Creeping mediastinal lymphangioma transgressing anatomical compartments: A rare case in an adult female patient.

Lymphangiomas, also known as lymphatic malformations, are rare non-neoplastic lesions of vascular origin showing lymphatic differentiation. These are most commonly reported in children within the neck and axillary region; however, mediastinum remains the commonest site in adults whereby diagnosis is usually incidental on imaging done for non-specific symptoms. Radiologically, these lesions are well-defined multicystic non-enhancing masses, with CT attenuation values ranging from simple to complex fluid and fat. Being benign, these mostly present clinically either due to mass effect exerted on structures, secondarily infected or developing intra lesion haemorrhage. We present a rare case of mediastinal lymphangioma with secondary hilar and intrapulmonary extension in a middle-aged female presenting with occasional haemoptysis and shortness of breath. The patient underwent thoracotomy with complete dissection of the mediastinal tumour, per operative Bleomycin administration in pulmonary component, and made subsequent uneventful post-operative recovery.

Comparison of delta-tocotrienol and alpha-tocopherol effects on hepatic steatosis and inflammatory biomarkers in patients with non-alcoholic fatty liver disease: A randomized double-blind active-controlled trial.

OBJECTIVE: We aimed to compare the efficacy of δ-tocotrienol with α-tocopherol in the treatment of patients with non-alcoholic fatty liver disease (NAFLD). DESIGN AND INTERVENTIONS: This study was a double-blinded, active-controlled trial. The patients with NAFLD were randomly assigned to receive either δ-tocotrienol 300 mg or α-tocopherol 268 mg twice daily for 48 weeks. ENDPOINTS: The primary endpoints were change from baseline in fatty liver index (FLI), liver-to-spleen attenuation ratio (L/S ratio), and homeostatic model assessment for insulin resistance (HOMA-IR) at 48 weeks. Key secondary endpoints were change in markers of inflammation, oxidative stress, and hepatocyte apoptosis. Clinical assessment, biochemical analysis, and computed tomography scan of the liver were conducted at baseline, 24 and 48 weeks. RESULTS: A total of 100 patients (δ-tocotrienol = 50, α-tocopherol = 50) were randomized and included in the intention to treat analysis. Compared with baseline, there was a significant improvement (p < .001) in FLI, L/S ratio, HOMA-IR, and serum malondialdehyde in both groups at 48 weeks that was not significant between the two groups. However, there was a significantly greater decrease in body weight, serum interleukin-6, tumor necrosis factor-alpha, leptin, cytokeratin-18, and increase in adiponectin in the δ-tocotrienol group compared to the α-tocopherol group at 48 weeks (p < .05). No adverse events were reported. CONCLUSION: δ-tocotrienol and α-tocopherol exerted equally beneficial effects in terms of improvement in hepatic steatosis, oxidative stress, and insulin resistance in patients with NAFLD. However, δ-tocotrienol was more potent than α-tocopherol in reducing body weight, inflammation, and apoptosis associated with NAFLD. TRIAL REGISTRATION: Sri Lankan Clinical Trials Registry (https://slctr.lk/SLCTR/2019/038).

Spontaneous Pneumomediastinum in COVID-19 Pneumonia: A Rare Occurence.

Spontaneous pneumomediastinum with COVID pneumonia is a rare occurrence with or without accompanying subcutaneous emphysema or pneumothorax. The aim of this study was to establish relation of this complication to severity of lung disease and its clinical outcome. The study was conducted for a period of seven months from April to October 2020 in the CT Department of Armed Forces Institute of Radiology and Imaging (AFIRI), Rawalpindi, Pakistan. All COVID positive patients having spontaneous pneumomediastinum on high resolution CT (HRCT) chest were included (n=14). These patients were assessed for severity of lung disease as per CT severity score (CTSS), and were followed up for their clinical outcome. All patients with spontaneous pneumomediastinum had moderate to severe degree of COVID pneumonia; mortality in patients with pneumomediastinum was 50%; and was seen in those patients who had greater severity of lung disease as per the CTSS. Key Words: Spontaneous, Pneumomediastinum, COVID, Pneumothorax, Subcutaneous, Emphysema.

Chest CT Severity Score as an Auxiliary Grading Tool to COVID-19 Pneumonia Imaging Classification: A Tertiary Care Experience in Pakistan.

OBJECTIVE:   To identify utility of chest computed tomography severity score (CT-SS) as an additional tool to COVID-19 pneumonia imaging classification in assessing severity of COVID-19. STUDY DESIGN: Descriptive analytical study Place and Duration of Study: Armed Forces Institute of Radiology and Imaging, (AFIRI) Rawalpindi, from April 2020 to June 2020. METHODOLOGY: Five hundred suspected COVID-19 cases referred for high resolution computed tomography - chest were included in the study. Cases were categorised by radiological findings using COVID-19 pneumonia imaging classification, proposed in the radiological society of North America expert consensus statement on reporting chest CT findings related to COVID-19. CT-SS was calculated for all scans. Patients were clinically classified according to disease severity as per 'Diagnosis And Treatment Program of Pneumonia of New Coronavirus Infection' recommended by China's National Health Commission. The relationships between radiological findings, CT-SS, and clinical severity were explored. RESULTS: Based on the radiological findings, 298 cases were graded as typical, 34 as indeterminate, 15 as atypical, and 153 as negative for pneumonia. The apical and posterior basal segments of lower lobes were most commonly involved. The CT-SS showed higher values in patients of severe group as compared to those in moderate group (p < 0.05). CT-SS threshold for recognising severe COVID-19 was 18.5 (area under curve, 0.960), with 84.3% sensitivity and 92.5% specificity. CONCLUSION: In coherence with COVID-19 pneumonia imaging classification, CT-SS may provide a comprehensive and objective assessment of COVID-19 severity. Key Words: COVID-19, COVID-19 pneumonia, CT-SS, High resolution computed tomography.

Central Nervous System Vasculitis Secondary to Sarcoidosis: A Rare Case of Lupus Pernio With Complete Occlusion of Right Internal Carotid Artery.

Sarcoidosis is a systemic inflammatory disorder resulting from an inappropriate immune response to ubiquitous environmental stimuli. It has a predilection for African Americans and people of Northern European countries. The classic histology is that of a non-caseating granuloma. Central nervous system involvement is a rare occurrence in sarcoidosis and even in this manifestation, the presence of vasculitis is comparatively uncommon. We present a case of a 35-year-old female, who presented with complaints of persistent headache of moderate intensity and had a violaceous plaque on nose, being treated by a dermatologist. The patient on further workup had mildly raised proteins on cerebrospinal fluid analysis. MRI brain showed multiple foci in bilateral frontoparietal regions and centrum semiovale, while digital subtraction angiography brain depicted vasculitis of small vessels of brain and complete occlusion of right internal carotid artery at its origin. Biopsy of lesion on nose was performed that showed chronic granulomatous inflammation. A diagnosis of brain vasculitis secondary to sarcoidosis was made. The patient was treated with plasmapheresis and pulse steroid therapy initially, and later on with cyclophosphamide and azathioprine. This resulted in resolution of headache and nose lesion.

Transvenous Catheter-Based Thrombolysis With Continuous Tissue Plasminogen Activator Infusion for Refractory Thrombosis in a Patient With Behcet's Disease.

Behcet's disease (BD) classically presents with recurrent oral ulcers, genital ulceration, uveitis and skin manifestations. Middle-aged people are usually affected with the male gender being associated with severe variant of the disease. It can involve any organ system of the body. Although central nervous system and vascular involvement tend to occur less frequently, they are the commonest cause of mortality. We present a case of a 30-year-old man referred with suspicion of cerebral venous sinus thrombosis to our hospital and subsequently diagnosed with BD. The patient developed, despite being on immunosuppression and anticoagulation, extensive arteriovenous thrombi of lower limbs requiring catheter-directed thrombolysis with continuous 24-hour infusion of tissue plasminogen activator for refractory right lower limb venous thrombosis and placement of inferior vena cava filter to prevent pulmonary embolism. Later disease remission was achieved with rituximab.

Delta-tocotrienol supplementation improves biochemical markers of hepatocellular injury and steatosis in patients with nonalcoholic fatty liver disease: A randomized, placebo-controlled trial.

OBJECTIVE: The aim of this study was to examine the effects of delta-tocotrienol (δ-tocotrienol) supplementation on biochemical markers of hepatocellular injury and steatosis in patients with nonalcoholic fatty liver disease (NAFLD). DESIGN: The study design was a two-group, randomized, double-blind, placebo-controlled trial. The patients with NAFLD were randomly assigned to receive δ-tocotrienol 300 mg twice daily or placebo for 24 weeks. ENDPOINTS: The primary endpoints were change from baseline in fatty liver index (FLI) and homeostasis model of insulin resistance (HOMA-IR) after 24 weeks. Secondary endpoints included change from baseline in high sensitivity C-reactive protein (hs-CRP), malondialdehyde (MDA), alanine transaminase (ALT), aspartate transaminase (AST) and grading of hepatic steatosis on ultrasound. Between-group differences were tested for significance using ANCOVA. Mean differences (MD) with 95 % CIs are reported. RESULTS: A total of 71 patients (tocotrienol=35, placebo=36) were randomized and included in the intention to treat analysis. Compared with placebo, δ-tocotrienol significantly reduced (MD [95 % CI]) FLI (-8.52 [-10.7, -6.3]; p < 0.001); HOMA-IR (-0.37 [-0.53, -0.21]; p < 0.001), hs-CRP (-0.61[-0.81, -0.42]; p < 0.001), MDA (-0.91 [-1.20, -0.63]; p < 0.001), ALT (-8.86 [-11.5, -6.2]; p < 0.001) and AST (-6.6 [-10.0, -3.08]; p < 0.001). Hepatic steatosis was also reduced by a significantly greater extent with tocotrienol than with placebo (p =0.047). No adverse events were reported. CONCLUSION: δ-tocotrienol effectively improved biochemical markers of hepatocellular injury and steatosis in patients with NAFLD. δ-tocotrienol supplementation might be considered as a therapeutic option in the management of patients with NAFLD. TRIAL REGISTRATION: Sri Lankan Clinical Trials Registry (SLCTR/2015/023, 2015-10-03).

Central Nervous System Tuberculosis With Shower Like Pattern of Intracranial Tuberculomas in an Immunocompetent Patient.

Central nervous system tuberculosis (CNS TB), though comparatively uncommon as compared to other forms of extrapulmonary tuberculosis (TB), results in high morbidity and mortality. The symptoms are non-specific and of a progressive nature resulting in delayed diagnosis. We present a case of CNS TB that presented two months after the onset of symptoms. The patient's condition reached the point of being bedbound. On investigation, the widespread involvement of the brain with shower-like pattern of ring enhancing tuberculomas and associated tuberculous meningitis was found. This was a surprising finding considering the patient was immunocompetent. Contrast-enhanced magnetic resonance imaging showed lesions in midbrain, pons, medulla, thalamus, bilateral cerebellar hemispheres and bilateral cerebral hemispheres. Upon treatment initiation the patient responded well with resolution of all lesions.

An Unfamiliar Complication of Frontoethmoid Sinus Fibrous Dysplasia: Intradiploic CSF Cyst.

Fibrous dysplasia is a slow growing fibro-osseous tumor, which is infrequent in craniofacial location and very rarely found in paranasal sinuses. Its occurrence is usually in children and young adolescents. The complications common in this location are related to the sinus ostia obstruction, like sinusitis or mucocele formation. Aneurysmal bone cyst formation has also been reported. We present a case of frontoethmoid fibrous dysplasia which extends to the nasal cavity and extraaxial frontal region. The peculiarity about the case is its association with the intradiploic CSF cyst formation, which to best of our knowledge has never been reported before.

Diffusion-weighted MR Imaging and ADC Mapping in Differentiating Benign from Malignant Thyroid Nodules.

OBJECTIVE: To determine the diagnostic accuracy of Diffusion-Weighted Imaging (DWI) and Apparent Diffusion Coefficient (ADC) mapping in differentiating benign from malignant thyroid nodules by taking histopathology as the gold standard. STUDY DESIGN: Across-sectional analytical study. PLACE AND DURATION OF STUDY: Department of Radiology at Combined Military Hospital (CMH), Lahore, from August 2012 to July 2013. METHODOLOGY: Thirty-five patients, who were referred to radiology department of CMH, Lahore, for ultrasound or Fine Needle Aspiration Cytology (FNAC) of thyroid gland, fulfilling the inclusion and exclusion criteria, were included in the study. They were evaluated on 1.5 Tesla MRI machine with T1- and T2-weighted imaging as well as fat-suppressed technique. DWI was done using b-values of 0 and 1000 s/mm2and ADC values were calculated for the thyroid nodules. All of these patients were subjected to ultrasound guided core biopsy and histopathology results were correlated with ADC values. RESULTS: The benign nodules showed facilitated diffusion while malignant nodules showed restricted diffusion. T-test was used to assess the difference in mean ADC values between benign and malignant nodules. The mean ADC value of the malignant thyroid nodules (0.94 ±0.16 x 10-3mm2/s) was significantly lower than that of the benign thyroid nodules (1.93 ±0.13 x 10-3mm2/s) (p-value < 0.05). ADC value of 1.6 x 10-3mm2/s was used as a cut-off, for differentiating benign from malignant thyroid nodules. The sensitivity, specificity, PPV, NPV and diagnostic accuracy of DWI and ADC values in differentiating benign from malignant thyroid nodules were 93%, 95%, 93%, 95% and 92.3%, respectively. CONCLUSION: DWI is a non-invasive diagnostic tool for characterization and differentiation between benign and malignant thyroid nodules. It not only decreases the burden of unnecessary surgeries when pre-operative FNAC and biopsy are inconclusive, but is also helpful in reaching a definite diagnosis when a nodule is not amendable to biopsy due to any reason.

ONION PEEL APPEARANCE IN BALOS CONCENTRIC SCLEROSIS--A VARIANT OF MULTIPLE SCLEROSIS.

Balo's concentric sclerosis (BCS) is a variant of multiple sclerosis (MS). It may present as a lesior clinically and radiologically indistinguishable from brain tumour particularly on computerized tomography (CT) scans. Diagnosis only gets clear when magnetic resonance imaging and spectroscopy (MRI & MRS) and brain biopsy is done. We report a case of 30 year old male with progressive headache and left hemi paresis for 3 weeks. There was upper motor neuron (UMN) facial palsy on the left with bilateral papilledema. CT scan of brain showed large hypo-dense area in right frontoparietal lobe consistent with brain tumour. On MRI the diagnosis of BCS was made on basis of concentric lesions of myelinated and demyelinated rings. Demyelination wa confirmed on brain biopsy.