Lymphocytic interstitial pneumonitis

Findings and interpretation:

• There are bilateral ground glass opacities and interstitial bands, with a mid to lower lung zone predominant distribution, as well as mild thickening of the fissures and interlobular septae. Few ground glass nodules are seen in the same distribution.
• There are scattered thin walled cysts throughout both lungs, in a peripheral and lower lung zone distribution.
• Thickening of the bronchovascular bundles at the right hilum.
• There is mild mediastinal lymphadenopathy.

Pertinent negative findings:

• No pleural effusions.
• No areas of consolidation.

The findings reflect a cyst forming interstitial lung disease.

Principal diagnosis:

Lymphocytic interstitial pneumonitis

Differential diagnosis:

• Pneumocystis pneumonia (however, there is no history of HIV positive status)
• NSIP (non-specific interstitial pneumonia) however, cysts are not a feature of this entity

Management:

Alert referring physician of findings.

Refer for pulmonary MDT for further investigation / treatment planning. Recommend HIV serology testing. Lung biopsy may be required for a definitive diagnosis. These cases are usually treated by corticosteroids.  

Diffuse Pontine Glioma

Findings and interpretation:

• There is a mass lesion in the brainstem, centred at the pons, appearing heterogeneously T2 hyperintense and T1 hypointense. It extends through the right cerebral peduncle to the right thalamus. 
• The mass is causing expansion of the pons with mass effect causing effacement of the 4^th ventricle; there is a CSF ventricular shunt in situ.
• The mass shows a mild degree of peripheral post-contrast enhancement.
• There are central, T2 hyper-intense, non-enhancing areas within the mass, which likely represent central necrosis.

Pertinent negative findings:

• No T1 hyperintensity to suggest haemorrhage.
• No hydrocephalus, indicating that the CSF shunt is adequately functioning.
• There are no other intracranial lesions.

The findings represent an aggressive brain neoplasm. This is likely primary given the patient’s age.

Principal Diagnosis:

Diffuse brainstem (pontine) glioma.

Differential diagnosis:

• Ependymoma (these are usually located in the 4^th ventricle)
• Metastases (unlikely given the patient’s age)

Management:

Neurology / oncology MDT to discuss treatment options (chemotherapy / radiotherapy).  

Acute on chronic pancreatitis, hepatic steatosis and varices

Findings and interpretation:

• There is ill defined soft tissue and fat stranding surrounding the pancreas with multiple thin walled cysts within the soft tissue; the cysts show near-water fluid density contents. Part of the body and tail of the pancreas is replaced by the soft tissue, which has the appearance of an inflammatory mass.
• The liver is enlarged, and shows homogeneous low parenchymal density.
• The portal vein, while patent, is compressed at the confluence by the inflammatory soft tissue.
• There is a large degree of splenic, gastric and esophageal varices.
• The spleen is enlarged, with a hypo-enhancing lesion in its medial pole.

Pertinent negative findings:

• No discrete pancreatic mass.
• No portal vein thrombosis.

The findings represent acute on chronic pancreatitis with peri-pancreatic inflammatory tissue and multiple pseudo-cysts.

Hepatomegaly is caused by hepatic steatosis. Splenomegaly and varices are caused by compression of the portal vein by the pancreatic inflammatory process.

The splenic lesion is most likely an old splenic infarct.

Principal diagnosis:

Acute on chronic pancreatitis with hepatic steatosis, and portal venous compression causing splenomegaly and varices.

(Given the young age of the patient, congenital triglyceridemia is the likely underlying cause.)

Differential diagnosis:

None.

Management:

Alert referring physician of findings.

Recommend discussion at gastro-intestinal MDT to discuss treatment options.

Neurofibromatosis type 1

Findings and interpretation:

• There is smooth scalloping of multiple contiguous vertebral bodies posteriorly at the mid-thoracic level, with associated expansion of the dural sac and enlargement of the subarachnoid CSF space.
• The neural foramina are enlarged at these levels with thinning of the pedicles.
• There is associated protrusion of the expanded, CSF filled spinal meninges through the neural foramina; this forms a CSF filled meningeal sac at one level.

Pertinent negative findings:

• Normal spinal cord (no tumour).

Incidental:

• Degenerative disc changes at the mid-thoracic spine.

The findings represent dural ectasia with lateral meningocele formation.

Principal diagnosis:

Neurofibromatosis type 1

Differential diagnosis:

• Marfan’s / Ehlers Danlos syndromes (not typically associated with lateral meningoceles)

Management:

Discuss with referring physician; this would most likely be a known case of neurofibromatosis type 1.

Management is aimed at detecting complications of NF1; surveillance imaging is indicated.  

Pulmonary hypertension caused by atrial septal defect

Findings and interpretation:

• The pulmonary trunk is enlarged, appearing greater in diameter than the adjacent ascending aorta. The right and left main pulmonary arteries are also enlarged.
• The right ventricle and atrium are enlarged, with hypertrophy of the interventricular septum the interventricular septum appears straightened / bowed to the left.
• The peripheral pulmonary arteries in each of the upper and lower lobes in both lungs have a larger diameter than the accompanying bronchi.
• There is a large defect in the inter-atrial septum.

Pertinent negative findings:

• The lungs are clear with no interstitial lung disease.
• No filling defects in the pulmonary arteries to suggest acute / chronic pulmonary embolism.

The findings reflect pulmonary arterial hypertension; this is most likely caused by a congenital structural heart defect in the inter-atrial septum.

Principal diagnosis:

Pulmonary arterial hypertension caused by an atrial septal defect.

Differential diagnosis:

• Congenital pulmonary valvular stenosis
• Idiopathic dilatation of the pulmonary trunk

Management:

Alert referring physician of findings.

Recommend further investigation by echocardiography.

Recommend discussion at cardiology MDT to discuss possible management by endovascular closure device.

Acute haemorrhage from adrenal myelolipoma

Findings and interpretation:

Non-contrast CT:

• There is a large, well defined left-sided retroperitoneal mass, which contains a low density component consistent with macroscopic fat, as well as a high density component consistent with acute haematoma. The left adrenal gland cannot be identified separate to the mass. The high density fluid extends caudally into the left perinephric space.
• Status post gastric bypass surgery with suture material noted at the gastro-jejunal and jejuno-jejunal anastomoses.
• Minimal left pleural effusion.

Arterial phase:

• There is linear contrast media density within the adrenal haematoma anteriorly, consistent with acute arterial extravasation.

Portal venous phase:

• The contrast density appears larger and more globular on this phase, consistent with dissolution within the haematoma; this confirms arterial extravasation.

Pertinent negative findings:

• No peri-anastomotic fluid collections / extra-luminal leakage of oral contrast.

Incidental findings:

•  
• Reactive right iliac fossa lymph nodes.
• Bilateral breast prostheses.

The findings represent acute arterial haemorrhage into a left adrenal fatty neoplasm. The neoplasm itself has non-aggressive characteristics.

There is no evidence of surgical complications such as anastomotic leak / breakdown.

Principal diagnosis:

Acute arterial haemorrhage into an adrenal myelolipoma.

Differential diagnosis:

None.

Management:

Urgently contact referring physician and inform of findings.

Recommend urgent endovascular embolisation of the bleeding myelolipoma.