Aortic Limited Intimal Tear in a 16-Year-Old Boy.

Teaching point: While demanding urgent management, limited intimal tear (LIT), a rare subtype of acute aortic syndrome (AAS), poses challenges in terms of accurate and timely diagnosis.

Piezogenic papules.

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SurLym trial: study protocol for a multicentre pragmatic randomised controlled trial on the added value of reconstructive lymphatic surgery to decongestive lymphatic therapy for the treatment of lymphoedema.

INTRODUCTION: Lymphoedema is a chronic condition caused by lymphatic insufficiency. It leads to swelling of the limb/midline region and an increased risk of infection. Lymphoedema is often associated with mental and physical problems limiting quality of life. The first choice of treatment is a conservative treatment, consisting of exercises, skin care, lymph drainage and compression. Reconstructive lymphatic surgery is also often performed, that is, lymphovenous anastomoses, lymph node transfer or a combination. However, robust evidence on the effectiveness of reconstructive lymphatic surgery is missing. Therefore, the objective of this trial is to investigate the added value of reconstructive lymphatic surgery to the conservative treatment in patients with lymphoedema. METHODS AND ANALYSIS: A multicentre randomised controlled and pragmatic trial was started in March 2022 in three Belgian university hospitals. 90 patients with arm lymphoedema and 90 patients with leg lymphoedema will be included. All patients are randomised between conservative treatment alone (control group) or conservative treatment with reconstructive lymphatic surgery (intervention group). Assessments are performed at baseline and at 1, 3, 6, 12, 18, 24 and 36 months. The primary outcome is lymphoedema-specific quality of life at 18 months. Key secondary outcomes are limb volume and duration of wearing the compression garment at 18 months. The approach of reconstructive lymphatic surgery is based on presurgical investigations including clinical examination, lymphofluoroscopy, lymphoscintigraphy, lymph MRI or CT angiography (if needed). All patients receive conservative treatment during 36 months, which is applied by the patient's own physical therapist and by the patient self. From months 7 to 12, the hours a day of wearing the compression garment are gradually decreased. ETHICS AND DISSEMINATION: The study has been approved by the ethical committees of University Hospitals Leuven, Ghent University Hospital and CHU UCL Namur. Results will be disseminated via peer-reviewed journals and presentations. TRIAL REGISTRATION NUMBER: NCT05064176.

Intrascrotal Testicular and Extratesticular Epidermoid Cysts: About Two Cases.

Painless solid testicular masses on ultrasonography are commonly malignant. However, if the lesion is well demarcated, rounded, and hypoechoic with alternating hyperechoic and hypoechoic layers, and no internal vascular flow, the possibility of an epidermoid cyst should be considered. Epidermoid cysts are uncommon benign testicular lesions and are extremely rare in the intrascrotal extratesticular region. Including these cysts in the differential diagnosis may allow the urologist to perform testis-sparing surgery. Teaching Point: The possibility of an epidermoid cyst should be considered when a scrotal mass shows an 'onion ring' appearance on sonography and no vascularity on Doppler.

Abdominal CT findings in Puumala hantavirus-infected patients.

BACKGROUND: Previous clinical studies have reported abdominal findings on ultrasonography or MRI in Puumala hantavirus-infected patients. PURPOSE: To determine if abdominal computed tomography (CT) can lead to a diagnosis of Puumala virus infection in the presence of a suggestive clinical picture. MATERIAL AND METHODS: CT findings were studied retrospectively in 30 patients who presented to the emergency department of two (Belgian) hospitals with serologically confirmed Puumala hantavirus infection. RESULTS: The most frequent finding was perirenal fascial thickening (90%), followed by perirenal fat stranding (87%). Retroperitoneal fat stranding was found in 19 patients (64%) in the perivesical spaces along the fascia of the external iliac vessels with or without involvement of the presacral fat. Half of the patients had pelvic ascites, and pleural fluid was found in 7 of them. The right and left mean pole-to-pole kidney's lengths were respectively 125.7 mm and 127.8 mm in 28 patients. CONCLUSION: Retroperitoneal fat stranding, perirenal fascial thickening and/or perirenal fat stranding were found in most patients with acute Puumala virus infection who have undergone CT. Although nonspecific, these findings may help to suggest Puumala hantavirus infection in the right clinical settings.

Early Chest Imaging in Patients with Puumala Hantavirus Infection.

PURPOSE: To describe early chest imaging abnormalities in patients with acute Puumala virus infection. MATERIALS AND METHODS: This retrospective study (2005-2017) comprised 64 patients who were admitted to the emergency department of a Belgian hospital. These patients were diagnosed with serologically confirmed acute Puumala virus infection and had at least one chest X-ray (CRX). Imaging studies were evaluated by two experienced chest radiologists reaching agreement by consensus, and abnormalities were reported according to the Fleischner Society glossary of terms for thoracic imaging. When a patient underwent multiple CRX, only the findings of the first were recorded. Six patients underwent chest high-resolution computed tomography (HRCT). RESULTS: CRX showed abnormal findings in 33 patients (51.5%). Most common findings were linear atelectasis (29.7%) and small pleural effusion (20.3%). HRCT showed interlobular septal thickening in four patients and crazy-paving pattern with consolidations in one patient with adult respiratory distress syndrome. CONCLUSIONS: Early CRX commonly showed linear atelectasis and small pleural effusion in Puumala virus infected patients above 30 years of age. Chest HRCT most frequently showed atelectasis and smooth interlobular septal thickening. While uncommon, early and severe pulmonary involvement can be associated with Puumala virus infection, albeit these findings are not specific.

Adductor Insertion Avulsion Syndrome with Proximal Femoral Shaft Stress Fracture: Not Only Found in Young Athletes.

The adductor insertion avulsion syndrome, also called "thigh splints," is usually considered a sports injury, causing thigh and groin pain. It is related to chronic traction stress of the adductor muscles at their insertion site along the posterior margin of the proximal and mid-femoral diaphysis, and it can get complicated by stress fracture. We report the case of a 64-year-old woman-significantly older than previously reported cases-with a history of complete functional loss of the right hip following intensive physiotherapy and a final diagnosis of adductor insertion avulsion syndrome.

Ultrasound in pediatric orbital cellulitis.

Orbital cellulitis is an infrequent but serious complication of sinus infections in children, as was the case of a 7-year-old who presented to the emergency room with ultrasound signs of preseptal cellulitis. Despite a well conducted antibiotic treatment a control ultrasound demonstrated associated signs of retro-septal extension. This case brings to light the essential role of ultrasound in suspected cellulitis, as a mean to differentiate between preseptal cellulitis and retroseptal (orbital) cellulitis. In the paediatric population ultrasound should be the first intention exam to diagnose the extension of the illness, and help guide the management and follow-up of the patients.

Systematic scrotum ultrasound in male infertility: what to look for.

Ultrasound is a useful, cost-effective and minimally invasive tool that can be used in the workup of male infertility. Patient history, semen analysis and hormonal results often precede ultrasound examination as a part of the workup of male factor infertility.In our article, we advocate the added value of a systematic approach of the scrotal ultrasound. We propose a checklist for the complete analysis of testicular and paratesticular structures, useful in everyday practice for both clinicians and radiologists, highlighting what can be expected of and what should be found in the radiologist's report.

Communication between the distal interphalangeal joint and the navicular bursa in the horse at Computed Tomography Arthrography.

Diffusion of drugs injected into the distal interphalangeal joint or the navicular (podotrochlear) bursa can influence diagnosis and treatment of foot pain. Previous anatomical and radiographic studies of the communication between these synovial structures have produced conflicting results and did not identify the location of any communication if present. This anatomic study aimed to assess the presence and site of communication between the distal interphalangeal joint and the navicular bursa in the horse by computed tomography arthrography. Sixty-six pairs of cadaver forelimbs were injected with contrast medium into the distal interphalangeal joint and imaged by computed tomography arthrography. The presence of a communication, location of the communication and additional structural changes were assessed. Navicular bursa opacification occurred in 7 distal limbs (5.3%) following distal interphalangeal joint injection. One limb showed a communication through the T-ligament and 6 limbs showed a communication through the distal sesamoidean impar ligament. In 3 cases, the communication through the distal sesamoidean impar ligament was associated with a distal border fragment. Our study showed that communication between the distal interphalangeal joint and navicular bursa is uncommon and inconsistent. Clinically, the presence of a communication could (1) influence the interpretation of diagnostic analgesia of the distal interphalangeal joint or the navicular bursa by facilitating the diffusion of local anaesthetic between these structures; (2) allow the drug and its potential adverse effects to spread from the treated synovial cavity to the non-targeted synovial cavity; (3) be responsible for the failure of joint drainage in the case of sepsis.