Pulmonary arterio-venous malformation: a catastrophe

Pulmonary Arteriovenous Malformations (PAVM) are abnormal fistulous connections between a pulmonary artery and a pulmonary vein that generate a right-to-left shunt by avoiding the normal pulmonary capillary bed. We report an unusual case of a young female patient who presented to the department of Obstetrics and Gynaecology with Bleeding per vagina diagnosed as Failed intrauterine pregnancy; Unilateral pedal edema and Breathlessness. Pulmonary Thromboembolism was suspected and Computed Tomography pulmonary angiogram (CTPA) was advised for, which showed abnormal communication between dilated left main pulmonary artery and dilated tortuous superior pulmonary vein. Multiple adjacent solid and ground glass nodules were also noticed which were suggestive of initial telangiectatic state of PAVMs. Most of PAVMs are related to Hereditary Hemorrhagic Telangiectasia, whereas only 10 to 20% are isolated sporadic cases. Pregnancy has been considered as a precipitant factor for PAVMs in most of the cases, patients and pregnant women affected by PAVMs are asymptomatic, but when the clinical manifestations occur, they are often related to the right-to-left shunting and may include dyspnoea, hypoxia, and pulmonary hypertension. Moreover, presence of one or multiple PAVMs during pregnancy is associated with an increased risk of severe complications such as rupture, haemothorax, and hypovolemic shock. Hence this case reports highlights the necessity for the radiologists to think in terms of PAVM as a differential diagnosis beyond the suspicion of Pulmonary thromboembolism to look for any abnormal arteria venous communication while reporting CTPA in pregnant women with breathlessness and foresee the catastrophic complications in an already known case of PAVM during pregnancy. Also, the radiologists should identify subtle solid or ground-glass nodules adjacent to large PAVMS which are the initial telangiectatic stage of PAVMs.

Lithopedion: the calcified marvel

The term lithopedion was derived from the Greek words Lithos and Pedion. It is a rare ectopic pregnancy with incidence as low as 1.5-2.0% of all ectopics. An 80-year old female patient presented to the orthopaedic out-patient department with complaints of lower back pain and mild lower abdominal pain, no history of any trauma. The patient was a known case of Ttype II diabetes and hypertension on medication, no other comorbidities. The patient was referred to the department of radio-diagnosis, for plain radiograph of the lumbo-sacral spine, antero-posterior and lateral view for further evaluation. The plain radiograph revealed a well-defined oval shaped radio-density in the pelvis more towards the right side. Further evaluation was done in the form of ultrasound abdomen and computed tomography. Computed tomography revealed a mummified fetus which is in close proximity to the internal organs and adhering to bowel loop. Low socioeconomic status combined with lack of education of the population are the primary causes for delay in diagnosis resulting in undiagnosed ectopic pregnancy and its later transformation into a Lithopedion.