RADIOLOGY SLIDESH WS FRONTRUNNERS BOARD REVIEW
WHAT DO YOU SEE?
Patient with persistent ST ↑ 2 weeks after MI
LV ANEURYSM
AORTIC DISSECTION: CT with 3D reconstruction
WHAT WOULD YOU CALL THIS IF THIS PATIENT HAD THE SAME MRI FINDINGS AND WAS POSITIVE FOR DVT (BEFORE ECHO)??
ENDOCARDITIS
Patient presents with F/C, night sweats, weight loss, & a murmur.
ASBESTOSIS This chest CT scan in "soft tissue" window demonstrates multiple bright pleural plaques on the right and on the left in a patient with prior history of asbestos exposure. There are also pericardial as well as pleural effusions.
OSTEONECROSIS: CRESCENT SIGN
Note the lucent crescent sign (BLACK ARROW) and the discontinuity where the subchondral bone has collapsed (black arrowhead). Disregard the white arrows (Lucent channel in left femoral neck from previous dynamic hip screw).
PLASMACYTOMA IN MULTIPLE MYELOMA Left pedicles of L1 & L2 vertebra show plasmacytomas. A plasmacytoma is a mass of plasma cells that can produce a lytic lesion of bone. There can be deformity and pain and obviously, pathological fractures with potential for cord compression, a common board scenario (back pain, weakness in the legs, ↑ Ca, anemia, renal insufficiency).
MULTIPLE MYELOMA
Plasmacytoma with pathological fracture at the neck of the L. femur.
Classic “punched-out”, lytic lesions in the skull.
PULMONARY ALVEOLAR PROTEINOSIS
PAP Hx: minimally productive or nonproductive cough, fever, and mild dyspnea on exertion CT in the same patient shows the characteristic ground-glass opacification with septal thickening. Groundglass opacification of alveolar spaces that reflect the presence of the phosholipidproteinaceous material of PAP within the alveoli. The septal thickening is only seen in area of ground-glass opacity. The diseased lung usually is quite well demarcated from surrounding normal lung tissue, Serum LDH usually ↑; Restrictive defect, ↓ DLCO, and hypoxemia; PAS+ alveolar macrophages on BAL. Infection is the main complication; Nocardia in 8%. Light microscopy of the lung parenchymal tissue shows alveoli filled with a granular PAS base-reactive and diastase-resistant eosinophilic material. Electron microscopy of the material in the alveoli shows multilamellated structures and membranous vesicles. Two therapeutic whole lung lavages were performed. The patient improved.
PITUITARY MACROADENOMA
The T1 weighted MRI scan in sagittal view here demonstrates a macroadenoma of the pituitary that is bright with gadolinium enhancement. Such an enlarging mass can produce the classic bitemporal hemianopsia by pressure effect on the optic chiasm superiorly.
TB OSTEOMYELITIS (POTT’S DISEASE)
There is bony destruction of T8 and 9 in these two sagittal MRI views in a case of tuberculous osteomyelitis (Pott's disease). The vertebral destruction has resulted in impingement upon the spinal cord.
OSTEOMYELITIS WITH EPIDURAL ABSCESS
This 56 year old man had a five year history of Parkinson's disease. Six months earlier he had been treated for septicemia, and had made a full recovery. Over recent weeks he had suffered an increasing number of falls. He was admitted and again found to be septicemic, for which he was treated. However he also complained of pain in the groin, and was noted to have bilateral weakness and spasticity of the legs. An MRI of the spine, obtained to investigate his leg weakness, reveals staphylococcal osteomyelitis with epidural abscess at C6/7. At surgery an epidural abscess was identified and drained. Staph aureus was isolated from the abscess and from the blood.
OSTEOMYELITIS AND DISKITIS DUE TO SALMONELLA
Radiologic Findings: Loss of the subchondral line of the endplates at the L2-3 intervertebral disk space; Loss of the L2-3 intervertebral disk space, with marked adjacent sclerosis; Large bony erosion anteriorly at L2-3
SILICOSIS
This chest radiograph demonstrates silicotic nodules of varying sizes scattered throughout the lung, resulting in an interstitial lung disease. Remember, if you see FEVER in a pt with Silicosis, think SilicoTB! Remember, too, that, because of the ↑ risk of TB in these pts, silicosis is a 10mm cutoff on the PPD.
HIGH-RISK OCCUPATIONS FOR SILICOSIS 1. Construction
7.
Road worker
2. Demolition
8.
Glass manufacturing
3. Mining
9.
Pottery
4. Sandblasting
10.
Railroad track setting, laying, and repair
11.
Painting
12.
Plumbing
5. Stone masonry 6. Brick layers
Look out for these on the exam!
WHAT’S THE DX ?
Patient presents with inspiratory increase in JVP, distant heart sounds, hypotension, and pulsus paradoxus
TAMPONADE/PERICARDIAL EFF.
WHICH WOULD MAKE THIS …?
ELECTRICAL ALTERNANS
INTEROSSEOUS WASTING
Interosseous wasting, a consequence of a LEFT apical tumor, later found, in this patient
WHAT DO YOU SEE?
47 year old non-smoking woman with wrist pain, finger pains, & weight loss.
HPOA
Periosteal reaction along the medial margins of the distal radius and ulna.
WHAT’S YOUR DX FOR THE EXAM?
ELDERLY WOMAN WITH DYSPHAGIA
DIFFUSE IDIOPATHIC SKELETAL HYPEROSTOSIS DISH is considered a form of primary osteoarthritis and in the differential of Ank Spond. Patients with DISH are often obese and 60% have diabetes Sensation of ‘stiffness’, yet relatively well-preserved spinal ROM. Criteria: 1. Flowing ossification (“flowing wax”) of the anterior longitudinal ligament, involving at least 4 adjacent disk spaces 2. Lack of intervertebral disk space narrowing
DISH: “FLOWING WAX”
D
FRONTRUNNERS BOARD REVIEW, INC. BRADLEY D. MITTMAN, MD
HIV-ASSOCIATED IDIOPATHIC ULCER
Solitary, large, wellcircumscribed ulceration with a heaped-up border appearance typical of idiopathic esophageal ulceration of HIV.
ESOPHAGEAL CANDIDIASIS
Typical white (yellow more severe) plaques can give a shaggy appearance on esophagram
ESOPHAGEAL CANDIDIASIS
PANCREATITIS: COMPLICATIONS
CBD NARROWING FROM CHRONIC PANCREATITIS: ERCP
This cholangiogram is primarily meant to illustrate this Common Bile Duct stricture (closed arrows) with proximal dilation that has been caused by a pancreatic head that is inflamed and encircling the CBD.
CBD NARROWING FROM CHRONIC PANCREATITIS: THC
A different view of the same thing in another pt, this time using a Transhepatic Cholangiogram instead of ERCP.
SCLERODERMA
Degenerative changes and fibrosis of the perioral skin limit mobility of the mouth in PROGRESSIVE SYSTEMIC SCLEROSIS. Oral hygiene may be compromised in this setting. Look for the pt who has “difficulty putting in her dentures”.
CROHN DISEASE
ULCERATIVE COLITIS
Anatomic Distribution
Rectal sparing. Terminal Ileum is often involved and is very important.
Rectum is always involved. Terminal ileum is rarely involved.
Type of Inflammation
Transmural
Strictly mucosal
Distribution of Inflammation
Periodic Skip-lesions: Discrete ulcers with islands of normal mucosa.
No skip lesions. Diffuse inflammation and edema throughout, leading to edema and ulceration.
Microscopic Pathological Features
Non-caseating granulomas
Crypt Abscesses
Macroscopic Pathological Features
Fissures piercing through wall, which can lead to fistulas.
Thickened colonic wall early on. Can see thin, atrophic wall in case of toxic megacolon. Pseudopolyps are more common.
Complications
May see strictures Gallstones Hydronephrosis from ureter involvement.
No strictures are seen. Toxic Megacolon. Many systemic complications.
Cancer
Intestinal Adenocarcinoma Overall risk is slim compared to Ulcerative Colitis.
Risk for diffuse Colonic Adenocarcinoma (not arising from discrete polyps) Increased risk for cholangiocarcinoma
NORMAL COLONOSCOPY VIEWS:
A
B
C C
D D
A. Sigmoid Colon The sigmoid colon demonstrates thickened circular folds corresponding to hypertrophied musculature. Several diverticula are present. B. Descending Colon The descending colon forms a long tube and is relatively featureless. C. Splenic Flexure A long, bluish indentation from the spleen. Normal colonic vasculature is seen. D. Transverse Colon The typical-appearing triangular folds of the transverse colon.
ULCERATIVE COLITIS …
2/19/2016
ULCERATIVE COLITIS CLINICAL FEATURES 2/19/2016
Diarrhea (usually) ‘constipation’ Rectal Bleeding Mucous/Pus Frequency Urgency Tenesmus Cramping
UC Basics
2/19/2016
Friable granular inflammation Extends from rectum proximal 40% rectum and sigmoid 40% More than rectum but subtotal 20% Total colon (pan colitis)
UC Microscopic Features
2/19/2016
Involves only mucosa and submucosa Crypt distortion Plasma cell and lymphocytic infiltrates Cryptitis and crypt abscesses
UC, Endoscopic & Radiologic FEATURES 2/19/2016
Edema Granular inflammation, friable Pseudopolyps Narrowings Foreshortening of colon Loss of haustrae Toxic megacolon
ULCERATIVE COLITIS: haustra
Fecaliths Ulcerations
Loss of haustra giving a tubular appearance; fecaliths, ulcerations
Normal haustral pattern
CROHN’S DISEASE: : TERMINAL ILEUM STRICTURE
There is a large area of narrowing involving nearly the entire terminal ileum. Again, a favorite site of involvement of Crohn’s disease is the terminal ileum.
CROHN'S DISEASE TERMINAL ILEUM STRICTURE
This upper GI series reveals a focal area of stricture in the terminal ileum, consistent with Crohn's disease.
CROHN'S, ENTEROENTERIC FISTULA FORMATION The barium enema seen here demonstrates fistulae in a case of Crohn's disease. Loops of small bowel and colon converge in an area of adhesions and inflammation resulting from the transmural inflammation, to form an entero-enteric fistula. Other fistulae frequently seen are perirectal, enterocutaneous, and enterovesicular fistulae.
CROHN’S DISEASE: WHAT WHEN? 1. EARLY CHANGES: •
Focal inflammation
•
Aphthous ulcers
2. ADVANCED DISEASE: •
Discontinuous ulceration
•
Skip lesions
•
Cobblestoning
•
Strictures, fistulae, cicatrization
COLONIC CROHN’S WITH PSEUDOPOLYPS GIVING A “COBBLESTONE” APPEARANCE
Diffuse submucosal edema, inflammation, and ulceration produce multiple pseudopolyps, giving this “cobblestoning” appearance.
GARDNER’S SYNDROME: OSTEOMAS
The radiograph of the femur reveals multiple osteomas (arrows) in a patient with "Gardner's syndrome". The osteomas are typically incidental findings.
MEGAKARYOCYTE “Megas” are the platelet “mothership” cells. Megakaryocytes arise from the haemopoietic stem cell and, during maturation, undergo nuclear reduplication without cytoplasmic division, resulting in large polyploid cells. During differentiation, cytoplasmic territories become demarcated within the megakaryocyte membrane. Subsequently, megakaryocytes disintegrate with the release of platelets.
CML
CHRONIC MYELOGENOUS LEUKEMIA
The blood film in chronic myeloid (or granulocytic) leukaemia shows a very marked leucocytosis composed of granulocytes at all stages of maturation, particularly neutrophils and band forms, and sometimes occasional blasts. Basophilia and eosinophilia may be present. The spleen is moderately enlarged. The Philadelphia (Ph) chromosome, due to a t(9,22) reciprocal translocation, is found in almost all cases. The disease usually progresses from a stable phase to an accelerated phase in which blast transformation (blast crisis) to A.M.L. or Philadelphia-positive A.L.L. takes place.
ACANTHOSIS NIGRICANS 5 types:
A diffuse, velvety thickening and hyperpigmentation of the flexural skin, chiefly in axillae and other body folds.
Hereditary benign AN: no associated endocrine disorder Benign AN: may be assoc’d with insulin-resistant states (DM, acromegaly, Cushing’s, Addison’s and hypothyroidism) Pseudo-AN: Cx of obesity (which is also assoc’d with insulin resistance) Drug-induced AN: OCPs, nicotinic acid (high dose) Malignant AN: adenoca (2/3 gastric)
SCLERODERMA--MORPHEA
Indurated, poorly defined plaque with a central yellow so-called “carnauba wax”colored area surrounded by a lilac border.
Morphea is a localized cutaneous sclerosis characterized by early violaceous, later ivory-colored plaques, which may be solitary, linear, or generalized Aka “localized scleroderma”, “circumscribed scleroderma” F:M=3:1 There is some evidence that Borrelia burgdorferi may actually be the causative agent, at least in some patients. For morphea lesions not associated with borrelia burgdorferi, there is no effective tx beyond symptomatic as necessary; Otherwise, high-dose parenteral PCN or Ceftriaxone regimens may reverse.
CRYOGLOBULINEMIA
Above, associated Raynaud’s phenomenon and arterial occlusion have resulted in extensive necroses, hemorrhage, and ulcerations.
Type I (monoclonal): non-inflammatory Types II and III (mixed) are associated with leukocytoclastic vasculitis on histology and are inflammatory--these therefore give “palpable purpura” Associated clinical findings: Livedo Reticularis to extremities Acrocyanosis and Raynaud’s phenomenon Urticaria induced by cold, associated with purpura Vasculitis, arthralgias, neuro sx’s HSM, GN Dx: clinical suspicion confirmed with detection of cryoglobulins Tx: NSAIDs, cytotoxic agents, plasmapheresis
APHTHOUS ULCERS
AKA “Aphthous stomatitis” or “canker sores” “Aphthous” from the Greek “ulcer” Most common in oropharynx (buccal and labial mucosa) and less common in esophagus, UGI and LGI tracts, and anogenital mucosa Multiple associated disorders, including Behcet’s disease Cyclic neutropenia HIV
HELIOTROPE RASH IN DM
Heliotrope flowers
Primary Systemic Amyloidosis Pinch Purpura. The uppermost papule is yellowish and non-hemorrhagic; the lower portion is hemorrhagic. Socalled “pinch purpura” of the upper eyelid can appear as hemorrhagic papules after pinching or rubbing the eyelid.
Post proctoscopic periorbital purpura Waxy papules, usually eyelids or perialar area Macroglossia Patchy alopecia Bullous eruptions Biopsy of normal skin, rectum, gingiva, SQ abdominal fat pad Other commonly clinical presentations: cardiac, renal, hepatic, GI, carpal tunnel Re: Type AL is primary; AA is secondary. Usually no derm findings in secondary type. Multiple myeloma increased with AL type.
Rocky Mountain Spotted Fever Rash on 4th day of fever (range
2-6 days); sudden onset F/C, severe H/A Wrists, ankles, arms--> trunk (“centripetally”, unlike measles), palms, soles Mac/pap to petechiae to purpura
Tick bite, mid-to-late summer R. Rickettsii Rare in Rocky Mountain states! Most common in S. Atlantic states Wood tick=Dermacentor andersoni in the Western US Dog tick--D. variabilis in East Only 60% give a h/o a tick bite Diffuse vasculitis, hyponatremia, thrombocytopenia Extensive cutaneous necrosis due to DIC occurs in 4%; these may become gangrenous Dx: Comp. fix. titre; Weil-Felix DFA of skin bx (false + in 30%) thus dx must be made clinically and confirmed later Tx: Doxy/TCN; chloramphenicol
BACILLARY ANGIOMATOSIS
A systemic infection caused by Bartonella species, occurring almost exclusively in HIV, characterized by cutaneous vascular tumors resembling Kaposi’s sarcoma and symptomatic multisystemic infection, usually involving the liver (peliosis hepatis) and/or spleen (parenchymal bacillary peliosis) B. henselae and B. quintana. In immunocompetent individuals, B. henselae is also the agent of cat-scratch disease. Contact (bites, scratches) with cats bearing usually B. henselae
CLUBBING
Clubbed fingers are the result of hyperplasia of the fibrovascular tissue between the nail matrix and the bony phalanx. The pathogenesis is unknown, but thought to be related to increased blood flow to these tissues.
Associated conditions include: Cardiac disease Cyanotic heart disease Endocarditis Pulmonary disease Bronchiectasis TB Primary and metastatic ca Lung Abscess Mesothelioma GI disease IBD Hepatic cirrhosis
OSLER-WEBER-RENDU (Hereditary Hemorrhagic Telangiectasias) CASE An 80-year-old woman is admitted for evaluation of a nosebleed that continued despite packing or other traditional treatments. Results of physical examination are unremarkable, except for the presence of prominent, visible blood vessels on her tongue.
Superficial Telangiectasias
ORAL HAIRY LEUKOPLAKIA
Oral hairy leukoplakia in a HIV-infected man. Oral hairy leukoplakia is a raised, white lesion that is usually seen on the lateral margin of the tongue and caused by Epstein-Barr Virus.
Pseudopseudohypoparathyroidism Metastatic calcification
Short 4th metacarpal
RAYNAUD’S PHENOMENON
Raynaud's phenomenon: reflex vasoconstriction. Note only some fingers affected. This patient had SLE.
THE 55 EKGS TO KNOW
OPHTHALMOLOGY SLIDE SH W “FOCUSING ON WHAT’S IMPORTANT”
FRONTRUNNERS BOARD REVIEW
IRITIS Seen mainly in young people. Occasionally associated with systemic conditions such as ANKYLOSING SPONDYLITIS and sarcoidosis. Presentation: · PAINFUL RED EYE · PHOTOPHOBIA with REDUCED VISION Examination: · Visual acuity is reduced to varying degree · Redness mainly around the cornea (CILIARY INJECTION) · Pupil is usually CONSTRICTED OR IRREGULAR REACTING POORLY TO LIGHT. Management: · REFER the patient within 24 hours. · SLIT-LAMP examination to confirm dx · Treatment is with intensive TOPICAL STEROID to reduce inflammation and MYDRIATIC to dilate the pupil so that the iris does not stick to the cornea causing problem with glaucoma.
THIRD NERVE PALSY
Third cranial nerve palsy caused by an aneurysm of the posterior communicating artery: An 81year-old woman complained of headache and double vision. On examination she had an unreactive left pupil and was unable to cross the midline when looking to the right . She was unable to open her right eyelid . A cerebral angiogram revealed an aneurysm of the posterior communicating artery.
PUPILLARY INVOLVEMENT IN CN III PALSY: The pupil is affected in compressive third nerve palsy but not if the cause is infarction because the parasympathetc nerve that innervates the pupil travels at the surface of the third nerve. In compressive lesions, this is affected early. Whereas in infarction, the center of the nerve is usually affected more than the surface of the nerve, which even if involved, can still obtain nutrients and oxygen from the CSF. Pupil-involving third nerve palsy is generally an emergency: look for mechanical factors, ie aneurysm or tumor Pupil-sparing third neve palsy: look for diabetes or HTN. Remember, diabetes spares the pupil.
LEFT 6TH NERVE PALSY EXAMPLE #2
INTERNUCLEAR OPTHALMOPLEGIA
Eyes converge in “D�, illustrating that CN III is intact. Therefore, the lesion is to the MLF, or medial longitudinal fasciculus, the usual etiology in MS palsies. The MLF relays signals from the CN 3 on one side to the CN 6 on the other for proper conjugate response.
OPTIC NEURITIS Optic neuritis is a common initial presentation in Multiple Sclerosis. In the early stages the optic disc frequently appears normal (retrobulbar neuritis). Later it may become pale with a clearly defined margin--as in the RIGHT half of this disc. Subsequently, the patient may develop the complete pallor of optic atrophy; or the disc may return to a normal appearance.
HERPES OPTHALMICUS
Herpes zoster opthalmicus is seen when herpes zoster affects the opthalmic division of the trigeminal nerve, resulting in corneal involvement and skin lesions of the forehead and eyelids. The skin eruption respects the midline of the face (i.e., lesions do not cross the midline). Involvement of the anterior tip of the nose (aka Hutchinson’s sign; not seen here) is an ominous sign, indicating a high risk of ocular complications (nasociliary nerve also supplies the cornea).
RETINAL DETACHMENT IN D.R. RETINAL TEAR AS MECHANISM #2
PAPILLEDEMA Papilledema is a term that indicates a swollen optic nerve due to increased intracranial pressure, whether from: 1. Malignant HTN 2. Intracranial mass (LP contraindicated) 3. Pseudotumor cerebri Papilledema is not a diagnosis, but rather a sign of an underlying disorder. Most commonly noted in pseudotumor cerebri, which is most likely to occur in young, caucasian, overweight females.
AMAUROSIS FUGAX: CAROTID ANGIOGRAM
Magnetic resonance angiography (MRA) reveals the source of this patient’s symptoms L. eye amaurosis fugax. Arrow shows an ostial stenosis of the ipsilateral internal carotid artery.
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