CT

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Achalasia: An Uncommon Presentation with Classic Imaging

Joseph Adamson, BS*, Mina Altwail, MD^ and Shanna Jones, MD^

DOI: https://doi.org/10.21980/J86D2BIssue 3:3[mrp_rating_result]
The chest X-ray demonstrated a markedly widened mediastinum (red brackets), raising concern for thoracic aortic aneurysm/aortic dissection, which prompted labs and contrast-enhanced computed tomography (CT) of the chest. The CT revealed a dilated proximal esophagus that narrowed distally (yellow tracing and red arrow), with particulate material, mass-effect on the trachea (purple outline), and bilateral patchy opacities suggesting aspiration. Barium esophagram showed a drastically dilated esophagus filled with contrast (yellow arrow), terminating into the classic “bird’s beak sign” (red arrow) at the lower esophageal sphincter (LES). Esophageal manometry later confirmed achalasia, proving that widened mediastina can have unexpected etiologies.
Abdominal/GastroenterologyVisual EM
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An Unusual Case of Pharyngitis: Herpes Zoster of Cranial Nerves 9, 10, C2, C3 Mimicking a Tumor

Jason Cheng, DO*, Gregory Reinhold, DO* and Rahmon Zuckerman, DO*

DOI: https://doi.org/10.21980/J8B05K Issue 3:2[mrp_rating_result]
On exam, the patient was sitting upright while holding an emesis basin filled with saliva. His voice was noticeably hoarse. Examination of the head and neck revealed vesicular eruptions on the left scalp in the V1 dermatome and on the left mastoid process (Images 1 and 2). Physical exam also shows vesicular eruptions on the left posterior oropharynx that did not cross midline (Image 3).
ENTVisual EM
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Necrotizing Soft Tissue Infection

Sahil Aggarwal, BS* and Jonathan Peña, MD*

DOI: https://doi.org/10.21980/J8X92TIssue 3:2[mrp_rating_result]
Computed tomography (CT) of the abdominal and pelvis with intravenous (IV) contrast revealed inflammatory changes, including gas and fluid collections within the ventral abdominal wall extending to the vulva, consistent with a necrotizing soft tissue infection.
Infectious DiseaseVisual EM
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Spontaneous Pneumomediastinum: Hamman Syndrome

Tushank Chadha, BS* and Ethan Kunstadt, MD*

DOI: https://doi.org/10.21980/J8NS72 Issue 3:2[mrp_rating_result]
The initial CT scans showed extraluminal gas surrounding the distal esophagus as it traversed the posterior mediastinum, concerning for possible distal esophageal perforation that prompted surgery and GI consultations. There was no evidence of a drainable collection or significant fat stranding. The image also showed an intraluminal stent traversing the gastric antrum and gastric pylorus with no indication of obstruction. Circumferential mural thickening of the gastric antrum and body were consistent with the patient’s history of gastric adenocarcinoma. The shotty perigastric lymph nodes with associated fat stranding, along the greater curvature of the distal gastric body suggested local regional nodal metastases and possible peritoneal carcinomatosis. The thoracic CT scans showed extensive pneumomediastinum that tracked into the soft tissues of the neck, which given the history of vomiting also raised concern for esophageal perforation. There was still no evidence of mediastinal abscess or fat stranding. Additionally, a left subclavian vein port catheter, which terminates with tip at the cavoatrial junction of the superior vena cava can also be seen on the image.
RespiratoryVisual EM
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Procedural Sedation for the removal of a rectal foreign body

John Costumbrado, MD, MPH*, Valerie Lew, BS* and David Wagner, MD*

DOI: https://doi.org/10.21980/J81332Issue 3:2[mrp_rating_result]
Axial and coronal views on CT showed evidence of a large, tube-shaped foreign body in the rectum (see arrows) without evidence of acute gastrointestinal tract disease.
Abdominal/GastroenterologyProceduresVisual EM
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A Case of Otomastoiditis

Chad Correa, BS* and Claire Thomas, MD^

DOI: https://doi.org/10.21980/J8RK89Issue 3:2[mrp_rating_result]
The patient underwent computed tomography (CT) of the head which revealed opacification of the left middle ear (red arrow) and mastoid air cells (red circles). Additionally, there was thickening of the soft tissues of the external auditory canal (blue arrowhead), likely reflecting concurrent otitis externa. Based on the imaging, he was admitted for findings consistent with acute otomastoiditis.
ENTInfectious DiseaseVisual EM
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Large Ventral Hernia

Meryl Abrams, MD*, Raymond Feuga, MD*, Nicholas Governatori, MD* and Jennifer White, MD*

DOI: https://doi.org/10.21980/J86K9QIssue 3:2[mrp_rating_result]
Computed tomography (CT) scan with intravenous (IV) contrast of the abdomen and pelvis demonstrated a large pannus containing a ventral hernia with abdominal contents extending below the knees (white circle), elongation of mesenteric vessels to accommodate abdominal contents outside of the abdomen (white arrow) and air fluid levels (white arrow) indicating a small bowel obstruction.
Abdominal/GastroenterologyVisual EM
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Elderly female with acute abdominal pain presenting with Superior Mesenteric Artery Thrombus

Sassan Ghassemzadeh, MD*

DOI: https://doi.org/10.21980/J82W52 Issue 3:2[mrp_rating_result]
Computed tomography (CT) angiogram of the abdomen and pelvis revealed a superior mesenteric artery (SMA) thrombosis 5 cm from the origin off of the abdominal aorta. As seen in the sagittal view, there does not appear to be any contrast 5 cm past the origin of the SMA. On the axial views, you can trace the SMA until the point that there is no longer any contrast visible which indicates the start of the thrombus.  The SMA does not appear to be reconstituted. There was normal flow to the celiac artery. (See annotated images).
Abdominal/GastroenterologyCardiology/VascularVisual EM