Findings and interpretation:

CTPA:

• There are multiple filling defects in the segmental and sub-segmental arteries of the lower lobes bilaterally, and right middle lobe.
• There are multiple bilateral peripheral nodular consolidations at the lung bases, most of which show central cavitation; these are downstream from the occluded pulmonary arteries.
• There is a filling defect extending from the IVC into the right atrium.
• There are bilateral mild pleural effusions.

CT abdomen and pelvis:

• There is hepato-splenomegaly and a patchy hepatogram, with no enhancement of the hepatic veins.
• There is enlargement of the left renal vein with a large filling defect occupying the entire vein and extending into the IVC. There is enlargement and slight hypo-enhancement of the left kidney.
• There is a moderate amount of free fluid in the abdomen and pelvis.

There is bilateral pulmonary embolism and causing pulmonary infarcts. There is a thrombus in the right atrium, which extends from thrombosis in the IVC; the hepatic veins and left renal vein are also thrombosed. This is causing Budd Chiari syndrome and left renal venous congestion.

Principal diagnosis:

Thrombophilic state manifesting in thrombosis of various veins and resultant pulmonary embolism with consequent effects on multiple organ systems.

Differential diagnosis:

• Infectious endocarditis with septic emboli (however, this does not cause thrombosis in other systems).

Management:

Urgently contact referring physician and inform of the findings to commence immediate anticoagulation and possible catheter directed thrombolysis / mechanical thrombectomy.

Further management will require thrombophilia screen / work up.

Findings and interpretation:

• There are innumerable T2 and FLAIR hyperintense white matter lesions with a generalized distribution throughout both cerebral hemispheres in a generalized, fairly symmetrical distribution. They involve the subcortical, deep and periventricular white matter, as well as the internal and external capsules.
• These lesions are also seen in the brainstem, cerebellar peduncles and cerebellar hemispheres. A single lesion is detected in the cervical spinal cord at the level of C3/C4.
• The lesions are most concentrated at the calloso-septal interface, where they have an elliptical shape with an orientation perpendicular to the lateral ventricles.
• A few of the lesions show avid enhancement on the post-contrast sequence, some of which show ring enhancement.

Pertinent negative findings:

• There is no oedema surrounding the lesions.
• The lesions do not show diffusion restriction.

The findings most likely represent a de-myelinating process in the brain. The enhancing lesions represent active de-myelination.

Principal diagnosis:

Multiple sclerosis

Differential diagnosis:

Neurovasculitis (This is unlikely as the distribution of disease is typical of multiple sclerosis)

Small vessel chronic ischemia with leukoariaosis (however, this would not be expected to enhance)

Brain metastases from unknown primary (however, in this case all of the lesions would enhance and show marked peri-lesional oedema)

Management:

Compare with previous imaging if available.

Recommend discussion at neurology MDT with regards to active disease and medical treatment options.

Findings and interpretation:

• There is high STIR and low T1 marrow signal intensity in the proximal half of the femur, with a fracture of the proximal third of the shaft of the femur.
• There is a large, heterogeneously T2 hyperintense mass arising from the fractured proximal third of the bone, with extension into the quadriceps and adductor muscle groups.
• There is high STIR signal in the surrounding subcutaneous fat, indicating oedema.

Pertinent negative findings:

• The distal half of the bone is normal.

The findings represent pathological fracture of the proximal third of the femur due to an aggressive bony lesion. This is most likely a primary bone malignancy.

Principal diagnosis:

Osteosarcoma of the femur with pathological fracture

Differential diagnosis:

• Ewing’s sarcoma
• Other soft tissue sarcoma

Management:

Alert referring physician of findings.

Recommend staging CT thorax abdomen pelvis.

Recommend bone scan to search for multiple bone involvement.

Recommend discussion at sarcoma MDT regarding image guided biopsy for histopathological diagnosis (this should be planned with the orthopaedic surgeons in order to avoid biopsy tract seeding in tissue that will not be resected). It may be more appropriate to refer to a tertiary sarcoma centre for further management.

Findings and interpretation:

Chest radiograph:

• There is mediastinal and bilateral hilar lymph node eggshell calcification.
• There is bilateral widespread reticulonodular opacities in the lungs, with a predominantly midzone distribution.

CT:

• In addition to the calcified lymph nodes noted on the chest radiograph, there are bilateral perihilar stellate mass-like opacities with central, coarse calcifications.
• There is a surrounding fibrotic reaction and architectural distortion.
• There are scattered, spiculated nodules throughout both lungs.
• There is generalised nodular thickening of the fissures and interlobular septae.
• There is bilateral pleural thickening.

The findings represent a chronic, interstitial lung disease.

Principal diagnosis:

Conglomerate fibrosis on a background of sarcoidosis

Differential diagnosis:

• Silicosis with progressive massive fibrosis
• Coal worker’s pneumoconiosis with progressive massive fibrosis

Management:

Review any previous imaging if available.

Recommend tissue biopsy for histological diagnosis if diagnosis not already known.

Refer for pulmonary MDT discussion with regards to further management (lung transplant may be indicated).

Findings and interpretation:

• There is bony destruction and periosteal reaction at the antero-superior vertebral body corner, as well as narrowing of the L3/L4 intervertebral disc space.
• There is a large paraspinal collection adjacent to the site of vertebral destruction on the right side, with calcified foci seen within the collection. The collection extends into the right ilio-psoas muscle.
• There is a large left sided ilio-psoas collection.
• There are a few retroperitoneal and left common iliac enlarged lymph nodes with a necrotic centre.
• There is moderate right sided hydronephrosis.

Pertinent negative findings:

• There is no obvious extension of the abscesses into the spinal canal / spread into the epidural space.

Incidental:

• Two nodules are seen in the lung bases, one on each side.

The findings represent an indolent spondylodiscitis, giving rise to large adjacent abscesses. The right ureter is involved in the inflammatory process in its proximal segment, causing obstructive nephropathy.

Principal diagnosis:

Tuberculous spondylodiscitis

Differential diagnosis:

• Brucellosis spondylodiscitis

Management:

Review chest radiograph for evidence of post-primary pulmonary tuberculosis.

Contact referring physician and inform of findings; recommend placing the patient in isolation.

Recommend drainage of abscesses and collecting samples for culture and sensitivity.

Findings and interpretation:

• There is a large amount of free air in the peritoneal cavity, indicating pneumoperitoneum.
• The cecum is grossly distended and filled with faeces. Immediately distal to it is a short segment of ascending colon which shows concentric thickening of the walls and stenosis of the lumen.
• There is also dilatation of the distal ileum, which is filled with gas.
• Enhancing peritoneal lining, noted in the perihepatic region.
• There are multifocal segments of small bowel wall thickening.
• Bilateral pleural effusions.

Pertinent negative findings:

• No visible perforated peptic ulcers.
• No lesions in the liver to suggest metastases.

Incidental:

• Large umbilical hernia containing fat.
• Calcified old fibroids in the uterus.
• Grossly distended gallbladder.
• Hiatus hernia.
• Atrophied kidneys indicating chronic kidney disease.

The findings represent bowel obstruction proximal to the ascending colon, causing dilatation of the cecum and distal ileum. The obstruction is caused by a stenosing annular adenocarcinoma of the ascending colon. This has caused rupture and perforation of the cecum with resultant pneumoperitoneum. 

Principal diagnosis:

Perforated cecum due to bowel obstruction by a carcinoma in the colon, leading to pneumoperitoneum.

Differential diagnosis:

Pneumoperitoneum caused by a perforated peptic ulcer; however, the other findings make this very unlikely.

Management:

Urgently contact referring physician / general surgeon on call and alert of findings. This case would require emergency laparotomy.