Findings and interpretation:

• There are multiple, large masses of heterogeneous density in the abdomen and pelvis, located in the mesentery as well as on the hepatic capsule and within the liver parenchyma. These masses are heterogeneously enhancing.
• The largest masses are found in the pelvis, where the ovaries cannot be identified separately from the masses.
• There are filling defects in the right main pulmonary artery, as well as the second and third order arteries on the right and the left lower lobe pulmonary artery.
• There is retroperitoneal lymphadenopathy.
• There is a wedge shaped area of consolidation in the left lower lobe of the lung posteriorly.

Pertinent negative findings: No bony lesions suspicious for bone metastases.

The findings represent a malignant, metastatic process that is likely arising from the ovaries. There is pulmonary embolism, which is likely precipitated by the abdomino-pelvic malignancy, with a resultant pulmonary infarct in the left lower lobe.

Principal diagnosis:

Metastatic carcinoma of the ovaries

Pulmonary embolism, likely caused by paraneoplastic pro-thrombotic state

Differential diagnosis:

• Metastases to ovaries, peritoneum and liver from unknown primary (this is highly unlikely as the pattern of spread and radiological findings are characteristic of ovarian cancer)

Management:

Urgently contact referring physician and inform of the finding of pulmonary embolism.

Refer for gynaecology MDT discussion regarding image guided biopsy of one of the neoplastic masses for tissue diagnosis, as well as referral to the appropriate specialist centre for further management.

Findings and interpretation:

• There is free air and fluid in the peritoneal cavity. There are foci of extraluminal air surrounding the first part of the duodenum.
• The walls of the first part of the duodenum are thickened, with a focal defect seen posteriorly.
• There is sigmoid and descending colonic diverticulosis.
• Enhancing peritoneal lining, noted in the perihepatic region.
• There are multifocal segments of small bowel wall thickening.
• There is a nasogastric tube in situ, which is improperly positioned with the tip coiled in the oesophagus. 
• Bilateral pleural effusions.

Pertinent negative findings:

• No other focal pathology in the small or large bowel to account for bowel perforation, such as diverticulitis or obstructing bowel mass.

Incidental:

• Sigmoid and descending colonic diverticulosis.
• Non-obstructing left renal pelvis calculus and bilateral renal cysts.
• Left adrenal lesion.
• Hiatus hernia.

The findings represent bowel perforation, with bowel contents including gas seen in the peritoneal cavity. There is inflammatory change in the first part of the duodenum, associated with a duodenal ulcer.

Peritoneal inflammation indicating chemical peritonitis.

Small bowel inflammation is likely caused by gastric contents in the peritoneal space.

Principal diagnosis:

Perforated ulcer of the first part of the duodenum

Differential diagnosis:

None

Management:

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

Findings and interpretation:

• Bilateral symmetric generalised patchy T2 and STIR hyperintensity of the muscles of the proximal lower limbs.
• Patchy post contrast enhancement of the previously mentioned muscles.

Pertinent negative findings:

• There is no involvement of the subcutaneous fat or skin.
• No superficial tissue calcifications.

There is a systemic inflammatory myopathy with involvement of the proximal lower extremities.

Principal diagnosis:

Polymyositis

Differential diagnosis:

• Dermatomyositis (however, there is no involvement of the skin/ superficial tissues and no calcifications)
• Focal myositis (however it is a diffuse symmetrical process)

Management:

Alert referring physician of findings.

Investigate for associated connective tissue diseases or malignancy (as this may be a paraneoplastic process). However, this is extremely unlikely given the age of the patient.

Refer for rheumatology MDT with regards to treatment options / further investigations.

End stage pulmonary sarcoidosis

Chest radiograph

• There are widespread reticulonodular opacities in both lungs, with a slightly mid-zone predominant distribution.
• There are bi-apical and bibasal lung bullae.
• There is an endotracheal tube in situ; this is in adequate position in the mid-trachea.
• There is a central line in situ; this is in adequate position with the tip in the right atrium.
• There is a nasogastric tube in situ; this is in adequate position with the tip within the stomach.

CT:

• Large regions of both lungs are replaced by thin walled cysts and fibrotic bands, involving the apical, subpleural, peribronchovascular, and basal regions in a bilateral, symmetrical fashion.
• The upper regions of the lung are more severely affected than the lower regions.
• Replacement of lung parenchyma with clusters of thin walled cysts is seen in the apices and bases, which is in keeping with a honeycombing pattern of lung fibrosis.
• There are a few scattered nodules in the lung parenchyma.

Pertinent negative findings:

• No mediastinal lymphadenopathy.
• Unremarkable appearance of the thoracic spine (upper zone lung fibrosis may be related to ankylosing spondylitis, which is not present).

The findings represent end stage fibrosis of the lungs, secondary to chronic interstitial disease

Principal diagnosis:

End stage pulmonary sarcoidosis

Differential diagnosis:

• Chronic hypersensitivity pneumonitis (typically less severe).

Management:

Recommend discussion at pulmonary MDT with regards to placement on lung transplant list.

Findings and interpretation:

Plain film:

• The lower lumbar vertebrae as well as the sacrum have unfused posterior bony elements. The bony spinal canal is widened.

MCUG:

• The bladder shows multiple diverticula.
• There is bilateral ureteric reflux; the distal ureters are dilated.

The findings represent a congenital malformation of the spine and spinal cord, with neurogenic impairment resulting in denervation of the bladder.

Diagnosis:

Spina bifida with neurogenic bladder

Differential diagnosis:

None

Management:

Recommend discussion at urology MDT with regards to further management.

Findings and interpretation:

• Multiple small nodules arising from the walls of the lateral ventricles, showing low signal intensity on the T2 and SWI images, and no enhancement on the post contrast images.
• Widespread patchy subcortical and cortical T2 and FLAIR signal hyperintensity involving the cerebral hemispheres bilaterally, again showing no enhancement

Pertinent negative findings:

• There is no third ventricle/ foramen of Monro mass.

The findings in the brain represent cortical and subcortical tubers, as well as subependymal hamartomas. These findings indicate a congenital neuro-ectodermal disorder.

Diagnosis:

Tuberous sclerosis

Differential diagnosis:

None

Management:

Periodic MRI brain (every 1 – 3 years) to monitor for pre-symptomatic sub-ependymal giant cell astrocytomas.

Periodic ultrasound scanning of the kidneys to monitor for lesions which may be renal cell carcinomas (although angiomyolipomas are much more common).

MDT discussion regarding management of active issues.