Findings and interpretation:

Chest radiograph:

• There is a large, cystic structure in the right upper lobe with thick walls.
• There is an air-fluid level within the cystic lesion.

CT thorax:

• There is a multi-loculated cystic mass with thick walls and thick, nodular internal septations.
• There are smaller adjacent thick walled cystic lesions. 
• The cystic mass contains dependent fluid with a posterior air-fluid level.

Negative findings:

There is no systemic arterial supply to the mass.

The findings represent a congenital lesion in the lung. The presence of fluid within the lesion is suggestive of infection.

Principal diagnosis:

Congenital pulmonary airway malformation with super-imposed infection.

Differential diagnosis:

• Pulmonary abscess

Management:

Alert referring physician of findings.

Recommend discussion at paediatric surgery MDT following resolution of acute symptoms to discuss surgical excision.

Findings and interpretation:

Non-contrast CT brain:

• Diffuse expansion of the left temporal lobe, extending into the left thalamus, lentiform nucleus and insular cortex.
• The involved brain parenchyma shows heterogeneous attenuation. The process predominantly involves the white matter with sparing of the cortex.

MRI:

• The involved regions of the brain parenchyma seen on CT show heterogeneously high T2 and FLAIR signal intensity, which also extends to the left occipital lobe. There is a mild degree of mass effect with midline shift to the right. 
• The affected regions show patchy diffusion restriction.
• There is mild patchy parenchymal enhancement, as well as leptomeningeal enhancement around the involved brain territories.

Pertinent negative findings:

• There is no evidence of haemorrhage or significant intracranial mass effect.

There is a diffuse, pathological, likely malignant process involving at least two lobes of the brain.

Principal diagnosis:

Gliomatosis Cerebri

Differential diagnosis:

• Lymphoma
• Herpes simplex encephalitis

Management:

Alert referring physician of findings.

Refer for discussion at neurology MDT. The patient may need to be referred to a tertiary neurology / oncology centre.

Findings and interpretation:

• There are multiple metallic coils within vascular structures in both lungs.
• There are multiple aneurysmal dilatations and vascular malformations with enlarged feeding vessels in the pulmonary arterial tree.
• There are bibasal and bi-apical atelectatic bands and parenchymal scarring.
• There is a mosaic pattern in both lungs.
• The hepatic artery is dilated and tortuous.
• There are diffuse liver parenchymal telangiectasias resulting in a patchy and heterogeneous hepatogram with early sinusoidal filling and early opacified hepatic veins. The portal and hepatic veins are also dilated.

Coil embolisation of abnormal vascular structures in the lungs was previously performed. Mosaic pattern and patchy hepatogram are a result of uneven perfusion to the lung and liver parenchyma.

The constellation of findings represent a congenital multi-system vascular disorder resulting in telangiectasia and vascular malformations forming in various organ systems.

Diagnosis:

Hereditary haemorrhagic telangiectasias (Osler Weber Rendu)

Differential diagnosis:

None

Management:

Recommend periodic screening for pulmonary and cerebral arterio-venous malformations (AVM’s). Cerebral AVM’s should be referred to an interventional neuro-radiologist for possible endovascular coiling. Symptomatic pulmonary AVMS’s should also be treated in similar fashion.  

Recommend referral for discussion at pulmonary MDT for management of active issues.

Findings and interpretation:

Hand radiograph:

• There is globular, peri-articular soft tissue calcinosis involving the 3^rd and 5^th
• There is diffuse arthropathy and thinning of the articular cartilage, particularly at the PIP and DIP, and radiocarpal joints.

HRCT:

• There is a peripheral rim of ground glass opacification with sub-pleural sparing, showing a gradient with sparing of the apices and increasing involvement of the lower lobes and bases.
• There are reticular opacities seen in the same distribution, with basal predominance.
• There is traction bronchiectasis at the lung bases.

Pertinent negative findings:

• There is no honeycombing / any significant degree of fibrosis.
• The oesophagus is non-dilated (there is no achalasia, which is a feature of scleroderma).
• There is no acro-osteolysis/ resorption of the distal tufts.
• There is no erosive arthritis.
• The liver is of normal density (may be hyperdense with amiodarone administration).

Incidental findings:

• Cardiomegaly.

The lung findings are characteristic of non-specific interstitial pneumonia (NSIP). In conjunction with the musculoskeletal findings, this points to a multi-systemic disorder which causes interstitial lung disease and musculoskeletal manifestations such as soft tissue calcification.

Principal diagnosis:

Systemic sclerosis / scleroderma.

Differential diagnosis:

NSIP:

• Drug induced interstitial lung disease
• Usual interstitial pneumonia

Musculoskeletal findings:

• Hyperparathyroidism

Management:

Notify the referring physician of the findings.

Recommend discussion at pulmonary / rheumatology MDM.

Findings and interpretation:

• There is gross, circumferential, nodular thickening of the wall of a short segment of terminal ileum. The involved segment of bowel shows aneurysmal dilatation.
• The involved segment of bowel has an exo-enteric component, which forms an irregular mass superior to it.
• There is right sided hydronephrosis, as well as hypo-enhancement in the right kidney. The right ureter is dilated down to its lower third, where it comes into contact with and is inseparable from the bowel mass.
• There is right perinephric and peri-ureteric fat stranding.

Pertinent negative findings:

• There are no significantly enlarged local lymph nodes.
• There is no evidence of metastatic spread (no liver parenchymal / suspicious bony lesions).
• The mass is not causing bowel obstruction.

The findings represent a malignant neoplasm arising from the terminal ileum, causing obstruction of the right ureter with resultant obstructive nephropathy and evidence of pyelonephritis.

Principal diagnosis:

Lymphoma of the small bowel

Differential diagnosis:

• Adenocarcinoma of the small bowel
• Gastro-intestinal stromal tumour

Management:

Alert referring physician of findings.

Recommend referral to interventional radiology for right nephrostomy insertion.

Recommend staging CT thorax abdomen pelvis.

Recommend discussion at MDT with regards to image guided biopsy / surgical management.

Findings and interpretation:

• There are centrilobular nodules and branching opacities showing a tree-in-bud appearance within the right middle lobe and both upper and lower lobes of the left lung. There are bilateral upper lobe nodules.
• There is patchy subsegmental consolidation in both lobes of the left lung, as well as the lower lobe of the right lung. There is also nodular pleural thickening, and a drained left pleural effusion with a drainage catheter in situ.
• There are multiple hypodense nodules that are distributed diffusely in the spleen.
• There are enlarged lymph nodes in both axillae, lower cervical region, as well as the mediastinum. The lymph nodes show central low density.

Pertinent negative findings:

• No evidence of bony / spine involvement.

The findings represent a multi-system granulomatous infection, primarily involving the lung.

Principal diagnosis:

Re-activation multi-system tuberculosis

Differential diagnosis:

• Sarcoidosis

Management:

Contact referring physician and inform of findings; recommend placing the patient in isolation, screening close contacts and testing sputum for acid-fast bacilli.

Refer for discussion at pulmonary MDT with regards to further management / possibility of image guided biopsy of axillary lymph nodes.