Issue 4:2

Pneumocystis jirovecii (carinii) Pneumonia

Brian Knight, BS^*, Jonathan Patane, MD^* and Robert Katzer, MD, MBA^*

DOI: https://doi.org/10.21980/J8RW6NIssue 4:2 No ratings yet.

Chest X-ray showed diffuse, patchy interstitial and alveolar infiltrates bilaterally concerning for Pneumocystis jirovecii(previously Pneumocystis carinii) pneumonia (PJP). The AP radiograph (top left figure) showed the classic “bat-wing” distribution on the left side. Repeat radiograph (bottom figure) one day after admission showed worsening of the infiltrates.

Acute Pancreatitis

Ronald Goubert, BS^*, Jonathan Peña, MD^*, Alisa Wray, MD, MAEd^* and Eleanor Chu, MD^{^}

DOI: https://doi.org/10.21980/J88W5XIssue 4:2 No ratings yet.

Computed tomography of the abdomen and pelvis with contrast show edema of the pancreas (red outline) and duodenum (yellow arrow) with peripancreatic inflammation, fluid and fat stranding (blue highlight). The distal pancreatic tail was noted to appear normal (green arrow). There was no organized drainable fluid collection, and no parenchymal hypo-enhancement. These findings are consistent with moderate severity acute interstitial pancreatitis.

Abdominal/Gastroenterology Visual EM

Renal and Splenic Infarcts

Niketu Patel, MPH^* and Loice Swisher, MD^*

DOI: https://doi.org/10.21980/J8804KIssue 4:2 No ratings yet.

On the coronal sections of computed tomography (CT), bilateral renal infarctions (blue arrows) and several splenic infarctions (green arrows) are noted. Of particular interest, part of the clot totally occluding the left renal artery visibly extends into the aorta (red arrow). The vascular reconstruction image is remarkable for the absent left kidney, the unusual contour of the right kidney and the abnormal splenic blush.

Visual EM Abdominal/Gastroenterology

Erectile Dysfunction as a Presenting Symptom for Renal Cell Carcinoma

Frank Mayer III, MBA^*, Jonathan Wooden, MD^* and Megan Stobart-Gallagher, DO^*

DOI: https://doi.org/10.21980/J8563BIssue 4:2 No ratings yet.

The MRI showed extensive spondylotic changes suggestive of malignancy (red arrows) with severe spinal canal stenosis at the lumbar spine L3-L4 (purple arrows) level contributing to clumping of cauda equina nerve roots and severe bilateral neuroforaminal narrowing with diffuse disc bulges abutting the exiting nerve roots at multiple levels. Findings also showed a hypo-attenuated tumor (blue arrow) and hyper-attenuated loculated tumor (green arrow) consistent with renal cell carcinoma (RCC).

Visual EM Renal/Electrolytes

Pectoralis Muscle Tendon Rupture

Wyatt Verplaetse, MD^* and Gregory Podolej, MD^*

DOI: https://doi.org/10.21980/J81D01Issue 4:2 No ratings yet.

There is a noticeable difference in appearance and location of maximal prominence of the right pectoral muscle with arms outstretched (image 1). This is accentuated by having the patient perform an isometric arm press. (image 2).There is absence of the anterior axillary fold with adduction against resistance. The stump of the pectoralis muscle was palpated along his armpit. He otherwise has full range of motion in the shoulder with minimal pain.

Visual EM Orthopedics

Saddle Pulmonary Embolus

Colin Therriault, MD^*, Daniel Natkiel, DO^* and Megan Stobart-Gallagher, DO^{^}

DOI: https://doi.org/10.21980/J8N63P Issue 4:2 No ratings yet.

An electrocardiogram (ECG) showed evidence of right heart strain with an incomplete right bundle branch block, S1Q3T3 (see red arrow [S1], blue arrow [Q3], and black arrow [T3]), and ST-segment elevation in the septal leads (green arrows). Bedside echocardiography showed a dilated right ventricle with ventricular wall akinesis (red arrow) sparing the apex (purple arrow), which is known as McConnell’s Sign. It also showed a mobile hyperechoic mass (yellow arrow). These ultrasound findings were concerning for pulmonary embolism (PE), so computed tomography (CT) angiogram of the chest was ordered and confirmed massive bilateral obstructive filling defects (red arrows) consistent with saddle pulmonary embolism. Additionally, noted is flattening of the interventricular septum (blue arrow) consistent with right heart strain. Laboratory studies were notable for a troponin-I of 0.29 ng/mL, a B-type natriuretic peptide of 792.3 pg/mL, lactic acid of 5.30 mmol/L, and a creatinine of 2.0 mg/dL, consistent with end organ dysfunction. All other lab work was within normal limits.

Visual EM Cardiology/Vascular Respiratory

Sigmoid Diverticulitis Complicated by Colovesical Fistula Presenting with Pneumaturia

Faraz Khan, BS^*, Justin Yanuck, MD^* and C Eric McCoy, MD, MPH^*

DOI: https://doi.org/10.21980/J80G9TIssue 4:2 No ratings yet.

A CT scan of his abdomen/pelvis shows acute sigmoid colonic diverticulitis with adjacent extraluminal collection containing gas (axial view, white arrow) consistent with perforation, along with abutment of the urinary bladder with intraluminal bladder gas (sagittal and coronal views, white arrowheads) suggesting colovesical fistula.

Abdominal/Gastroenterology Visual EM

A Woman with Arm Spasms

Anita Mudan, MD^* and Wilma Chan, MD, EdM^*

DOI: https://doi.org/10.21980/J8VP88Issue 4:2 No ratings yet.

The patient had a witnessed episode of isolated left upper extremity jerking, shown in the video, during which she was completely awake and conversant. Lab results were significant for serum glucose of 1167 mg/dL, no anion gap, and negative serum/urine ketones. She had a computed tomography (CT) of the head that did not show any acute pathology, and underwent a brain magnetic resonance imaging (MRI) without any signs of stroke or other pathology, shown below.

Renal/Electrolytes Neurology Visual EM

Idiopathic Intracranial Hypertension and Optic Nerve Sheath Diameter

Lauren Ann Selame, MD^*and Zachary Risler, MD, MPH^*

DOI: https://doi.org/10.21980/J84631Issue 4:2 No ratings yet.

Optic nerve sheath diameter (ONSD) was measured via ultrasound with diameter 5.7mm on left and 6.2mm on right. In order to measure ONSD via optic ultrasound the high-frequency linear array probe (7.5-10-MHz or higher) is utilized in B-mode. The patient is positioned supine and an occlusive dressing, such as Tegaderm, is placed over a closed eyelid with copious conductive gel on top of the dressing. Being careful not to put pressure on the globe, an axial cross-sectional image of the globe is obtained. As demonstrated in the image “annotated left eye ONSD pre-lumbar puncture,” there are two main anechoic areas of the globe, the anterior chamber and the vitreous humor. These anechoic structures are separated by the hyperechoic iris, which surfaces the hyper-echoic-lined lens. At the back of the vitreous humor is the retina, which leads posteriorly into the optic nerve. The optic nerve is the hypoechoic structure posterior to the retina and surrounded by the hyperechoic subarachnoid space, which is encased by the hypoechoic dura mater. The outer edge of the hypoechoic dura matter is where the ONSD is measured.1 The user applies calipers to measure 3mm perpendicularly behind the retina along the hypoechoic optic nerve, and at this level the transverse dimensions of the ONSD are measured using calipers as shown in the images.Computed tomography (CT) of the head was performed and showed no abnormalities. Lumbar puncture was performed in left lateral decubitus position revealing elevated opening pressure of 29cm H2O. Thirty-five mL of clear cerebral spinal fluid was drained and was negative for all infectious studies. Optic nerve sheath diameter was again measured post-lumbar puncture with diameters 5.4mm on left and 5.4mm on right.

Visual EM Ophthalmology

Pericardial Clot on Point-of-Care Ultrasound

Rame Bashir, BS^*, Esther Kim, BS^*, Shadi Lahham, MD, MS^* and John C Fox, MD^*

DOI: https://doi.org/10.21980/J8ZH1TIssue 4:2 No ratings yet.

Focused assessment with sonography in trauma (FAST) scan was positive for a clinically significant pericardial effusion as evidenced by the hypoechoic fluid around the myocardium, indicated by the blue arrow in image 2. Findings are also consistent with tamponade process as evidenced by restricted expansion and collapse of the right ventricle during diastole. The hyperechoic floating structure between the pericardium and myocardium, adjacent to the right ventricle, represents a pericardial clot, indicated by the white arrow.The density of the pericardial clot differs from that of the myocardium, thus serving as an additional variable to avoid confusing this as part of the myocardial structure.

Cardiology/Vascular Ultrasound Visual EM