Recurrent meningitis in an adult secondary to an inner ear malformation: imaging demonstration.

Congenital labyrinthine dysplasia with a translabyrinthine cerebrospinal fluid (CSF) fistula may be an anatomic cause for recurrent meningitis. This condition is usually seen in children aged 5 to 10 years who present with sensorineural hearing loss (SNHL) and CSF discharge through the nose or ear, with or without recurrent meningitis. Multidetector-row computed tomography (MDCT) and high-resolution T2-weighted magnetic resonance imaging (MRI) of the petrous portion of the temporal bone can help to diagnose this abnormality. We report a case of translabyrinthine CSF fistula in an adult-a 30-year-old man-who presented with recurrent pneumococcal meningitis, a long history of a clear nasal discharge, and evidence of SNHL. MDCT and MRI of the temporal bone demonstrated a cystic-appearing cochleovestibular malformation (an incomplete partition type I) in the right inner ear. Imaging also showed an absence of the basal turn of the cochlea and the cribriform membrane at the lateral end of the right internal auditory canal, which was shorter and narrower than normal. Evidence of fluid in the right middle ear suggested a CSF fistula.

Optochiasmatic tuberculomas: a vision-threatening paradoxical response in tuberculous meningitis.

The single main cause of death from infectious diseases worldwide is tuberculosis, which is more prevalent in developing countries. Tuberculous meningitis (TBM) is a severe form of TB in which morbidity and mortality depend upon the stage of presentation. Intracranial brain parenchymal tuberculomas may form paradoxically, days to months after starting antituberculous drug therapy. Tuberculomas may develop in and around he optic chiasm and optic nerves after institution of antituberculous treatment as a quite rare occurrence in TBM; this may lead to severe visual loss if not treated properly. We describe a 56-year-old man with documented TBM being treated with first line antituberculous drugs who developed visual impairment 2 months after starting the treatment. MRI after gadolinium administration revealed multiple perichiasmatic and a few parenchymal ring enhancing lesions due to tuberculomas. The patient was treated with corticosteroids and antituberculous therapy was continued after which he recovered his vision gradually. Visual impairment developing in a patient on treatment with antituberculous drugs should give rise to a suspicion of rare optochiasmatic tuberculomas; this necessitates urgent contrast-enhanced MRI of the brain and prompt treatment with steroids.

Subcutaneous emphysema due to bronchial foreign body demonstrated by multidetector-row computed tomography.

Foreign body aspiration is an important cause of emergency hospital admissions in young children less than 3 years of age. It may manifest with acute respiratory difficulty, choking and wheeze acutely or may be asymptomatic. Surgical emphysema is an unusual presentation of bronchial foreign body aspiration in young children. We describe an infant with bronchial foreign body aspiration that manifested with subcutaneous emphysema and pneumomediastinum. Multidetector-row CT with virtual bronchoscopy helped in the diagnosis by detecting and localizing the intraluminal foreign body in the right main bronchus that was removed with rigid bronchoscopy.

Hemobilia in a child due to right hepatic artery pseudoaneurysm: multidetector-row computed tomography demonstration.

We present a case of a 12-year-old boy who developed upper gastrointestinal bleeding in the form of hematemesis and melena 1 month after blunt trauma to liver. Computed tomography (CT) angiography with multidetector-row CT demonstrated pseudoaneurysm of right hepatic artery related to old liver laceration to be the cause of the bleeding. Pseudoaneurysm was resected using the roadmap provided by CT angiography findings.

Perinephric fluid collections due to renal lymphangiectasia.

Fluid collections around the kidneys on cross-sectional imaging may be caused by urine, blood, pus, lymph, or plasma. Ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) can not only show and characterize the fluid, but also may help determine the underlying cause of the perinephric fluid collection, such as ureteric obstruction, kidney injury, infection, or renal lymphangiectasia. Renal lymphangiectasia is characterized by abnormal and ectatic lymphatic vessels within and around the kidneys. Dilated lymphatics may result in peripelvic cysts (intrarenal lymphangiectasia) and perinephric fluid collections (extrarenal lymphangiectasia), which can be visualized using US, CT, and MRI. Proper diagnosis on imaging helps in planning a conservative management approach to this benign condition, which requires intervention for only significant symptoms or complications. We describe a 60-year-old man with normal kidney function and bilateral perinephric fluid collections in whom renal lymphangiectasia was diagnosed noninvasively on the basis of characteristic findings on US, CT, and MRI.

Intrabiliary rupture of hepatic hydatid cyst: multidetector-row CT demonstration.

Rupture of a hydatid cyst into the biliary tract, also known as cystobiliary communication, is the most common complication of hepatic hydatid cyst. This may lead to obstructive jaundice, pancreatitis, cholangitis, and sepsis with high mortality. Imaging plays an important role in the preoperative diagnosis of this condition which facilitates its management. We studied six patients with rupture of hepatic hydatid cyst into a large bile duct in whom multidetector-row CT (MDCT) suggested the diagnosis. The imaging findings included a single hepatic cyst less than 10 cm in diameter in all the cases; interruption of the cyst wall adjacent to a bile duct signifying cyst-bile duct communication was seen in five patients. The common bile duct was dilated in all the patients, with linear membranes in four and diffuse irregular high dense intrabiliary material observed within the common bile duct in two of them. Intrahepatic ducts were dilated in all the six cases and two patients showed linear dense contents within distended gallbladder. Subcapsular and intrathoracic rupture was associated in one patient each. MDCT demonstration of hydatid cyst in the liver together with a dilated common bile duct and distended gallbladder containing high density hydatid material suggest rupture of the cyst into biliary tree. MDCT enhances demonstration of the dilated common bile duct with hydatid material inside. The diagnosis is reinforced by the demonstration of the cystobiliary communication itself.

Klebsiella brain abscess in a neonate.

Klebsiella pneumoniae is rarely associated with neonatal cerebral abscess. A case of Klebsiella brain abscess in a neonate is described. Diagnosis of abscess was confirmed by magnetic resonance imaging and ultrasound-guided aspiration.

Sagittal sinus thrombosis due to L-asparaginase.

Cerebral Sinovenous Thrombosis (CSVT) is a serious complication of L-asparaginase chemotherapy for leukemia in children. Clinical features of headache, altered consciousness, focal neurological deficit, and seizures developing during or immediately after treatment with L-asparaginase should alert the treating physician to the possibility of CSVT. Immediate imaging of the brain should be done using CT and MRI and the veins should be visualized noninvasively by CT and MR venography. We report two children on induction therapy for acute leukemia who presented with seizures, headache, and altered consciousness. Venous infarcts with and without hemorrhage were seen on CT in one patient and the empty delta sign was seen after contrast injection; however, the early changes were missed by CT. MRI detected dural sinus thrombosis relatively earlier in another patient, while the CT findings were equivocal; in this patient, contrast-enhanced MRI showed the empty delta sign and MR venography confirmed absent flow in the superior sagittal sinus, which was diagnostic of sinus thrombosis. Rapid anticoagulation was started with heparin and maintained with warfarin. The child with a unilateral small nonhemorrhagic infarct made a complete recovery while the other, with bilateral hemorrhagic infarcts, did not survive. We stress the importance of early diagnosis of CSVT using CT and MRI in children with leukemia being treated with L-asparaginase; this will permit timely treatment.

Giant adrenal myelolipoma: Incidentaloma with a rare incidental association.

Adrenal myelolipoma is an unusual, benign and biochemically inactive tumor that is composed of mature adipose and hematopoietic tissue. It is usually diagnosed accidentally and nowadays much more frequently because of widespread use of ultrasonography, computed tomography (CT) and magnetic resonance imaging. Adrenal myelolipoma is usually unilateral and asymptomatic, though known to be associated with obesity, hypertension, endocrinological disorders and some malignancies. We report herein two cases of right-sided giant adrenal myelolipoma diagnosed by multidetector-row CT. One patient was symptomatic because of a large mass in the right upper abdomen, which on imaging with CT was seen to be right adrenal myelolipoma. Another patient had a large left side Bochdalek hernia and right adrenal myelolipoma was incidentally discovered on CT.

Perinephric abscess caused by ruptured retrocecal appendix: MDCT demonstration.

Acute appendicitis may occasionally become extraordinarily complicated and life threatening yet difficult to diagnose. One such presentation is described in a 60-year-old man who was brought to the hospital due to right lumbar pain and fever for the last 15 days. Ultrasonography showed a right perinephric gas and fluid collection. Abdominal computed tomography with multidetector-row CT (MDCT) revealed gas-containing abscess in the right retroperitoneal region involving the perinephric space, extending from the lower pole of the right kidney up to the bare area of the liver. Inflamed retrocecal appendix was seen on thick multiplanar reformat images with its tip at the lower extent of the abscess. Laparotomy and retroperitoneal exploration were performed immediately and a large volume of foul smelling pus was drained. A ruptured retrocecal appendix was confirmed as the cause of the abscess.

Multidetector-row computed tomography in cerebral hydatid cyst.

Intracranial localization is a rare manifestation of hydatid cyst disease (Echinococcosis). It comprises only 2% of cases of Echinococcosis infection even in endemic areas and is predominantly seen in children. Clinical manifestations resulting from raised intracranial tension are nonspecific. Imaging with computed tomography (CT) may suggest the diagnosis preoperatively with reasonable accuracy. Multidetector-row CT (MDCT) with its high resolution multiplanar reformations can demonstrate the relationship of the cyst with adjacent brain structures and thus help in planning surgery. This has a practical utility in places where magnetic resonance imaging is not available. We describe a case of cerebral hydatid cyst in a 13-year-old boy who was diagnosed with MDCT, which helped in planning its surgical removal.