Visual EM

Imaging Findings of Small Bowel – Diverticulitis: A Case Report

Albert Zhou, MD^*, Sarah Bella, DO^*, and Amy Patwa, DO^*

DOI: https://doi.org/10.21980/J8F078 Issue 8:1 No ratings yet.

Bedside ultrasound was performed and showed thickened bowel wall (orange marker), fat enhancement (green marker), and phlegmonous structure with central echogenicity (yellow marker). Imaging of the abdomen and pelvis with CT showed marked wall thickening and inflammatory change involving a 7.0cm segment of the distal/terminal ileum suspicious for severe ileitis with phlegmon and microabscess on the coronal image (yellow arrow). Additonally, the transverse images show a small rim-enhancing focus within this region of inflammation measuring up to 1.4cm which could represent microabscess (yellow arrow). Diagnosis of diverticulitis by ultrasound is made by identifying the following findings: colon wall thicker than 5mm, fat enhancement, evidence of abscess, visualized diverticuli, air artifacts suggesting diverticuli, and tenderness with compression of the probe.6 Diagnosis of diverticulitis by CT is made by identifying the following findings: colonic wall thickening, pericolic fat stranding, abscess formation and enhancement of the colonic wall. Often, these signs are associated with an identifiable inflamed diverticulum.7

Abdominal/Gastroenterology Visual EM

Aortic Dissection Case Report

Chelsea Bunce, DO^*, Christopher Bryczkowski, MD^* and Mary Rometti, MD^*

DOI: https://doi.org/10.21980/J8964Z Issue 8:1 No ratings yet.

In transverse view, point-of-care ultrasound (POCUS) showed an anechoic circular true lumen (blue highlight) and half-circular anechoic false lumen (green highlight), separated by a near hyperechoic dissection flap (orange highlight) that pulsated with blood flow. When viewed in sagittal orientation, the anechoic true lumen (blue highlight) appears longitudinal, separated from the false lumen (green highlight) by a dissection flap (orange highlight). Stills showing the measurements of these dissections are also provided.

Cardiology/Vascular Visual EM

Electrocardiogram Abnormalities Following Diphenhydramine Ingestion: A Case Report

Patrick Bruss, MD^*, Christine Bowman, MD^* and Teagan Carroll, BS^*

DOI: https://doi.org/10.21980/J85H1P Issue 8:1 No ratings yet.

The blue arrow points to one of the terminal R waves in aVR, and the green arrow points to one of the large S waves in lead I, indicating right axis deviation. These findings are pathognomonic for sodium channel blockade. Due to the specific ECG findings and knowledge of diphenhydramine overdose, it was evident that these ECG findings were due to a cardiac sodium channel blockade. Sodium channels are essential within myocardial tissue to ensure the rapid upstroke of cardiac action potential, as well as rapid impulse conduction throughout cardiac tissue. Therefore, sodium channel blockers tend to exhibit significant dysrhythmic properties due to severe conduction disturbances.2 The blockage of the cardiac sodium channels appears as terminal R waves in aVR as well as terminal S waves in lead I due to delaying, and possibly blocking, the electrical conduction pathway of the heart. The orange arrows show resolution of terminal R wave in aVR and terminal S wave in lead I, after administration of sodium bicarbonate.

Toxicology Pediatrics Visual EM

Epilepsy Caused by Neurocysticercosis: A Case Report

Mary G McGoldrick, MD^*, Daniel Polvino, MD^* and Grant Wei, MD^*

DOI: https://doi.org/10.21980/J81P96 Issue 8:1 No ratings yet.

In our patient, two lesions were most notable on CT in the frontal and occipital lobes. The lesion in the left frontal lobe (blue circle) was an approximately 1.5 centimeter (cm) rounded area with rim enhancement and surrounding hypodensity, consistent with vasogenic edema. A similar sized low-density area in the left occipital lobe (red circle) was noted, with increased peripheral density at the 3 o’clock position representing calcification. There were no areas of apparent hemorrhage or midline shift. The final radiology report concluded there were multiple cystic lesions, one with surrounding vasogenic edema in the left frontal lobe.

Neurology Visual EM

$A Case of Community-Acquired Tuberculosis in an Infant Presenting with Pneumonia Refractory to Antibiotic Therapy 10$

A Case of Community-Acquired Tuberculosis in an Infant Presenting with Pneumonia Refractory to Antibiotic Therapy

Audra N Iness, MD^*, Andrea T Cruz, MD, MPH^{^}^†, Scott R Dorfman, MD^{^^} and Esther M Sampayo, MD, MPH^{^}

DOI: https://doi.org/10.21980/J8X07M Issue 8:1 No ratings yet.

Chest radiographs during the initial presentation at seven weeks of life demonstrated right lower lobe (RLL) air space opacity on both PA and lateral views, compatible with pneumonia (referenced by yellow and green arrows, respectively). Repeat chest radiograph performed 12 days after the initial imaging revealed persistent right lower lobe opacity and right hilar fullness, seen as an opacified projection off of the mediastinal border as compared with the prior image, concerning for lymphadenopathy (designated by the aqua arrow). On the third presentation, computed tomography (CT) of the chest with intravenous contrast found persistent right lower lobe consolidation, innumerable 2-3 mm nodules, and surrounding ground glass opacities. This is best visualized as scattered areas of hyperdensity in the lung parenchyma. Axial images confirmed the presence of right hilar as well as subcarinal lymphadenopathy (indicated by white and pink arrows, respectively). Magnetic resonance imaging (MRI) of the brain with IV contrast was performed which showed a punctate focus of enhancement in the left precentral sulcus compatible with a tuberculoma (denoted with red arrow).

Infectious Disease Pediatrics Visual EM

Electronic Cigarette or Vaping-Associated Lung Injury Case Report

Amy Chuang, DO^*, Lauren Bacon, MD^* and Anthony Lucero, MD^*

DOI: https://doi.org/10.21980/J8S65P Issue 8:1 No ratings yet.

The CT of the chest with contrast showed subcutaneous emphysema (green star), pneumomediastinum (yellow arrow), and pneumopericardium (purple asterix) without an identifiable tracheal tear. Extensive air was visualized as hypodense areas within the chest wall within the soft tissue. The image also detailed a hypodense area surrounding the heart consistent with pneumopericardium. No disruption of the trachea was present. Additionally, the CT of the chest also showed bilateral ground glass airspace opacities (red stars) with subpleural sparing that is consistent with EVALI findings.2,5 These specific findings have been seen in many of the EVALI cases.5 This image is interesting because there is extensive pneumomediastinum with no clearly identifiable cause. The imaging shows no esophageal or tracheal or lung injury, so it is important to note relevant information collected during interview regarding patient’s recent history of vaping THC, especially when establishing a differential diagnosis.

Respiratory Visual EM

Case Report of a Tongue-Type Calcaneal Fracture

Kylie T Callan, BS^*, Michael Head, BA^*, Gregg Pickett, EMT^{^} and Ronald Rivera, MD^*

DOI: https://doi.org/10.21980/J8NH11 Issue 8:1 No ratings yet.

Examination of the right ankle demonstrated a large deformity of the superior talus with bruising and blanching of the overlying skin in the area of the Achilles tendon (see images 2,3). The remaining bones of the foot were not tender to palpation and the foot was neurovascularly intact throughout with only mild numbness in the area of the tented skin. Completing the trauma exam, the patient had no signs of head injury and no midline spinal tenderness to palpation. Inspection of the remaining long bones and joints showed no other injuries. There were mild skin scrapes on the right flank from the fall. X-rays of the right foot and ankle showed a longitudinal fracture of the calcaneal tuberosity from the articular surface to the posterior surface (see red outline) with extension into the subtalar joint (blue lines) and roughly 1.8 cm displacement between the fracture segments (yellow double arrow). These findings represented a tongue-type calcaneal bone fracture.

Orthopedics Trauma Visual EM

Mushroom for Improvement Case Report: The Importance of Involving Mycologists

Gary Bhagat, MD^*, Marit Tweet, MD^{^} and Steven Aks, MD^{^}^†

DOI: https://doi.org/10.21980/J8ZW7W Issue 7:4 No ratings yet.

The mushroom displayed here is large and lacks any gills. Small puffball mushrooms can resemble young immature button top Amanita type mushrooms. Opening the Amanita mushroom should reveal apparent gills and quickly differentiate the two- -the puffball mushroom should have a white interior without gills.

Abdominal/Gastroenterology Toxicology Visual EM

A Case Report of a Man with Burning Arm and Leg Weakness

Carolina Ornelas-Dorian, MD^*and Paul Jhun, MD^*

DOI: https://doi.org/10.21980/J8V659 Issue 7:4 No ratings yet.

A non-contrast computed tomography (CT) of the head and neck was performed, followed by an MRI of the cervical spine. The CT demonstrated congenital narrowing of the cervical spinal canal, with posterior disc osteophyte complex and disc bulge at C3-4 and C4-5 (arrow). The T2-weighted MRI additionally demonstrated obliteration of the anterior and posterior subarachnoid space at the level of C3-C5, with associated patchy central cord signal abnormality (arrow).

Neurology Visual EM

Thigh Mass Case Report

Mary Rometti, MD^*and Christopher Bryczkowski, MD^*

DOI: https://doi.org/10.21980/J8QD3C Issue 7:4 No ratings yet.

Point-of-care ultrasound (POCUS) demonstrates a large, subcutaneous mass with areas of mixed echogenicity. The mass contains fluid-filled, anechoic areas with internal septations and absent doppler flow. The majority of the mass appears isoechoic to the surrounding tissues with a hyperechoic border. Computed tomography (CT) of his right thigh shows a 16 x 8.1 x 9.5 cm heterogenous, complex mass within his hamstring muscles, inferior to the femur. His lab work was significant for a white blood cell (WBC) of 17.3 (103/µL).

Visual EM Hematology/Oncology