Findings and interpretation:

• There are ill defined ground-glass centrilobular nodules in both lungs with a generalised distribution.
• There are a few mildly enlarged mediastinal lymph nodes.
• There is mild nodular pleural thickening in the left hemithorax.

Pertinent negative findings:

• No areas of consolidation in the lungs.
• No pleural effusions.

The findings represent acute inflammation of the lungs at the bronchiolar level.

Principal diagnosis:

Sub-acute hypersensitivity pneumonitis

Differential diagnosis:

• Respiratory bronchiolitis – interstitial lung disease (this typically shows sparing of the lower lungs and bases)
• Infectious bronchiolitis

Management:

Review clinical notes for history of possible exposure to organic allergen/ history of smoking.

Refer to respiratory physician for further management.

Findings and interpretation:

• The thalami are hypo-attenuating and enlarged in size bilaterally indicating parenchymal infarction, with compression of the third ventricle by mass effect and causing obstructive hydrocephalus at that level with dilatation of the lateral ventricles.
• Generalised sulcal effacement indicating brain edema.
• Hyper-attenuation of the deep cerebral veins, vein of Galen and straight sinus, indicating venous sinus thrombosis.

The findings indicate venous infarction of the thalami caused by thrombosis of the deep cerebral veins.

Principal Diagnosis:

Deep cerebral venous thrombosis with bilateral thalamic infarction

Differential diagnosis:

None

Management:

Urgently alert referring medical team and inform of diagnosis.

Immediate administration of intravenous thrombolytic agents should be performed.

Findings and interpretation:

• There is an amorphous lesion in the body and trigone of the right lateral ventricle, appearing hyperintense on both T1 and T2 weighted images, and showing suppression on the T1 fat saturated images. These characteristics indicate that it contains material of a fatty nature.
• Foci showing the same signal characteristics are seen in the lateral ventricles, aqueduct of Sylvius and 4^th ventricle, within the subarachnoid space and insinuating into the cerebral and cerebellar sulci, and in the CSF cisterns including the pre-pontine cistern.
• There is dilatation of the lateral ventricles, most likely due to obstruction of the foramen of Monro by the material, leading to obstructive hydrocephaly and consequent T2 hyperintensity of the peri-ventricular white matter.
• There is midline shift to the left caused by disproportionate dilatation of the right lateral ventricle.

Pertinent negative findings:

• The lesion shows no enhancement on the post contrast images.
• There is no meningeal enhancement to suggest meningitis.

The lesion in the right lateral ventricle containing fatty material is a dermoid cyst, which appears to have ruptured causing dissemination of the fatty material throughout the CSF spaces; this has caused blockage of CSF flow, leading to obstructive hydrocephalus with consequent periventricular white matter gliosis and midline shift by mass effect of the dilated right lateral ventricle.

Principal diagnosis:

Ruptured intracranial dermoid cyst causing obstructive hydrocephalus.

Differential diagnosis:

• Intracranial lipoma; may contain calcifications; rupture is extremely rare.
• Teratoma; rupture is extremely rare.

Management:

Alert referring physician of findings.

Recommend urgent neurosurgery referral for CSF shunting.

Findings and interpretation:

Knee radiograph:

• There is a well defined, eccentric bony lesion in the proximal tibial metaphysis with a narrow zone of transition and a sclerotic border. However, there is ill-defined sclerosis at the superior margin of the lesion.
• Pertinent negative findings: There is no periosteal reaction adjacent to the lesion. No bony destruction.

MRI:

• The well defined bony lesion is surrounded by dense cortical bone with T2 hyperintensity in the central component.
• Immediately superior to this lesion there is thickening of the cortex with periosteal reaction. There is a central, small, well defined round lesion in the thickened cortex, which is hyperintense on T2. In the surrounding bone there is significant STIR hyperintense signal.

Pertinent negative findings:

• No soft tissue mass. No cortical/bony destruction.

The findings represent two bone lesions, both of which are non-malignant. One of these lesions is causing inflammation and edema in the bone.

Principal diagnosis:

Non-ossifying fibroma and osteoid osteoma

Differential diagnosis:

• Stress fracture (however, the finding of a nidus is strongly suggestive of osteoid osteoma)

Management:

Alert referring physician of findings.

Recommend radiofrequency ablation of osteoid osteoma.

No management is required for the non-ossifying fibroma.

Findings and interpretation:

Radiograph:

• There are marginal erosions at the articular surfaces of the 2^nd and 3^rd metacarpo-phalangeal joints, at the radial side; there are also erosions a the ulnar head and styloid, and triquetrum.
• There is joint space narrowing at the radiocarpal joint, and 2^nd, 3^rd and 4^th PIP joints with hypertrophic osteophytosis.
• There are Boutonniere deformities of the 3^rd and 4^th digits- flexion of the PIP joints and extension of the DIP joints.

HRCT:

• There is lower lobe, peripheral and basal predominant ground glass opacification which is bilateral and symmetrical.
• There is traction bronchiectasis in the lower lobes of both lungs.
• There is minimal reticulation in the affected areas of the lungs, and single cyst in the right lung base.

Pertinent negative findings:

• There is no honeycombing.

Incidental:

• There is a metallic object in the right lower lobe and clips at the right hilum, indicating a prior thoracic surgical intervention.

Principal diagnosis:

Rheumatoid arthritis and rheumatoid arthritis – associated interstitial lung disease (RA-ILD), presenting in a cellular NSIP (non-specific interstitial pneumonia) pattern.

Differential diagnosis:

• SLE arthritis – typically arthritis is not erosive.
• Systemic sclerosis / scleroderma – arthritis may resemble RA but typically there are other features such as calcinosis and acro-asteolysis.

Management:

Compare with previous imaging to assess progression.

Recommend discussion at rheumatoid and pulmonary MDT regarding further management.

Findings and interpretation:

• There is extensive scrotal oedema and fluid around the testes; there is also subcutaneous oedema at the anterior pelvis and around the left groin.
• There are foci of gas amid soft tissue density in the lumina of the left external iliac and common femoral vein, and no enhancement in these venous segments on the post-contrast images indicating deep venous thrombosis.
• There is a saccular structure extending from the left common femoral artery, which shows the same post contrast enhancement as the artery on all post-contrast phases; this represents a pseudo-aneurysm.
• The lower left common femoral vein, superficial femoral vein and profunda show the same post contrast enhancement as the adjacent arteries.

Pertinent negative findings:

• There is no free active contrast extravasation.

The findings represent arterial injury resulting in a pseudo-aneurysm arising from the left CFA in addition to an arteriovenous fistula between the CFA and CFV; the likely cause is prior large bore catheter insertion into the CFV. This has also caused DVT of the left CFV and external iliac vein.   

Principal diagnosis:

Iatrogenic arterial injury causing left arterio-venous fistula between the CFA and CFV, and pseudo-aneurysm formation. DVT also resulted from the same procedure, in which a catheter was inserted into the left CFV and external iliac veins.

Differential diagnosis:

• Traumatic injury to the left groin vessels rather than iatrogenic.

Management:

Refer to vascular surgery urgently for further management, which will likely be surgical rather than endovascular.