Findings and interpretation:

• The appendix is grossly thickened with hyper-enhancement of the walls. There is peri-appendiceal fat stranding. It lies in a retrocaecal position.
• Both kidneys are enlarged with innumerable cysts of varying sizes.
• There are innumerable well-defined hypodense lesions throughout the liver. These represent simple cysts.

Pertinent negative findings:

• There is no evidence of appendiceal perforation.
• All kidney cysts are simple, with no soft tissue masses / thickened, enhancing septae.

Incidental findings:

• Surgical clips in gallbladder bed with absent gallbladder indicates previous cholecystectomy.

Acute inflammation of the appendix in a patient with a congenital condition causing cyst formation in the kidneys and liver.

Principal diagnosis:

Acute appendicitis in a patient with autosomal dominant polycystic kidney disease

Differential diagnosis:

None

Management:

Urgently inform referring physician of appendicitis for surgical management.

Findings and interpretation:

• The left maxillary sinus is filled with fluid, appearing hyperintense on T2 and isointense on T1, with a small pocket of air in an anti-dependent position. The mucosal lining is enhancing on the post contrast images.
• There is an ill-defined, fungating mass arising within the base of the skull, centred on the clivus. The mass is markedly hyperintense on the T2 weighted images and iso-intense on T1.
• The mass extends into the pre-pontine cistern and exerts a modest degree of mass effect on the pons and midbrain, with minor displacement of the basilar artery. It also shows extension into the apex of the petrous bone and abuts the left internal carotid artery with no invasion.
• The mass shows heterogeneous enhancement on the post-contrast sequences.
• The mass exhibits modest diffusion restriction with somewhat bright signal on DWI and corresponding low ADC values.

The findings represent inflammation of the left maxillary sinus, which is responsible for the patient’s symptoms. Incidentally found is a midline, somewhat aggressive neoplastic bony mass, which appears to be slow growing.

Principal diagnosis:

Acute maxillary sinusitis with incidental clivus chordoma

Differential diagnosis:

Sinus:

• Mucocele
• Fungal sinusitis

Skull base lesion

• Giant cell tumour
• Chondrosarcoma

Management:

Recommend discussion at neurosurgery MDT regarding obtaining a biopsy and possible resection for the skull base lesion.

Findings and interpretation:

Chest radiograph:

• There is airspace opacification in the right lower and middle lung zones.
• There are no pleural effusions.

CT:

• There is widespread peribronchovascular and peripheral subpleural nodular consolidation in both lungs.
• There are patchy and randomly distributed areas of ground glass opacification.
• In the right lung base there are lesions of crescent shaped consolidation surrounding a central areas of ground glass opacification, showing the so-called ‘atoll sign’.

Pertinent negative findings:

• There are no significantly enlarged mediastinal lymph nodes/ pleural effusions.

Incidental:

• Incidentally noted left mastectomy.

There is chronic, migrating consolidation involving both lungs. It is likely auto-immune / cryptogenic in nature.

Principal diagnosis:

Cryptogenic organizing pneumonia

Differential diagnosis:

• Chronic eosinophilic pneumonia (usually more peripheral consolidation; no history of eosinophilia)
• Bronchopneumonia (no acute symptoms of infection; unusual distribution of disease for this diagnosis)
• Atypical and fungal lung infection

Management:

Alert the referring physician of findings and recommend corticosteroid administration.

Follow up imaging by HRCT to monitor response to treatment.

Multi-system Sarcoidosis

Findings and interpretation:

Feet radiograph:

• There is erosion of the tufts of the distal phalanges involving multiple toes bilaterally.
• There is severe erosive arthropathy of the PIP joint of the right third toe causing significant bony destruction and subluxation.
• There is subtle lace-like change in the left first toe distal phalanx.

Hands radiograph:

• There is erosion of the distal tuft of the distal phalanx of the right thumb, as well as severe erosive arthropathy of the DIP joint of the right thumb with bony debris and subluxation.
• There is peri-articular calcification at the DIP joint of the left thumb, with subtle bony lace-like change on both sides of the joint.
• There is dislocation of the PIP of the left fourth finger.
• There are multifocal lucencies in the hands bilaterally, bony remodelling of the right 4^th middle phalanx, and juxta-articular erosion at the right 4^th metacarpo-phalangeal joint.

MRI brain:

• There are FLAIR and T2 patchy hyper-intensities within the deep and sub-cortical white matter.
• There is marked, diffuse, nodular pachy and lepto-meningeal thickening; this shows avid enhancement on the post-contrast sequences.

Pertinent negative findings:

Hands and feet:

• No osteopaenia.

Brain:

• Relative sparing of the pituitary gland and hypothalamus, as well as the mid-brain / cranial nerves.

The constellation of findings represent a multi-system disease involving the CNS and musculoskeletal system, with the features of a granulomatous disease. This is causing white matter angiitis and active meningeal infiltration/inflammation in the CNS and erosive / destructive arthropathy in the hands and feet.  

Principal diagnosis:

Multi-system sarcoidosis

Differential diagnosis:

• Multi-system tuberculosis.
• Diffuse metastatic spread from unknown primary (this is extremely unlikely due to the pattern of disease and sites of involvement).

Management:

• Search for other sites of involvement, especially pulmonary; chest radiograph / CT chest may be performed.
• Gallium scan may be performed to search for active disease.
• Correlate with clinical/lab tests such as serum ACE; biopsy from an adequate site may be performed.
• Discuss at connective tissue disease MDM.

Findings and interpretation:

CT:

• There is hypoattenuation of the deep and subcortical white matter in the posterior parietal and occipital lobes bilaterally with a mostly symmetrical appearance. The hypoattenuation extends to the cortex in some areas, yet it is predominantly in the white matter.

MRI:

• There is confluent FLAIR and T2 signal hyperintensity in the same distribution seen on the CT scan, as well as multiple, small foci of signal hyperintensity in the corona radiata and periventricular white matter.
• The involved regions of the brain parenchyma do not show diffusion restriction.

Pertinent negative findings:

• There are no areas of diffusion restriction to suggest infarction.
• No associated parenchymal haemorrhage.

The findings represent vasogenic edema in a bilateral and almost symmetric distribution. The periventricular T2 hyperintense foci are probably sequelae of hypertension and small vessel ischemic disease.

Principal diagnosis:

Posterior reversible encephalopathy syndrome

Differential diagnosis:

• Hypoglycaemia
• Metabolic leukoencephalopathy

Management:

Alert referring physician of findings.

Recommend treatment of the underlying cause, which is typically hypertension.

Findings and interpretation:

Non-contrast brain CT:

• There is hyperdense material in the interpeduncular and suprasellar cisterns, extending into the 3^rd ventricle; this indicates subarachnoid haemorrhage.
• The 3^rd ventricle is dilated, as well as minimal dilatation of the lateral ventricles; this indicates obstructive hydrocephalus caused by the haemorrhage.

CT angiogram:

• There is a medium sized aneurysm of the basilar tip, at the site of the previously mentioned subarachnoid haemorrhage.
• There is also another similar sized aneurysm of the M1 segment of the right MCA, and a third smaller aneurysm at the right M1 bifurcation.

Pertinent negative findings:

• No active extravasation from the basilar tip aneurysm on the angiogram.
• No intraparenchymal haemorrhage.

The findings represent subarachnoid haemorrhage caused by a ruptured basilar tip aneurysm, in a patient with multiple intracranial aneurysms.

Principal diagnosis:

Aneurysmal subarachnoid haemorrhage.

Differential diagnosis:

None.

Management:

Immediately alert referring physician of findings.

Recommend neuro-interventional referral for possibility of endovascular management of the aneurysms by coil embolisation.

Findings and interpretation:

CT:

• There is nodular, marked, circumferential pleural thickening on the right side, with similar marked thickening of the pleural fissures. This appears to be encasing the right lung.
• There is significant volume loss of the right lung.
• There is a moderate right sided pleural effusion.
• There are multiple hypodense splenic lesions.

Pertinent negative findings:

• There is no mediastinal lymphadenopathy.
• There are no calcified pleural plaques.

The findings represent a malignant process originating from the pleural, with probable splenic metastases.

Principal diagnosis:

Pleural mesothelioma

Differential diagnosis:

• Pleural metastases from unknown primary (this is highly unlikely)

Management:

Alert referring physician of diagnosis.

Refer for discussion at pulmonary MDT to discuss further imaging (staging abdomen pelvis CT) and image guided biopsy of the pleura and splenic lesions.