Imaging of pulmonary infections encountered in the emergency department in post-COVID 19 era- common, rare and exotic. Bacterial and viral.

Pulmonary infections contribute substantially to emergency department (ED) visits, posing a considerable health burden. Lower respiratory tract infections are prevalent, particularly among the elderly, constituting a significant percentage of infectious disease-related ED visits. Timely recognition and treatment are crucial to mitigate morbidity and mortality. Imaging studies, primarily chest radiographs and less frequently CT chests, play a pivotal role in diagnosis. This article aims to elucidate the imaging patterns of both common and rare pulmonary infections (bacterial and viral) in the post COVID-19 era, emphasizing the importance of recognizing distinct radiological manifestations. The integration of clinical and microbiological evidence aids in achieving accurate diagnoses, and guiding optimal therapeutic interventions. Despite potential overlapping manifestations, a nuanced understanding of radiological patterns, coupled with comprehensive clinical and microbiological information, enhances diagnostic precision in majority cases.

Multimodality imaging review of ulnar nerve pathologies.

The ulnar nerve is the second most commonly entrapped nerve after the median nerve. Although clinical evaluation and electrodiagnostic studies remain widely used for the evaluation of ulnar neuropathy, advancements in imaging have led to increased utilization of these newer / better imaging techniques in the overall management of ulnar neuropathy. Specifically, high-resolution ultrasonography of peripheral nerves as well as MRI has become quite useful in evaluating the ulnar nerve in order to better guide treatment. The caliber and fascicular pattern identified in the normal ulnar nerves are important distinguishing features from ulnar nerve pathology. The cubital tunnel within the elbow and Guyon's canal within the wrist are important sites to evaluate with respect to ulnar nerve compression. Both acute and chronic conditions resulting in deformity, trauma as well as inflammatory conditions may predispose certain patients to ulnar neuropathy. Granulomatous diseases as well as both neurogenic and non-neurogenic tumors can also potentially result in ulnar neuropathy. Tumors around the ulnar nerve can also lead to mass effect on the nerve, particularly in tight spaces like the aforementioned canals. Although high-resolution ultrasonography is a useful modality initially, particularly as it can be helpful for dynamic evaluation, MRI remains most reliable due to its higher resolution. Newer imaging techniques like sonoelastography and microneurography, as well as nerve-specific contrast agents, are currently being investigated for their usefulness and are not routinely being used currently.

Gastrointestinal Manifestations of Immunodeficiency: Imaging Spectrum.

There is a wide spectrum of hereditary and acquired immunodeficiency disorders that are characterized by specific abnormalities involving a plethora of humoral, cellular, and phagocytic immunologic pathways. These include distinctive primary immunodeficiency syndromes due to characteristic genetic defects and secondary immunodeficiency syndromes, such as AIDS from HIV infection and therapy-related immunosuppression in patients with cancers or a solid organ or stem cell transplant. The gut mucosa and gut-associated lymphoid tissue (the largest lymphoid organ in the body), along with diverse commensal microbiota, play complex and critical roles in development and modulation of the immune system. Thus, myriad gastrointestinal (GI) symptoms are common in immunocompromised patients and may be due to inflammatory conditions (graft versus host disease, neutropenic enterocolitis, or HIV-related proctocolitis), opportunistic infections (viral, bacterial, fungal, or protozoal), or malignancies (Kaposi sarcoma, lymphoma, posttransplant lymphoproliferative disorder, or anal cancer). GI tract involvement in immunodeficient patients contributes to significant morbidity and mortality. Along with endoscopy and histopathologic evaluation, imaging plays an integral role in detection, localization, characterization, and distinction of GI tract manifestations of various immunodeficiency syndromes and their complications. Select disorders demonstrate characteristic findings at fluoroscopy, CT, US, and MRI that permit timely and accurate diagnosis. While neutropenic enterocolitis affects the terminal ileum and right colon and occurs in patients receiving chemotherapy for hematologic malignancies, Kaposi sarcoma commonly manifests as bull's-eye lesions in the stomach and duodenum. Imaging is invaluable in treatment follow-up and long-term surveillance as well. Online supplemental material is available for this article. ©RSNA, 2022.

Gas Where It Shouldn't Be! Imaging Spectrum of Emphysematous Infections in the Abdomen and Pelvis.

OBJECTIVE. The purpose of this article is to review the spectrum, etiopathogenesis, clinical presentation, imaging features, differential diagnoses, and management of emphysematous infections of the abdomen and pelvis. CONCLUSION. Emphysematous infections are associated with high morbidity and mortality and thus need urgent medical and surgical interventions. CT is the most sensitive modality to detect gas; CT provides definitive diagnosis in most cases and can depict the extent of involvement.

Pierre Robin Sequence: Diagnostic Difficulties Faced while Differentiating Isolated and Syndromic Forms.

Pierre Robin sequence (PRS) is characterized by the triad of retrognathia, glossoptosis, and airway obstruction. PRS may occur in isolation or in conjunction with other syndromes. Distinguishing isolated and syndromic forms of PRS helps clinicians decide the management plan. We describe two cases of PRS of Indian ethnicity and describe some of the difficulties that we faced while distinguishing isolated PRS from syndromic PRS. Both cases had a similar clinical presentation. However, one of the cases had a positive family history of congenital deafness and cleft palate, whereas the other case had apparent upper limb anomalies. These facts heightened the suspicion of an associated syndrome. However, based on the available facts and after thorough investigations, a tentative diagnosis of isolated PRS was made for both the patients. Both the cases were managed conservatively and were advised a long-term follow-up. When the associated anomalies are few, minor or concealed at birth, longitudinal follow-up of all PRS cases combined with thorough diagnostics including chromosomal analysis could help differentiate syndromic PRS from isolated PRS. Regardless, all cases of PRS require a multidisciplinary approach.

Beyond pyogenic liver abscess: a comprehensive review of liver infections in emergency settings.

Hepatobiliary infections are commonly encountered in emergency settings ranging from common pathology such as pyogenic abscess to relatively uncommon and rare etiologies. Since extensive literature is already available on imaging of more common bacterial infections, for the sake of focused discussion, this review will discuss radiological appearance of less commonly encountered hepatic infections of fungal, parasitic, viral, and tubercular etiologies. Epidemiological and clinical information remain extremely important for obtaining more accurate presumptive diagnosis. In the era of diverse population migration, a modern-era radiologist must be well versed about the imaging spectrum of liver infections.

Ewing's sarcoma with distant metastasis: A brief note on management and emerging therapies.

Ewing's sarcoma is an aggressive fatal malignancy of bones and soft-tissue. It predominantly affects the young population, with a worldwide incidence of three cases per million. The pelvis, extremities, and ribs are the most common sites. We present a case of massive Ewing's sarcoma of the right femur with metastasis to bones and lungs. The patient was treated with chemotherapy. However, he succumbed to his illness before completion of therapy. In conclusion, Ewing's sarcoma with distant metastasis is a high risk case with poor prognosis. Integrating novel molecular targets with conventional chemotherapeutic agents holds a promise for high-risk Ewing's sarcoma patients.

"The Great Masquerader": Sonographic Pictorial Review of Testicular Tuberculosis and its Mimics.

Testicular tuberculosis (TB) is an uncommon presentation of extrapulmonary TB. Although rare in incidence, it is a great masquerader and should be kept in consideration while assessing focal abnormalities involving the testis. Ultrasound findings alone may be non-specific and mimic other diagnoses including infection, inflammation, tumor, infarct, and trauma. The main objective of this sonographic pictorial review is to discuss the imaging findings, specific differentiating features against each differential and use of ancillary imaging findings whenever available. Concurrent involvement of epididymis, septated hydrocele, scrotal wall edema, and calcification of tunica vaginalis provides strong evidence in an appropriate setting. Available extratesticular ancillary imaging findings must be correlated for correct diagnosis due to non-specific imaging and clinical presentation. Misdiagnosis of scrotal TB may lead to otherwise avoidable epididymo-orchiectomy.

Rhabdomyosarcoma of the Gluteus Maximus - Case Report, Review of Literature and Emerging Therapeutic Targets.

BACKGROUND: Rhabdomyosarcoma is an uncommon mesodermal cancer, which predominantly affects the young population. Common sites of primary disease include the head and neck region, genitourinary tract and the extremities. Less than 25% of the cases of rhabdomyosarcoma are metastatic at presentation. Embryonal and alveolar are the most common histological subtypes of rhabdomyosarcoma. Literature about rhabdomyosarcoma located in the gluteal region is sparse. CASE: We present a case of a 3-year-old child with alveolar rhabdomyosarcoma arising from the gluteal region. The metastatic workup was negative. We determined the tumour to be of intermediate risk and managed the patient with systemic chemotherapy consisting of cycles of vincristine, actinomycin D and cyclophosphamide, along with local treatment (wide-margin excision and radiotherapy). No recurrence was observed in the follow-up period. CONCLUSION: Management of alveolar rhabdomyosarcoma of the gluteus maximus requires a multipronged approach consisting of systemic chemotherapy, local surgery and radiotherapy. Long-term surveillance is imperative in children for early identification and management of relapses and treatment-related adverse effects. Several biological agents and small-molecule inhibitors targeting the signalling and growth pathways of rhabdomyosarcoma are in the pipeline, which hold promise for personalised therapy in the future. However, due to the rarity and molecular heterogenicity of the tumour, integrating these novel agents with the existing therapy would be a challenge.

Cornelia De Lange Syndrome In A 4-Year-Old Child From India: Phenotype Description And Role Of Genetic Counseling.

INTRODUCTION: Cornelia de Lange syndrome (CdLS) is a congenital disorder marked by distinctive facial features, severe growth restriction, cognitive disability, global developmental delay, and anomalies involving multiple body organs. Majority cases of CdLS are caused due to sporadic mutations in the NIPBL, SMC1A, SMC3, RAD21, or HDAC8 genes, which form/regulate a multiprotein complex called cohesin. Cohesin is required for the separation of sister chromatids during cell division. CASE REPORT: We present a rare case of a 4-year-old child from India depicting classical features of CdLS. The patient was managed symptomatically by a multidisciplinary team and was requested regular follow-ups. CONCLUSION: Phenotype description according to ethnicity may help in diagnosing CdLS. A multipronged approach by a team of physicians from various faculties is required for providing comprehensive medical care to patients with CdLS.

Unilateral Primary Congenital Lymphedema of the Upper Limb in an 11-Month-Old Infant: A Clinical and Pharmacological Perspective.

BACKGROUND: Lymphedema is the accumulation of a protein-rich fluid in the interstitial space due to reduced lymph transport capacity. Congenital primary lymphedema affecting only one of the upper limbs is a rarity. CASE REPORT: We present a case of an 11-month-old infant presenting with swelling of the right upper limb, which had gradually progressed over the past five months. Lymphoscintigraphy was suggestive of lymphatic blockade in the right upper limb. All other investigations were within normal limits. A diagnosis of primary congenital lymphedema affecting the right upper limb was made. The patient was managed conservatively with complex decongestive therapy and was requested regular follow-up. The lymphedema did not increase within four months of follow-up. CONCLUSIONS: Complex decongestive therapy is the cornerstone of the management of primary congenital lymphedema. New investigational therapies such as leukotriene B4 antagonists hold a promise for patients with lymphedema.

Complete Rectal Prolapse in Children: Case Report, Review of Literature, and Latest Trends in Management.

BACKGROUND: Complete rectal prolapse is the circumferential descent of all the layers of the rectum through the anus. It often leads to bleeding, obstructed defecation, incarceration or fecal incontinence. CASE REPORT: We present a rare case of a 4-year-old child with complete rectal prolapse of 12 cm in length. The prolapsed rectum was manually repositioned after reducing the oedema. The precipitating factor was identified as excessive straining while passing stools. A change in position while passing stools was advised along with a high fibre diet and a stool softener. Recurrence was not observed in the 3 month of follow-up. CONCLUSION: Most cases of pediatric rectal prolapse are managed conservatively by addressing the associated and precipitating etiological factors. Surgical intervention may be required for recurrent or persistent cases.

Pediatric Pleomorphic Adenoma of the Parotid: Case Report, Review of Literature and Novel Therapeutic Targets.

Salivary gland tumors are extremely rare and encompass a diverse group of histologies. Less than 5% of the affected population is pediatric. We present a case of 6-year-old child with pleomorphic adenoma of the parotid. The patient underwent a superficial parotidectomy. Recurrence was not observed in the six months of follow-up. Surgery is the mainstay of the management of benign salivary gland tumors. Although novel molecular agents are being explored, personalized therapy would be a challenge due to the rarity and vast genetic/histologic variations of salivary gland tumors.

A case report of hypohidrotic ectodermal dysplasia: A mini-review with latest updates.

Ectodermal dysplasia (ED) is a rare hereditary disorder involving two or more of the ectodermal structures, which include the skin, hair, nails, teeth, and sweat glands. The two most common forms of the disease are hypohidrotic/anhidrotic ED and hidrotic ED. They are caused by the mutations of several genes. We present a case of a 9-year-old child with hypohidrotic ED, who presented with hypodontia, dyshidrosis, hypotrichosis, and raised body temperature. We treated the raised body temperature symptomatically with cooling techniques and antipyretics. A multidisciplinary approach with physicians from several fields is required to provide comprehensive medical care to patients with ED.

Giant Congenital Melanocytic Nevi: An Update and Emerging Therapies.

Giant congenital melanocytic nevi (GCMN) are a rare occurrence. Gain-of-function mutation in the NRAS gene is found to be associated with GCMN, causing abnormal proliferation of embryonic melanoblasts. The two major complications associated with GCMN are malignant melanoma and neurocutaneous melanosis. Treatment of GCMN has conventionally been surgical. However, the role of NRAS inhibitors and inactivation of nevus tissue by high hydrostatic pressure are being explored. We present a case of a 1-day-old neonate born with GCMN, along with a review of the literature.

Staphylococcal scalded skin syndrome: A pediatric dermatology case report.

Staphylococcal scalded skin syndrome is a condition which predominantly affects children and causes a spectrum of skin lesions. We present a case of a 2-month-old infant with complaints of fever and fragile blisters over the body. The mucosal areas were spared. The diagnosis of staphylococcal scalded skin syndrome was reached on clinical grounds and culture report. The patient responded well to the treatment, which included an antibiotic (cloxacillin), an analgesic (paracetamol), and hydration with intravenous fluids. He was discharged after 8 days, with almost complete resolution of his skin lesions. Having a high clinical suspicion for staphylococcal scalded skin syndrome, early diagnosis/treatment, and following robust hygiene measures are imperative for the effective management of staphylococcal scalded skin syndrome. More efforts are needed to develop novel therapies for staphylococcal scalded skin syndrome.

Neurofibromatosis and breast cancer: Do we need to revise the mammographic screening schedule in patients of neurofibromatosis?

Neurofibromatosis type 1 (NF-1) is a neurocutaneous syndrome with autosomal dominant mode of inheritance and has a high propensity to develop benign and malignant nervous system tumors. Although uncommon, case reports describing the association of NF-1 and breast cancer are available in the literature. We illustrate one such case of NF-1, with no family history of the disorder and presenting with multifocal invasive carcinoma of the right breast, in an attempt to describe the association between these two entities. We also attempt to extensively review the current literature on the subject. Since patients with NF-1 are at an increased risk of developing breast cancer, we recommend strict adherence to careful clinical breast examination and annual screening mammographic examination starting at 40 years of age in all patients of NF-1.

Split-Hand Malformation in a 4-Year-Old Child.

Split-hand deformity is one of the milder manifestations of a congenital disorder called split-hand/split-foot malformation. We present a case of a 4-year-old child with split-hand malformation in his left hand since birth. A median cleft was present in the affected hand with absence of the 3rd and 4th digits, giving rise to a characteristic lobster-claw appearance. Functionality of the affected hand was modestly impaired. As none of the close family members of the patient had similar limb malformations, the deformity was postulated to arise most likely from a de novo mutation. The patient was discharged after the parents were provided with genetic counseling.

Immunoglobulin G kappa biclonal gammopathy associated with multiple myeloma, plasmacytoma and cast nephropathy.

Biclonal gammopathies are characterized by simultaneous appearance of two different monoclonal proteins. Multiclonal gammopathies may be the result of a neoplastic transformation of a cell clone undergoing immunoglobulin (Ig) class switching or due to an independent neoplastic transformation event yielding proliferation of unrelated plasma cell clones. This in turn has implication on the disease manifestation, progression, prognosis and response to therapy. The prevalence of biclonal gammopathy is approximately 1% of all gammopathies and the most common combinations are IgG and IgA (33%), followed by IgM and IgG (24%). Multiple myeloma with biclonal gammopathy is very uncommon. The present case corresponds to an extremely rare occurrence of multiple myeloma with biclonal gammopathy revealing expression of two distinct monoclonal gammaglobulins both of IgG and kappa (κ) subtype in a 56-year-old diabetic man who presented with lower back pain and renal failure. To the best of our knowledge, only one case of IgG κ biclonal gammopathy associated with multiple myeloma have been reported in English literature. This case interestingly also had paraspinal plasmacytoma and cast nephropathy.