Findings and interpretation:

MRCP:

• The proximal segment of the CBD and the CHD are markedly dilated, down to a focal stricture at the level of the mid CBD.
• There is mural irregularity of some of the peripheral intrahepatic bile ducts, which demonstrate alternating segments of structuring, beading and mild dilatation.
• There are multiple rounded, focal intrahepatic lesions which show high T2 signal intensity, representing cystic structures.

CT:

• There is hepatomegaly.
• There are multiple rounded, non-enhancing, peripherally placed, branching lesions related to the bile ducts, with high density contents relative to simple fluid in the liver parenchyma; these represent cholangitic abscesses.
• The CBD at the mid-level (site of the stricture) shows mass-like mural thickening prior to its entry into the pancreatic head.
• The gallbladder is grossly distended.

Incidental findings:

• Simple right renal cyst.

The findings represent chronic inflammation of the bile ducts, resulting in biliary stasis leading to ascending cholangitis and the formation of multiple cholangitic hepatic abscesses. At the mid CBD there is a lesion with features highly suspicious for malignancy.

Principal diagnosis:

Primary sclerosing cholangitis complicated by ascending cholangitis and cholangiocarcinoma in the CBD.

Differential diagnosis:

The intrahepatic lesions may represent metastases- however the cystic appearance on MRI and branching configuration do not support this diagnosis.

The dilated CBD may resemble a choledochal cyst, or be caused by an inflammatory stricture; however, the stricture at the end of the dilated segment shows mass-like thickening which is much more in keeping with a neoplastic process.

Management:

Contact referring physician; recommend urgent biliary stenting by ERCP for biliary decompression, as well as biopsy / FNAC by EUS of the CBD mass.  

Refer for hepato-biliary MDM discussion; the patient may be a candidate for a Whipple procedure after obtaining a pathological diagnosis.    

Angio-invasive aspergillosis

Findings and interpretation:

• There are clustered pulmonary nodules in the lungs bilaterally, more numerous and larger on the right; these follow a random pattern of distribution and lower lung zone predominance.
• Some of the larger nodules show a surrounding ground-glass halo, which reflects haemorrhage around the nodule.
• There are bilateral mediastinal and hilar surgical clips, indicating prior bilateral pulmonary transplantation.
• There are a few pre-tracheal lymph nodes which do not exceed 1cm in the short axis; these show a non-specific appearance and are likely reactive in nature.
• The pancreas is completely replaced by fatty tissue, indicating complete pancreatic lipomatosis.

Pertinent negative findings:

• There are no grossly enlarged mediastinal lymph nodes.
• No discrete areas of ground glass opacification / mosaic pattern.

The findings indicate opportunistic infection in the setting of lung transplantation. Pancreatic lipomatosis indicates that the patient suffers from cystic fibrosis.

Principal diagnosis:

Angio-invasive aspergillosis complicating lung transplantation in a patient with cystic fibrosis.

Differential diagnosis:

• Other opportunistic infection such as CMV / mucormycosis.
• Post transplant lympho-proliferative disorder.
• Wegener’s granulomatosis (this is highly unlikely in the context of lung transplantation).

Management:

Urgently alert referring physician of findings to start treatment.

Refer to pulmonary MDM to discuss further investigations to confirm diagnosis, such as bronchio-alveolar lavage or CT guided biopsy for histological diagnosis.

T-cell lymphoma complicating coeliac disease

Findings and interpretation:

• There is marked circumferential, nodular thickening of the wall of a short segment of ileum. The involved segment of bowel shows aneurysmal dilatation with oral contrast media within.
• There are multiple enlarged lymph nodes in the ileal mesentery adjacent to the abnormal ileal segment. These exceed 1cm in short axis diameter and show loss of the normal reniform shape / fatty hilum. Smaller lymph nodes are detected more cranially at the root of the mesentery.
• There is a reduced number of jejunal folds, with an increased number of ileal folds, indicated reversal of the jejuno-ileal fold pattern.

Pertinent negative findings:

• There is no bowel obstruction / small bowel dilatation.
• There is no evidence of metastatic spread to the liver / lungs / distant lymph node groups.

Incidental:

• Subcapsular hypodense segment IVA lesion most likely reflects focal fatty sparing.

The findings represent a malignant neoplasm arising from the ileum. Reversal of the small bowel fold pattern is characteristic of coeliac disease. The enlarged mesenteric lymph nodes most likely indicates spread of malignancy from the small bowel rather than a manifestation of coeliac disease.  

Principal diagnosis:

T-cell lymphoma of the small bowel on a background of coeliac disease.

Differential diagnosis:

• Gastro-intestinal stromal tumour (this is far less likely, as it is not associated with coeliac disease).

Management:

Alert referring physician of findings.

Recommend discussion at oncology / gastrointestinal MDT with regards to image guided biopsy / further management by chemotherapy.

Cerebral arteriovenous malformation

Findings and interpretation:

CT brain:

• There are superficial tubular structures in the right temporal lobe, which are hyperdense compared to normal brain parenchyma.

MRI brain:

• There is a large cluster of extra-axial serpiginous structures overlying the right temporal lobe, replacing part of the brain parenchyma in that region.
• These structures show flow void on the T2 images, and vascular flow on the time of flight sequence.
• Arterial phase post-contrast sequence shows communication with the intracranial arteries emanating from the circle of Willis on the right side.
• Enlarged superficial cortical veins drain into the superior sagittal sinus and the right transverse sinus.   

Pertinent negative findings:

• No evidence of acute / previous haemorrhage.

The findings represent a cluster of abnormal vessels with arterial and venous components, draining into superficial cortical veins.

Principal diagnosis:

Cerebral arterio-venous malformation.

Differential diagnosis:

None

Management:

Refer to interventional neuro-radiologist for conventional angiography, and possible endovascular embolisation.

Lymphangioleiomyomatosis

Findings and interpretation:

Chest radiograph:

• The lung volumes are increased bilaterally.
• There are diffuse reticular opacities in both lungs.

CT thorax:

• There are diffuse small sized, thin walled cysts in a generalized distribution in the lungs bilaterally.
• The cysts are spherical and of similar shape and size.
• There is a minor degree of lung scarring the right upper lobe.

Pertinent negative findings:

• No nodules / pleural effusions / septal thickening in the lungs. No pneumothorax.
• The visualized upper portions of the kidneys are normal with no fatty masses detected.

The findings represent an interstitial, cyst forming disease of the lung.

Principal diagnosis:

Lymphangioleiomyomatosis

Differential diagnosis:

• Tuberous sclerosis complex (unlikely as the upper poles of the kidney do not show angiomyolipomas)
• Langerhans cell histiocytosis (unlikely as this entity typically shows irregular cysts of varying sizes, upper lobe predominance and pulmonary nodules)

Management:

Alert physician of findings and recommend respiratory physician referral.

Obtain complete imaging study of the kidneys to rule out tuberous sclerosis complex (CT abdomen/pelvis or ultrasound).

Recommend discussion at pulmonary MDT with regards to further management / confirming diagnosis by tissue biopsy.

Myelofibrosis complicated by portal vein thrombosis

Findings and interpretation:

• There is no contrast opacification of the portal vein or its main branches; multiple small peri-portal vessels are present.
• There is marked splenomegaly with retroperitoneal varices.
• There is a moderate amount of free fluid around the liver and spleen, in the pelvis and in the mesentery.
• There is increased bone density of all visualised bones, indicating diffuse osteosclerosis.

Pertinent negative findings:

• No enlarged lymph nodes.
• No liver disease.

Incidental:

• Chronic cholecystitis with cholelithiasis.

The findings represent portal venous thrombosis with cavernous transformation, which is causing ascites. Marked splenomegaly and diffuse osteosclerosis are characteristic of myelofibrosis. This condition causes a hypercoagulable state, predisposing to portal vein thrombosis.  

Principal diagnosis:

Myelofibrosis causing portal vein thrombosis.

Differential diagnosis:

• Sclerotic metastases
• Lymphoma causing splenomegaly

Management:

Alert referring physician of findings.

Refer for haematology MDM to discuss further management / treatment options.