Case Report of a Pelvic Kidney with Ureteral Obstruction from Inguinal Hernia Entrapment and Concurrent Cryptorchid TestisDOI: https://doi.org/10.21980/J8F345
The patient was afebrile with normal lactate and white blood cell count. Initial CT imaging showed an ectopic right pelvic kidney with entrapment of his right ureter within an indirect right inguinal hernia causing severe hydronephrosis (coronal: white arrow). Also discovered was an ovoid hypodensity in the right anterior pelvis consistent with right undescended testis (axial: orange arrow; coronal: green arrow) that was previously unknown to the patient, with a normal left scrotal testis (axial: red arrowhead; coronal: blue arrowhead). Other potential etiologies of the patient’s symptoms could include appendicitis or incarcerated inguinal hernia, though the imaging results and absence of systemic inflammatory response syndrome made these causes less likely.
Computerized tomography with angiography (CTA) of the entire aorta demonstrated an occluded distal infrarenal aorta with extension into the bilateral common femoral arteries (red outline), lack of flow through femoral arteries (yellow outline) and trickle flow reconstituted distally consistent with aortoiliac occlusive disease (blue outline). Some small segments of the proximal celiac axis showed signs of occlusion (purple outline). A short segment of non-specific bowel wall thickening, which may have been related to ischemic changes, was also seen (not seen on images). The included coronal slice shows the extent of the bilateral occlusive burden, with three-dimensional reconstruction emphasizing the same findings.
The CT imaging of the abdomen and pelvis demonstrated multiple loops of dilated small bowel with a whirl sign (red arrow) within the mid abdomen and a transition point (green arrow), suspicious for closed loop bowel obstruction and internal hernia.
A focused assessment with sonography in trauma (FAST) exam was performed initially to evaluate for intra-abdominal injury given the clinical picture. A phased-array ultrasound transducer was placed in sagittal orientation along the patient’s right and left flank, demonstrating extensive heterogenous fluid collections in Morrison’s pouch (red arrow), subphrenic space (solid green arrow), and splenorenal recess (dashed green arrow). To further evaluate, a phased-array transducer was placed over her pelvic area in transverse orientation, demonstrating, a large, heterogeneous mass (outlined in yellow arrows). The surgical team was promptly consulted and blood products were ordered. Although there was concern for impending hemorrhagic shock due to patient’s presenting tachycardia, the patient was hemodynamically stable enough for a CT scan of her chest, abdomen, and pelvis. The CT scan showed large-volume ascites, which exerted mass effect on all abdominal organs with centralization of bowel loops. Additionally, there was a large, 6.4 x 6.8 x 10.9-centimeter, midline pelvic mass (outlined in blue arrows).
A Case Report of Aortic Dissection Involving the Aortic Root, Left Common Carotid Artery, and Iliac ArteriesDOI: https://doi.org/10.21980/J8V93K
Computed tomography angiography (CTA) of the thoracic and abdominal aorta revealed an aortic dissection of the ascending aorta, with a dissection flap starting from the aortic root/aortic annulus (yellow arrows), extending into the aortic arch (light blue arrowhead) and involving the left common carotid artery (purple arrow), left subclavian artery (pink arrow), extending to the descending aorta (red arrows), and into the bilateral iliacs (green arrows). The true lumen (red star) and false lumen (blue star) created by the dissection flap can best be seen in the axial views.
At the time of presentation to the ED, laboratory results were significant for leukocytosis to 11.8 x 109 white blood cells/L and a partial pressure of carbon dioxide of 52 mmHg on venous blood gas. Computed tomography (CT) of the soft tissue of the neck with contrast showed edematous swelling of the epiglottis and aryepiglottic fold with internal foci of gas (blue arrow) and partial effacement of the laryngopharyngeal airway and scattered cervical lymph nodes bilaterally (Figure 1). Findings were consistent with epiglottitis containing nonspecific air. Additionally, the pathognomonic “thumbprint sign” (yellow arrow) was found on lateral x-ray of the neck (Figure 2). The CT findings as shown in figure 3 illustrate lateral view of the swelling of the epiglottis, gas, and blockage of the airway.
ABSTRACT: A 39-year-old previously healthy male presented with three days of right eye pressure and one day of binocular diplopia. He denied history of trauma, headache, or other neurological complaints. He had normal visual acuity, normal intraocular pressure, intact convergence, and no afferent pupillary defect. His neurologic examination was non-focal except for an inability to adduct the right eye past midline
While still in the ED, MRI with and without gadolinium contrast of the brain, orbits, and cervical, thoracic and lumbar spine were obtained to evaluate for possible CNS lesions including encephalitis, myelitis, or demyelination. Imaging, however, demonstrated multiple unexpected findings: a T1 hypointense, T2 hyperintense and heterogeneously enhancing right adrenal mass measuring 2.7 x 2.1 x 3 cm (yellow asterisk) along with heterogenous enhancement at the clivus, C6, C7, T7, T8, T12, and L3 vertebral bodies (red asterisks). There were otherwise no significant intracranial signal or structural abnormalities and normal orbits.
Episodic tender, warm, erythematous swelling of the extremity experienced by this patient is typical of erythromelalgia. Erythematous streaking on the volar surface of the left forearm (red arrow) and tender, warm, erythematous blanching swelling was present on the palmar hand (yellow arrow). Most patients with erythromelalgia also have lower extremity involvement including the dorsum or sole of the foot and toes.1
Spontaneous Coronary Artery Dissection Causing Cardiac Arrest in a Post-Partum Patient – A Case ReportDOI: https://doi.org/10.21980/J8F947
A post-ROSC electrocardiogram revealed ST elevations in leads I, aVL, and V3-V6, with reciprocal ST depressions in leads II, III, and aVF. Initial troponin I level was 0.238 ng/mL and a bedside cardiac ultrasound revealed decreased motion of the anterior wall. Cardiology was consulted and the patient was immediately taken to the catheterization lab where she was found to have long and diffuse luminal narrowing of her distal left anterior descending artery (LAD) resulting in 70% stenosis, consistent with the angiographic appearance of an intramural hematoma caused by dissection (white arrows). No intervention was performed.