Findings and interpretation:

• Both native kidneys are enlarged with innumerable simple cysts of varying sizes.
• There are innumerable well-defined hypodense lesions throughout the liver. These represent simple cysts.
• There is a renal graft in the right iliac fossa; there are hypo-enhancing lesions at the medial aspect of the renal graft, some of which expand past the renal border and alter the contour of the renal graft.
• There are multiple significantly enlarged and enhancing inguinal, iliac, peri-aortic and aorto-caval, and coeliac group lymph node.
• There is mild splenomegaly.
• There is mild abdomino-pelvic free fluid and a minimal left pleural effusion.

The patient has a congenital condition causing cyst formation in the kidneys and liver. There is a lympho-proliferative disorder involving the renal transplant with nodal spread.

Principal diagnosis:

Post-transplant lymphoproliferative disorder involving the renal graft in a patient with autosomal dominant polycystic kidney disease.

Differential diagnosis:

• Nephronia of the renal graft and unrelated lymphadenopathy

Management:

Alert referring physician of findings.

Recommend biopsy of renal graft and / or lymph nodes.    

Findings and interpretation:

CT chest / HRCT:

• The heart lies on the right side of the chest, indicating dextrocardia. The thoracic aorta is right sided. The abdominal organs are also inverted from left to right, showing total transposition of the thoracic and abdominal viscera / situs inversus.
• There are segmental centrilobular nodules in a tree-in-bud configuration in the lower lung zones bilaterally, which indicates endobronchial spread of infection.
• There is minor sub-segmental atelectasis in the lower aspect of the right upper lobe adjacent to the mediastinum.
• There is a minor degree of bronchiectasis in the right lower lung zones.

CT paranasal sinuses:

• The right maxillary sinus is completely occupied by soft tissue, which protrudes through the ostium into the nasal cavity, representing a polyp. There is circumferential mucosal thickening in the left maxillary sinus with an air-fluid level, indicating acute on chronic sinusitis.
• There is opacification of the ethmoid sinuses; the sphenoid sinuses show circumferential mucosal thickening. The nasal turbinates are hypertrophied.

The findings indicate congenital situs inversus totalis due to primary ciliary dyskinesia / Kartagener’s syndrome; this is complicated by infectious bronchiolitis. 

There is also acute on chronic inflammation of the paranasal sinuses and sino-nasal polyposis.

Principal diagnosis:

Kartagener’s syndrome causing infectious bronchiolitis in the lungs and acute on chronic pan-sinusitis and sino-nasal polyposis in the paranasal sinuses.

Differential diagnosis:

None.

Management:

Alert referring physician and recommend referral to respiratory medicine for treatment of acute infection.

Findings and interpretation:

• The left globe protrudes anteriorly, indicating proptosis.
• There is a well circumscribed soft tissue lesion within the lateral intraconal compartment of the left orbit.
• The lesion shows peripheral enhancement on the arterial phase, with gradually increasing and spreading enhancement on the venous phase.
• The mass is exerting mass effect on and displacing the extra-ocular muscles and orbital nerve.

Pertinent negative findings:

• There is no invasion of the surrounding structures; no bony remodelling.
• The contralateral orbit is normal.

The findings represent a non-aggressive lesion with vascular characteristics.

Principal diagnosis:

Left orbital cavernous haemangioma.

Differential diagnosis:

• Orbital lymphoma
• Orbital metastasis

Management:

Recommend referral to ophthalmic surgery for likely surgical resection.  

Findings and interpretation:

• There is a large, ill defined, mostly homogeneous anterior mediastinal mass of soft tissue density, which shows relatively uniform post-contrast enhancement. The mass invades surrounding structures such as the left lung, left main pulmonary artery and left brachiocephalic vein.
• The left main pulmonary artery is compressed by mass effect and contains a filling defect within representing a tumour thrombus; the left main bronchus is also stenosed by mass effect.
• The left pulmonary arterial tree shows occlusion / infiltration of the 2^nd and 3^rd order arteries in the upper and middle lung distribution by the invasive mass.
• There is a large, cavitating lesion in the cranial aspect of the left lower lobe, which shows thick walls and debris within. There is a smaller cavity with similar characteristics in the apex of the left lung.

Pertinent negative findings:

• The mass does not contain fat or calcifications.

There is a malignant, invasive anterior mediastinal mass that is invading and compromising the pulmonary arterial supply to the left lung, resulting in tumour thrombus with pulmonary embolism and causing pulmonary infarcts.

Principal diagnosis:

Anterior mediastinal lymphoma causing tumour thrombosis in the left pulmonary artery with resultant pulmonary embolism and pulmonary infarcts.  

Differential diagnosis:

• Thymic carcinoma
• Sarcoma

Management:

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

Recommend core biopsy of the mass for histological diagnosis.  

Findings and interpretation:

• There is a small postero-superior spur at the calcaneum, which shows high PD signal intensity indicating osteitis.
• There is also high PD signal within the Achilles tendon, indicating insertional achilles tendinopathy
• There is high PD signal at the angle between the Achilles tendon and the superior surface of the calcaneum, indicating retrocalcaneal bursitis.
• There is high PD signal intensity at the anterior talo-fibular ligament, indicating partial sprain or tear.

The findings represent inflammation centred at the insertion of the Achilles tendon, likely caused by the calcaneal exostosis (Haglund deformity).

Principal diagnosis:

Haglund syndrome.

Differential diagnosis:

Achilles tendinopathy / bursitis without other features.

Management:

Alert referring physician of findings and recommend orthopaedic referral.  

Findings and interpretation:

CT:

• There is a large area of soft tissue opacification occupying the left maxillary, ethmoid and sphenoid sinuses as well as most of the left nasal cavity; the soft issue is causing expansion of the involved sinuses and alternating sclerosis and thinning of the involved bony walls. The maxillary ostium is widened and the medial wall eroded as the soft tissue infiltrates the left nasal cavity and engulfs the middle turbinate.
• There is markedly hyperdense material within the soft tissue, particularly at the ethmoid and sphenoid sinuses.

MRI:

• There is high T2 circumferential peripheral mucosal thickening in the left maxillary sinus, which enhances on the post contrast images; however, there is material of lower T2 signal intensity inside the sinus which does not enhance.
• The soft tissue in the left ethmoid and sphenoid sinuses appears markedly low on T2 (almost signal void), while showing high T1 signal. This is characteristic of fungal material. It also shows no post-contrast enhancement.

Pertinent negative findings:

• The soft tissue shows no intracranial extension (into the dura). There is no extension into the orbits.

Incidental:

• There is mucosal thickening and marked sclerosis in the walls of the right maxillary sinus, indicating chronic sinusitis.

The findings represent a chronic sino-nasal infection, exhibiting the characteristics of fungal infection.

Principal diagnosis:

Chronic allergic fungal sinusitis.

Differential diagnosis:

• Invasive fungal sinusitis- however, there is no obvious intracranial extension extending past the dura mater.
• Sino-nasal carcinoma- however, the lesion does not show invasive / aggressive features.

Management:

Refer to ENT surgeon for further management; the management is typically surgical.