Lipoma arborescens with patellofemoral osteoarthritis and genu valgum.

Lipoma arborescens is a rare benign intra articular lesion characterized by lipomatous proliferation of the synovium. The condition typically affects the knee presenting with atraumatic pain and swelling. It should be considered in the differential diagnosis of monoarthritis and joint effusion. Diagnosis is made on MRI with characteristic features. We present a rare case of lipoma arborescens with patellofemoral osteoarthritis and genu valgum. We discuss the clinical presentation, radiological findings, and management.

Gluteus medius calcific tendonitis as a cause of severe anterior hip pain.

Calcific tendinopathy in the gluteus medius is uncommon and sporadically reported. It may be asymptomatic or present with acute or chronic pain. Pain is usually isolated to the lateral hip overlying the gluteal muscles or greater trochanter. We present a rare case of gluteus medius calcific tendonitis as a cause of severe anterior hip pain. Given the atypical local and clinical presentation these can be often misdiagnosed as septic arthritis or fracture which may lead to overtreatment and even unnecessary surgery. This article will detail the clinical presentation, imaging findings, and clinical course following treatment. This will facilitate the clinician in making a timely diagnosis and establishing an effective treatment course.

Grade III distal medial collateral ligament rupture co-existing with transient lateral patellar dislocation.

Lateral patellar dislocations are the second most common type of traumatic knee injury, accounting for approximately 2-3% of cases, the most common being anterior cruciate ligament (ACL) injury. There are several well-documented anatomical risk factors predisposing to patellofemoral instability for example: patella alta, trochlear dysplasia, ligamentous laxity, and genu valgum. Co-existing medial collateral ligament injury in cases of patellar dislocations in the absence of ACL injury is uncommon and infrequently reported in the literature. The authors present a case of a 14-year-old boy presenting with a left knee injury while playing football who was diagnosed on magnetic resonance imaging (MRI) with a transient lateral patellar dislocation, high-grade medial patellofemoral ligament (MPFL) injury and a full thickness (grade III) injury to the distal medial collateral ligament.

Coronary stent-graft use to salvage a juxta-anastomotic arterial rupture complicating a case of radio-cephalic fistuloplasty.

BACKGROUND: Stenosis is a common complication of haemodialysis arteriovenous accesses. Endovascular approaches with percutaneous transluminal fistuloplasty have largely replaced open surgical approaches as first line treatment. Vessel rupture is an uncommon complication of fistuloplasty and most reports describe venous rupture. Stent-graft deployment can salvage this, however, its use requires careful assessment of the distal vasculature. Arterial rupture with fistuloplasty has rarely been described in the literature. This is a novel case describing the use of a BeGraft coronary stent-graft to manage juxta-anastomotic arterial rupture and pseudoaneurysm complicating fistuloplasty. CASE PRESENTATION: A 77 year old female with end stage renal failure secondary to systemic amyloid light chain type amyloidosis was referred for a suspected radio-cephalic arteriovenous fistula stenosis after difficulty cannulating with poor flow during dialysis and clinical reduction in the fistula thrill. Both Doppler ultrasound and intravenous fistulography confirmed a venous stenosis 2 cm distal to the anastomosis. The stenosis was treated by fistuloplasty, however, this was complicated by a rupture of the juxta-anastomotic arterial segment intraoperatively. Intermittent balloon tamponade was used to minimise extravasation although a pseudoaneurysm formed within the damaged arterial segment. The patient's distal neurovascular status was assessed using the Barbeau test and we sonographically confirmed adequate retrograde arterial flow via a complete palmar arch directing blood from the ulnar artery. After discussion with the renal transplant team, a 4 mm BeGraft coronary stent-graft was deployed to control haemorrhage and bypass the pseudoaneurysm until adequate haemostasis and fistula flow was achieved. Follow-up 3 months post-procedure reported the patient continued with haemodialysis using the stented fistula with no further complications. CONCLUSIONS: To our knowledge, this is the first case report describing the application of BeGraft coronary stent-grafts to salvage fistuloplasty of a radio-cephalic arteriovenous fistula stenosis complicated by juxta-anastomotic arterial rupture and pseudoaneurysm formation. We demonstrate the safety and short-term efficacy of this technology.

Mycotic internal carotid artery pseudoaneurysm secondary to Mycobacterium tuberculosis.

Mycobacterium tuberculosis is a rare causative agent for mycotic aneurysms of the extracranial carotid arteries. We describe a case of acute mycotic pseudoaneurysm and abscess in the right proximal internal carotid artery in close proximity to the carotid bifurcation, and subsequent management with antibiotic therapy, surgical debridement and resection with an end-to-end anastomosis.

Tension hydrothorax in a patient with SARS-CoV-2 pneumonitis and pleural Mycobacterium tuberculosis.

Unilateral pleural effusions are uncommonly reported in patients with SARS-CoV-2 pneumonitis. Herein, we report a case of a 42-year-old woman who presented to hospital with worsening dyspnoea on a background of a 2-week history of typical SARS-CoV-2 symptoms. On admission to the emergency department, the patient was severely hypoxic and hypotensive. A chest radiograph demonstrated a large left-sided pleural effusion with associated contralateral mediastinal shift (tension hydrothorax) and typical SARS-CoV-2 changes within the right lung. She was treated with thoracocentesis in which 2 L of serosanguinous, lymphocyte-rich fluid was drained from the left lung pleura. Following incubation, the pleural aspirate sample tested positive for Mycobacterium tuberculosis This case demonstrates the need to exclude non-SARS-CoV-2-related causes of pleural effusions, particularly when patients present in an atypical manner, that is, with tension hydrothorax. Given the non-specific symptomatology of SARS-CoV-2 pneumonitis, this case illustrates the importance of excluding other causes of respiratory distress.

Giant parapharyngeal high-flow arteriovenous malformation causing airway compromise: emergency embolo-sclerotherapy via an endovascular-only approach.

Head and neck arteriovenous malformations are the commonest extracranial vascular malformations but demonstrate a unique challenge in the limited available surgical options secondary to their intimate association to vital structures. We present a case of middle-aged female patient who presented with threatened upper-airway obstruction and bleeding secondary to a slowly enlarging parapharyngeal arteriovenous malformations. She was treated with an endovascular-only approach with the proximal arteriole branches selectively undergoing embolo-sclerotherapy with an optimal radiological and clinical outcome. We also demonstrate the utility of elective tracheostomy prior to intervention.

Horseshoe adrenal gland associated with type 1 diastematomyelia in an asymptomatic adult.

A horseshoe adrenal gland is a rare congenital anomaly found almost exclusively in neonates and infants based on autopsy studies. It is a term used to describe a solitary adrenal gland situated in the midline, posterior to the inferior vena cava and abdominal aorta. To date, in the literature, there have been very few cases documented in adults and they have also been reported to be associated with other co-existing intra-abdominal, vascular and vertebral congenital anomalies. We describe a rare case of an asymptomatic adult patient who was incidentally found to have a horseshoe adrenal gland as well as a Type 1 diastematomyelia.

Asymptomatic peritoneal tuberculosis in a patient with a non-remitting fever and isolated pulmonary symptoms: a case report and literature review.

Tuberculosis (TB) remains one of the leading causes of death globally. Although abdominal or peritoneal TB is a recognised site for extrapulmonary TB to manifest, the diagnosis is often delayed due to the non-specific nature of the presenting clinical features. We present the diagnostically challenging case of a 32-year-old patient with recurrent episodes of fever and a non-productive cough that was initially treated as community-acquired pneumonia with oral antibiotics. A computed tomography scan of the thorax was unrevealing, aside from a large volume of ascites within the partially imaged upper abdomen. The patient did not report any abdominal symptoms and the abdominal examination was unremarkable. Subsequently, a transvaginal ultrasound, a contrast-enhanced computed tomography scan of the abdomen and pelvis, and magnetic resonance imaging of the abdomen and pelvis confirmed a large volume of ascites in the absence of any definite aetiology. A peritoneal biopsy was required before the diagnosis of peritoneal TB was eventually confirmed. This case highlights the importance of considering peritoneal TB in patients presenting with treatment-resistant chest symptoms and persistent pyrexia of undetermined aetiology, even in the absence of abdominal signs and symptoms.

Illuminating the nidus: The role of FDG PET/CT in high flow arteriovenous vascular malformations.

The appropriate identification and localization of a nidus of a high flow arteriovenous malformation is crucial to guide targeted interventional therapy. However, the nidus of a complex or previously treated HFAVM can be difficult to non-invasively demonstrate on magnetic resonance imaging alone. We describe a unique case of a 56-year-old female with a complex high flow arteriovenous malformation in which we demonstrated the feasibility of fluorodeoxyglucose positron emission tomography/computed tomography to non-invasively delineate the nidus which subsequently guided successful targeted interventional therapy.

Pulmonary artery pseudoaneurysm secondary to COVID-19 treated with endovascular embolisation.

Pulmonary artery pseudoaneurysms are uncommon and can cause severe, life-threatening haemoptysis. We present a case of a 74-year-old gentleman who was being treated for COVID-19 pneumonitis and a concomitant segmental pulmonary artery thrombus with conventional treatment and anticoagulation. The patient developed significant haemoptysis during admission. A repeat computed tomography pulmonary angiogram revealed an 8 mm left upper lobe pulmonary artery pseudoaneurysm. Anticoagulation was withheld and the pseudoaneurysm was successfully treated with endovascular embolisation with an Amplatzer® IV plug, leading to resolution of the haemoptysis. To our knowledge this is the first case of a pulmonary artery pseudoaneurysm secondary to COVID-19.

Guillain-Barre syndrome following the first dose of the chimpanzee adenovirus-vectored COVID-19 vaccine, ChAdOx1.

Prevention strategies for COVID-19 transmission are at the forefront of healthcare paradigms worldwide, the main emphasis of which is vaccination. We present an interesting case of a 37-year-old man who, 3 weeks following his first dose of the chimpanzee adenovirus-vectored COVID-19 vaccine, ChAdOx1, presented to hospital with a rapidly progressive ascending muscle weakness and back pain in the absence of any other triggers. He also had a negative COVID-19 swab during admission. A diagnosis of Guillain-Barre syndrome was confirmed by correlating the clinical features with cerebrospinal fluid analysis, nerve conduction studies and MRI of the brain and whole spine. The patient received treatment with 5 days of intravenous immunoglobulin and did not require any respiratory support. He was also regularly reviewed by a multidisciplinary team consisting of neurologists, speech and language therapists, and physiotherapists and is on the course to a recovery.

Splenic artery pseudoaneurysm: Challenges of non-invasive and endovascular diagnosis and management.

Splenic artery pseudoaneurysms (PAs) are uncommon and often occur as a complication of pancreatitis or trauma. Unlike true aneurysms, PAs are symptomatic in a majority of cases and patients can present with a constellation of non-specific symptoms. Diagnosis can be challenging due to variation in presenting features and mimicking pathologies. PAs are associated with a very high morbidity and mortality if left untreated. We present an unusual case of a 47-year-old gentleman diagnosed with a splenic artery pseudoaneurysm despite initial negative catheter angiography and discuss the challenges of splenic artery pseudoaneurysm diagnosis and management.

Bilateral sternocleidomastoid pseudotumors-a case report and literature review.

Sternocleidomastoid (SCM) pseudotumors, also known as fibromatosis colli or congenital torticollis, are painless benign neck lumps found in newborns. Whilst unilateral cases are relatively common, bilateral SCM pseudotumors are a rare phenomenon with only a handful of cases reported internationally. We present the case of a 5-week-old infant who was brought to the emergency department with painless, bilateral, palpable anterior neck masses following a slightly traumatic but otherwise uncomplicated spontaneous delivery. An ultrasound scan of his neck revealed well-defined soft tissue lesions within both of the SCM muscles. He was subsequently diagnosed with bilateral SCM pseudotumors. This case emphasizes the importance of considering this entity as a differential diagnosis in infants presenting with bilateral palpable neck masses.

Superior ophthalmic vein thrombosis secondary to COVID-19: an index case.

Superior ophthalmic vein thrombosis is a very rare condition, known to have a profound negative impact on vision and eye movement function and is usually associated with orbital infections, inflammation, tumors, or carotid cavernous fistulae. There is an increased risk of arterial and venous thrombosis associated with COVID-19, the presence of which is related to a significantly increased risk of mortality. We report an index case of superior ophthalmic vein thrombosis in a 61-year-old male patient who was diagnosed with COVID-19 pneumonitis and a concomitant saddle pulmonary embolus. He was swiftly treated with low molecular weight heparin which led to the resolution of the thrombosis within 3 weeks. This case highlights the importance of considering this entity in the context of COVID-19 as well as providing prompt treatment to reduce the risk of complications.

Metastatic renal cell carcinoma initially presenting as a unilateral breast lump.

Breast metastasis from primary renal cell carcinoma is a rare entity and infrequently reported in the literature. We present a case of a 65-year-old lady who presented to breast clinic with a 4-month history of rapidly growing right sided breast lump. She previously had a left mastectomy for breast cancer and a hysterectomy for endometrial cancer. Radiological evaluation with mammography and ultrasound revealed a large heterogeneous right breast lump with prominent vascularity which was biopsied. Histopathological and immunohistochemical features were not supportive of a primary breast carcinoma and favored metastasis from a renal tumor. The patient was unfortunately admitted to hospital due to increasing confusion and neurological symptoms and underwent whole-body cross-sectional CT imaging which demonstrated a giant tumor originating from the right kidney with associated intrathoracic, breast and intracranial metastasis. She was diagnosed with eosinophilic variant metastatic renal cell carcinoma. This case highlights the importance of considering alternative diagnoses to primary breast carcinoma in the context of an initial presentation of a unilateral breast lump.

Comminuted nasogastric tube fracture: a rare complication.

A nasogastric tube is commonly used as a method of enteral feeding or gastric decompression in clinical practice and its insertion is occasionally associated with local complications. In this case report, we present an extremely rare complication of a comminuted nasogastric tube fracture in a 54-year-old male patient receiving enteral feeding in hospital secondary to a diagnosis of haemophagocytic lymphohistiocytosis.

Gallbladder carcinosarcoma masquerading as a hepatic abscess.

Carcinosarcomas of the gallbladder are extremely rare tumors and infrequently reported in the literature. We demonstrate a case of a 64-year-old female who presented with a 2-month history of a right upper quadrant mass, intermittent fevers, and abdominal distension following recent travel to Ghana. A computed tomography (CT) scan of the abdomen and pelvis demonstrated a large hepatic lesion with co-existing gallbladder distension, suggestive of a hepatic abscess. The patient was initially managed with intravenous antibiotics but failed to respond to treatment. A subsequent magnetic resonance imaging (MRI) scan of the liver showed a locally invasive lobulated soft tissue lesion arising from the gallbladder fundus and extending into the liver parenchyma. The lesion was surgically excised with a central hepatectomy. Histopathologic analysis showed a carcinosarcoma of the gallbladder.

Multifocal pancreatobiliary malignancies: A diagnostic and therapeutic challenge.

The synchronous presentation of multifocal pancreatobiliary tumors is a rare occurrence and can prove to be a significant diagnostic and therapeutic challenge. We describe the case of a 70-year-old female who presented with a 2-week history of jaundice, reduced appetite, and mild epigastric discomfort of insidious onset. Radiological evaluation with computed tomography and magnetic resonance imaging demonstrated features consistent with a hilar cholangiocarcinoma , also known as a Klatskin tumor, involving both the cystic duct and gallbladder neck. In addition to this, a pancreatic neoplasm with associated splenic vein occlusion and metastatic deposits in the liver and lung were identified. The patient was managed with percutaneous transhepatic external biliary drainage and stenting by interventional radiology. Cytology results from the brushings obtained from the aforementioned procedure were nondiagnostic. Core biopsies were performed of the pancreatic lesion; the histopathological results of which were in keeping with pancreatic ductal adenocarcinoma . The patient was scheduled for chemotherapy however unfortunately deteriorated clinically prior to commencement. This case highlights the diagnostic and management challenges of synchronous pancreatobiliary malignancies.

Stress myocardial perfusion with qualitative magnetic resonance and quantitative dynamic computed tomography: comparison of diagnostic performance and incremental value over coronary computed tomography angiography.

AIMS: Assessment of haemodynamically significant coronary artery disease (CAD) using cardiovascular magnetic resonance (CMR) imaging perfusion or dynamic stress myocardial perfusion imaging by computed tomography (CT perfusion) may aid patient selection for invasive coronary angiography (ICA). We evaluated the diagnostic performance and incremental value of qualitative CMR perfusion and quantitative CT perfusion complementary to cardiac computed tomography angiography (CCTA) for the diagnosis of haemodynamically significant CAD using fractional flow reserve (FFR) and quantitative coronary angiography (QCA) as reference standard. METHODS AND RESULTS: CCTA, qualitative visual CMR perfusion, visual CT perfusion, and quantitative relative myocardial blood flow (CT-MBF) were performed in patients with stable angina pectoris. FFR was measured in coronary vessels with stenosis visually estimated between 30% and 90% diameter reduction on ICA. Haemodynamically significant CAD was defined as FFR <0.80, or QCA ≥80% in those cases where FFR could not be performed. A total of 218 vessels from 93 patients were assessed. An optimal cut-off of 0.72 for relative CT-MBF was determined. The diagnostic performances (area under the receiver-operating characteristics curves, 95% CI) of visual CMR perfusion (0.84, 0.77-0.90) and relative CT-MBF (0.86, 0.81-0.92) were comparable and outperformed visual CT perfusion (0.64, 0.57-0.71). In combination with CCTA ≥50%, CCTA + visual CMR perfusion (0.91, 0.86-0.96), CCTA + relative CT-MBF (0.92, 0.88-0.96), and CCTA + visual CT perfusion (0.82, 0.75-0.90) improved discrimination compared with CCTA alone (all P < 0.05). CONCLUSION: Visual CMR perfusion and relative CT-MBF outperformed visual CT perfusion and provided incremental discrimination compared with CCTA alone for the diagnosis of haemodynamically significant CAD.