproliferative disorder and revealed two microgranulomas and 34% eosinophils. The hepatic biopsy showed a diffuse acute hepatitis with marked infiltrate of T-lymphocytes (CD3+) and eosinophils. Cardiac examination with EKG and echocardiography was normal but the cardiac MNR dimostrated a severe pericardial inflammation with effusion. Only when the eosinophilic blood concentration raised to 52% the diagnosis of DRESS was made. The patient also resulted positive for HLA-B*58:01. She began treatment with high glucocorticoid i.v. (1 mg/kg/day) and obtained rapid improvement of the general condition of weakness, skin healing by desquamation and normalization of eosinophilia and hepatic function. She was discharged after one month of hospital stay. Conclusion This is a particular case of DRESS with extensive histological, blood, and radiological examination. It is important to employ elevated levels of glucocorticoids in the treatment of DRESS. The normal cardiac screening by EKG and echocardiography may sometimes prove inadequate for identifying real cardiac injury. We believe that it’s important to undergo cardiac MR imaging since appropriate therapy may prevent progression of cardiac disease.

Skeletal muscle imaging in facioscapulohumeral muscular dystrophy, pattern and asymmetry of individual muscle involvement

To better understand postural and movement disabilities, the pattern of total body muscle fat infiltration was analyzed in a large group of patients with facioscapulohumeral muscular dystrophy. Additionally, we studied whether residual D4Z4 repeat array length adjusted for age and gender could predict the degree of muscle involvement. Total body computed tomography scans of 70 patients were used to assess the degree of fat infiltration of 42 muscles from neck to ankle level on a semi-quantitative scale. Groups of muscles that highly correlated regarding fat infiltration were identified using factor analysis. Linear regression analysis was performed using muscle fat infiltration as the dependent variable and D4Z4 repeat length and age as independent variables. A pattern of muscle fat infiltration in facioscapulohumeral muscular dystrophy could be constructed. Trunk muscles were most frequently affected. Of these, back extensors were more frequently affected than previously reported. Asymmetry in muscle involvement was seen in 45% of the muscles that were infiltrated with fat. The right-sided upper extremity showed significantly higher scores for fat infiltration compared to the left side, which could not be explained by handedness. It was possible to explain 29% of the fat infiltration based on D4Z4 repeat length, corrected for age and gender. Based on our results we conclude that frequent involvement of fat infiltration in back extensors, in addition to the abdominal muscles, emphasizes the extent of trunk involvement, which may have a profound impact on postural control even in otherwise mildly affected patients.

3.5. The feasibility of measuring body weight on CT images and the first steps in anatomical mirroring

Objective To estimate body weight using the data of a post mortem total body CT scan and establish its efficacy in a forensic context. Material and method PMCT data were used to compute fat, soft tissue and bone volume using in house developed software based on density and HU. The digitally calculated body weight was then compared with the measured body weight on autopsy. Results Analysis of the obtained results showed a good correlation between the measured body weight and the CT-derived body weight. The highest discrepancies were noticed in children and decomposed bodies presumably due to different bone mineralization in children versus adults and putrefactive gas formation and liquefaction in decomposed bodies. In general, there was no distinct consistent over- or underestimation. In case of partial scans, where a body part was not scanned or was missing, mirroring the unaffected side was seen to give equally good results. Conclusion The weight of a body can be sufficiently estimated using volume measurements of different body tissues obtained from the PMCT data. This technique can be applied when concern is raised about the documented body weight, or if weighing was omitted all together. Furthermore the aforementioned body weight estimates can be useful in case of mass casualties, for victim identification purposes, or in case of traumatic deaths (e.g. dismemberments).