Role of MRI in the evaluation of acute pyelonephritis in a high-risk population with renal dysfunction: a prospective study.

AIMS: This study aims to evaluate the (a) accuracy of conventional and diffusion-weighted-imaging (DWI) sequences in the diagnosis of acute pyelonephritis and (b) minimum apparent diffusion coefficient (ADC) values for the diagnosis of acute pyelonephritis and the differentiation of renal abscesses from acute pyelonephritis. MATERIALS AND METHODS: Ultrasound, conventional MRI sequences, and DWI were used to evaluate the kidneys in 68 patients suspected to have acute pyelonephritis. Multiple similar regions of interest (ROIs) were placed over the renal parenchyma with visually identifiable diffusion restriction, over the non-diffusion-restricted renal parenchyma of affected kidneys and over the normal kidneys. Corresponding minimum ADCs were noted for analysis. Pyelonephritis was confirmed based on clinical criteria, laboratory findings, and by resolution/development of known complications of pyelonephritis. RESULT: DWI showed the highest sensitivity(100%), while DWI read with T2-weighted imaging (both being positive) showed the highest specificity(100%) for the diagnosis of acute pyelonephritis in our population with a high baseline creatinine. The minimum-ADC of the nephritic diffusion-restricted area in patients with confirmed pyelonephritis was significantly lower than the minimum-ADC in patients without pyelonephritis [(0.934 ± 0.220, mean ± SD) vs (1.804 ± 0.404) × 10-3 s/mm2] (p < 0.001). ROC cut-off of minimum-ADC for the diagnosis of acute pyelonephritis was 1.202 × 10-3 s/mm2 (area under curve 0.978). The minimum-ADC of the abscesses were significantly lower when compared to the minimum-ADC of the nephritic diffusion-restricted portion of the same kidney [(0.633 ± 0.248) vs (0.850 ± 0.191) × 10-3 s/mm2] (p < 0.001). CONCLUSION: DWI is an excellent stand-alone imaging tool that can be combined with conventional sequences for the diagnosis of APN even in patients with high serum-creatinine or other contraindications to intravenous contrast. Further, ADC values can be used to differentiate between renal abscesses and uncomplicated pyelonephritis.

MRI findings in tubercular radiculomyelitis.

This article aims to familiarize the reader with the MR imaging findings of tubercular radiculomyelitis (TBRM) and to identify the sources of infection. We evaluated 29 patients on a 1.5 T GE MRI in a cross-sectional study. MRI of the spine with contrast and lumbar puncture were performed in all patients. MRI brain was performed for 13 patients. The typical and atypical manifestations enlisted in this article, will enable early detection of TBRM when the clinical history is ambiguous, as TBRM can present with low backache in both retrovirus positive and negative patients.

Management of acquired bronchopleural fistula due to chemical pneumonia.

Bronchopleural fistula (BPF) is a sinus tract between the bronchus and the pleural space that may result from a necrotizing pneumonia/empyema (anaerobic, pyogenic, tuberculous, or fungal), lung neoplasms, and blunt and penetrating lung injuries or may occur as a complication of procedures such as lung biopsy, chest tube drainage, thoracocentesis, or radiation therapy. The diagnosis and management of BPF remain a major therapeutic challenge for clinicians, and the lesion is associated with significant morbidity and mortality. Here, we present a 70-year-old male with acquired BPF due to chemical pneumonitis caused by aspiration of kerosene who presented with the symptoms of fever, cough with expectoration, breathlessness and signs of tachycardia, tachypnea, diminished breath sounds, and crepitations. After a 3-week course of culture-sensitive antibiotics with ß-lactam and ß-lactamase inhibitors, open drainage of the empyema was done following which the patient showed symptomatic improvement and was discharged.

Aggressive Vertebral Body Hemangioma Causing Compressive Myelopathy - Two Case Reports.

INTRODUCTION: Hemangiomas are benign tumors characterized by proliferation of blood vessels. A few hemangiomas are aggressive, characterized by bone expansion and extraosseous extension. These benign tumors may be mistaken for metatasis resulting in unnecessary biopsies, which have a high risk of hemorrhage. These hemangiomas can spread not just into the paraspinal soft tissues but also into the epidural region of the spinal canal causing cord compression and paraparesis. These clinical symptoms can be relieved by surgical decompression of the posterior elements, embolization or radiotherapy. CASE REPORT: In this case report the authors describe the imaging features of two aggressive vertebral body hemangiomas in two patients with back pain. One patient had isolated motor deficit while the other patient had both sensory and motor deficit. On imaging this benign tumor was seen involving both the vertebral body and its posterior elements with paraspinal and epidural extension causing compressive myelopathy. CONCLUSION: Thus, these case reports help identify the characteristic imaging features of an aggressive vertebral body hemangioma, preventing unnecessary and often risky biopsy. The clinical symptoms of the patient can be relieved by surgical decompression of the posterior elements or by radiotherapy. Use of onyx for intraarterial embolization is now believed to be the safest and most efficacious method for treatment of aggressive vertebral body hemangiomas. However, in the absence of definite guidelines, a multicentric study is warranted to prove that embolization with onyx is better than surgery with post-operative radiotherapy.

MR urogram findings and diffusion restriction in the renal papilla and calyx in papillary necrosis-a new finding: preliminary report.

Renal papillary necrosis is a clinicopathological entity where any or all of the papillae undergo selective necrosis, which can be demonstrated either radiologically or histologically. The most important causes are diabetes, pyelonephritis, obstructive uropathy, tuberculosis, analgesic abuse or overuse, sickle cell disease and renal vein thrombosis. Although this condition was first described in the 19th century the clinical diagnosis of this condition remains a problem to this day. Uncomplicated papillary necrosis may initially remain occult to imaging by ultrasound and non-contrast CT, but may later be complicated by obstructive uropathy. A few studies have described renal papillary necrosis on CT urogram. In this case series, the authors describe the finding of calyceal filling defect with diffusion restriction in the calyx and the tip of the renal pyramid on MR urogram, along with other findings that are classically seen on intravenous urogram or CT urogram. To the best of our knowledge, the finding of diffusion restriction at the tip of the renal pyramid has not been described before. Further, literature review showed only a single study describing the classical findings of papillary necrosis on an MR urogram. The early diagnosis of papillary necrosis on MR imaging equips the radiologist to suggest short-term clinical and radiological follow-up to check for the development of hydronephrosis. Additionally, such risk stratification may enable early ureteric stenting to prevent the development of obstructive uropathy.

A case report of renal papillary necrosis due to tuberculosis-CT urogram and static MR urogram findings.

The urinary tract is a common site of tuberculosis, which causes significant morbidity in the form of chronic renal disease. T uberculosis is not only common in developing countries but with the spurt in the number of immune-suppressed patients and the increasing incidence of drug -resistant strains, an increase in the number of patients suffering from genitourinary tuberculosis is expected even in developed countries. Genitourinary tuberculosis occurs owing to haematogenous dissemination of tubercular bacilli. Urinary tract tuberculosis can result in complications such as ureteric stricture, chronic pyelonephritis and papillary necrosis, resulting in compromised renal function. This renal compromise makes it prudent to avoid contrast- enhanced studies if other alternatives are available. There is a dearth of-cases of papillary necrosis reported on static MR urogram. The authors report a case of tuberculosis complicated by papillary necrosis on both CT urogram and static MR urogram.

Ureteral Reflux into an Ectopic Upper Moeity of a Duplex Kidney from the Bladder Neck with Distal Ureteral Pseudodiverticulum Formation.

Urinary incontinence is a condition causing significant psychological trauma and affects the quality of life of the affected individual. Though common causes of urinary incontinence of non-traumatic aetiology in young adults include detrusor instability and congenital conditions like meningomyelocoele, an ectopic ureter is an important surgically correctable cause of urinary incontinence. The cause of incontinence in an ectopic ureter is insertion of the ureter distal to the internal urethral sphincter. The authors describe a case report of an ectopic ureter arising from a duplex moiety with poor renal function using multiple modalities. This highlights the utility of multiple modalities in arriving at an accurate diagnosis, with adequate clinically useful information. In this case, the formation of a pseudo-diverticulum resulted in diagnostic confusion.

A case report of racemose pattern of intracranial tuberculoma with brain stem and hypophyseal involvement developing paradoxically during treatment.

Tuberculosis involving the central nervous system, a source of considerable morbidity and mortality, forms 5-10% of the disease burden associated with tuberculosis. Central nervous system tuberculosis may present as meningitis, tuberculoma, abscesses, cerebritis or miliary tuberculosis. The most common site of tuberculoma has been reported to be at the grey-white matter junction and the periventricular region. They may even be found in the epidural, subdural and subarachnoid spaces, and the brain stem, with the rarer sites of involvement being the cavernous sinus, sella turcica, hypophysis, hypothalamus, sphenoid sinus and the mastoid air cells. Although tuberculosis is very common in developing countries, with the increasing prevalence of immunosuppression owing to human immunodeficiency virus and patients surviving chemotherapy or organ transplantation, the incidence of tubercular infections has been rising in developed countries. The authors report a case of intracranial tuberculosis in a human immunodeficiency virus-negative patient, who underwent incomplete treatment for tubercular peritonitis and presented with unilateral ptosis. Tuberculous involvement was noted in a racemose pattern in the subarachnoid space, cavernous sinuses, suprasellar cistern and parasellar region. To the best of our knowledge, the term racemose pattern of tuberculoma has not been described before, while about 10 cases of tuberculoma involving the cavernous sinuses have been reported in the literature. Furthermore, the racemose pattern of tuberculosis in the subarachnoid space, as well as involvement of the cavernous sinus, hypothalamus, pituitary and the cisterns, developed paradoxically after initiation of antitubercular chemotherapy.