Findings and interpretation:

US:

• There is prominent echogenicity along the caudo-thalamic grooves bilaterally. No associated ventriculomegaly.

CT:

• The caudothalamic groove echogenicity is seen as blood hyperdensity on CT.
• Mild hydrocephalus is noted on the CT
• There is extension of blood hyperdensity into the left occipital lobe.
• There are bilateral, confluent regions of parenchymal hypodensity.

The findings represent germinal matrix haemorrhage due to prematurity, complicated by venous parenchymal brain infarcts.

Principal diagnosis:

Grade IV germinal matrix haemorrhage

Differential diagnosis:

None

Management:

Urgently alert referring physician of diagnosis.

The baby should be managed in the neonatal intensive care unit.

Findings and interpretation:

• There are dilated small bowel loops in the lower abdomen, with a calcified, laminated object in the lumen of one of the dilated loops.
• There is air in the extrahepatic and central intrahepatic bile ducts, indicating pneumobilia. Air is also seen in the gallbladder lumen.
• The gallbladder is contracted with thickened walls. It appears adherent to the adjacent segment of duodenum.

Incidental findings:

• There is relative hypertrophy of the left lobe of the liver, with irregular liver margins, indicating cirrhosis.
• There are esophageal / gastric varices, indicating portal venous hypertension caused by liver cirrhosis.

The findings represent chronic inflammation of the gallbladder with a cholecysto-duodenal fistula, and passage of a large gallstone through the fistula, followed by impaction of the gallstone in an ileal loop with resultant mechanical small bowel obstruction.  

Principal diagnosis:

Gallstone ileus

Differential diagnosis:

None

Management:

Alert referring physician of findings and recommend surgical consultation.  

Findings and interpretation:

Radiograph:

• There is nodular and confluent airspace opacification in a bilateral, midzone distribution.

CT:

• There is confluent consolidation in a generalised distribution throughout both lungs, although the consolidation becomes more patchy and subsegmental in some areas. This tends to spare the bases and apices.
• There are scattered cysts with thin walls within the areas of consolidation and the surrounding lung parenchyma.
• There are a few enlarged mediastinal lymph nodes.

MRI:

• There is confluent FLAIR and T2 hyperintensity in the deep and periventricular white matter of the cerebral hemispheres with a bilateral, symmetrical distribution. This extends to the internal and external capsules, basal ganglia, brainstem, and is also present in the middle cerebellar peduncles.
• The hyperintensity tends to spare the sub-cortical U fibres.
• There is a small lesion occupying the anterior left frontal lobe within the subcortical white matter, which shows high signal on both T1 and T2, with a hypointense rim on T2. On susceptibility weighted imaging the rim shows blooming artefact. This indicates subacute blood with a rim of haemosiderin deposition.
• There is blooming artefact in the basal ganglia on SWI indicating calcification.

Pertinent negative findings:

• There are no pleural effusions in the chest.
• There is no mass effect or mass occupying lesions in the brain.
• There is no diffusion restriction or contrast enhancement within the hyperintense abnormality in the brain.

Incidental findings:

• Gallstone in gallbladder neck.

The findings represent an inflammatory / infectious condition of the lung parenchyma as well as the cerebral white matter. There is also a subacute cerebral parenchymal haemorrhage.

Principal diagnosis:

HIV encephalopathy and pneumocystis pneumonia in an HIV-infected patient with AIDS.

Differential diagnosis:

Brain:

• Viral haemorrhagic encephalitis
• PML (progressive multifocal leukoencephalopathy)
• Toxic leukoencephalopathy

Chest:

• Other atypical pneumonia, such as viral / CMV pneumonia
• Lymphoid interstitial pneumonia

Management:

Alert referring physician of findings; recommend correlation with sputum culture and sensitivity / broncho-alveolar lavage with culture.

Recommend testing for HIV status of the patient if not already known.

Findings and interpretation:

• There is patchy T2 signal hyperintensity in multiple thoracic and lumbar spine vertebrae.
• There are sub-periosteal and paravertebral T2 hyperintense collections, extending over several consecutive vertebrae in the superior and inferior segments of the thoracic and thoraco-lumbar spine.
• At the superior thoracic spine level, the collections extend into the epidural space, to form a circumferential epidural collection which effaces the CSF space at that level and focally compresses the spinal cord.
• The collections show thick, nodular enhancing walls.
• There are multiple enlarged left cervical lymph nodes.
• There are multiple T2 hyperintense bi-apical lung lesions, which may represent focal areas of consolidation / interstitial thickening.
• There are bilateral, well defined, hyper-enhancing cerebello-pontine angle lesions which extend into the internal acoustic meatus on both sides.

Pertinent negative findings:

• There is relative sparing of the intervertebral discs with no spinal deformity.

The findings represent a multi-level spondylodiscitis, giving rise to adjacent abscesses, some of which extend into the epidural spinal space to form epidural abscesses. This is extending into the spinal canal and causing focal spinal cord compression.

Bilateral acoustic neuromas / schwannomas indicate a congenital disorder.  

Principal diagnosis:

Multi-system tuberculous infection with pulmonary, nodal and spinal involvement; the patient incidentally has neurofibromatosis type II

Differential diagnosis:

• A different causative organism is possible, such as brucellosis; however, this is extremely unlikely and does not explain the lung pathology

Management:

Review chest radiograph for evidence of post-primary pulmonary tuberculosis.

Urgently contact referring physician and inform of epidural abscess and spinal cord compression.

Recommend drainage of abscesses and collecting samples for culture and sensitivity.

Findings and interpretation:

• The PCL (posterior cruciate ligament) fibres are disrupted superiorly, up to the site of attachment to the femur; there is heterogeneous high signal (T2 and STIR) in this segment of the PCL. This indicates a complete thickness PCL tear.
• There is a supra-patellar knee joint effusion; this shows fat-fluid levels on the axial images. This indicates a lipohaemarthrosis.
• There is horizontal high signal running through the medial meniscus and extending to the posterior horn, indicating a radial tear.
• Both tibial plateaus are fractured with high STIR and low T1 signal, indicating oedema of the marrow.
• The fibres of the medial collateral ligament are disrupted, indicating MCL tear.

Pertinent negative findings:

• The anterior cruciate, as well as lateral collateral ligament are intact.
• The lateral meniscus is intact.

The findings indicate severe trauma to the knee with bony fractures and soft tissue injuries.  

Principal diagnosis:

Traumatic knee injury

Differential diagnosis:

None

Management:

Alert referring physician and recommend orthopaedic referral.

Findings and interpretation:

• There is a well-defined, solid mass of intermediate size, located within the left suprahyoid carotid space, and extending up to the skull base.
• The lower limit of the mass lies a short distance above the carotid bifurcation, and it displaces the carotid arteries and parapharyngeal space antero-medially. It displaces the internal jugular vein postero-laterally.
• The mass shows uniform, mostly homogeneous enhancement.

Negative findings:

• There are no vessels within the mass.
• There is no erosion / pressure effects on the adjacent bony structures.

The findings represent a benign neoplasm arising from the vagus nerve.

Principal diagnosis:

Vagal nerve schwannoma

Differential diagnosis:

• Glomus vagale paraganglioma (this is less likely as there are no internal vessels; more avid enhancement would be expected)
• Carotid body paraganglioma (this would typically be located at the carotid bifurcation and would cause splaying of the carotid arteries, which is not seen on this study)

Management:

Alert referring physician of findings and recommend further investigation by contrast enhanced MRI.

Refer for neurosurgical / maxillofacial surgery MDT discussion with regards to further management.