Skeletal changes mimicking intrathoracic disease on chest radiographs.

Various chest radiographs are illustrated to demonstrate features where bony changes may mimic intrathoracic disease. To confirm the skeletal origin and nature, further conventional radiographs often suffice, and the need for CT or scintigraphy may therefore be obviated. At the time of presentation for radiography of the chest, further pertinent clinical details can be obtained from the patient by the department staff, as required. All previous radiographs and radiological reports should be readily available. In order to add to the educational value of the 13 cases illustrated, all are presented in quiz format, with the answers and further images included in the text.

Fluid-calcium level in the thigh versus clinical diagnosis of a soft-tissue abscess: ultrasound features of dermatomyositis.

Ultrasound features of a fluid-calcium level in a soft-tissue mass in the thigh in dermatomyositis are described. As the mass was tender, a soft-tissue abscess required to be excluded by aspiration.

Incidental computed tomography diagnosis of a giant oesophageal leiomyosarcoma.

Leiomyosarcoma of the oesophagus is a very unusual tumour; only 53 cases have been reported in the English-language literature. A case is reported here of a patient with a giant leiomyosarcoma, without any symptoms of dysphagia. The diagnosis was made incidentally during CT examination of the chest for detection of possible pulmonary metastases from a coexisting carcinoma of the bladder. This was confirmed by a barium swallow, oesophagoscopy and tissue diagnosis. The literature pertaining to this most uncommon tumour is reviewed.

Significance of short tau inversion recovery magnetic resonance sequence in the management of skeletal injuries.

The conventional radiographs and urgent short tau inversion recovery (STIR) magnetic resonance image (MRI) examinations of 27 consecutive patients with occult bony injuries were prospectively analysed over a 12 month period. A STIR MRI study was undertaken where the plain films were normal (n = 15) or inconclusive (n = 12) and where the patients' clinical setting was highly suggestive of an underlying bony injury. In six patients, MRI only revealed soft-tissue injuries or joint effusions and did not demonstrate any bony injury but in the remainder fractures or bone contusions were shown to be present. The MRI studies were performed on a 0.2 Tesla lower field strength unit and the examinations were expeditiously performed, inexpensive, and done on a priority basis between electively booked patients. Radio-isotope studies were not available and hence were not included in the study protocol. Apart from demonstrating the value of STIR MRI (without additional T1-weighted sequences in most patients), the purpose of this study was to highlight the alteration in management in 18/27 patients (66%) and the significant alteration in management in six of these patients.

Concomitant presentation and resolution of a post-traumatic pneumothorax and pneumopericardium.

The association of a right pneumothorax and a pneumopericardium due to non-penetrating trauma is exceedingly unusual. A patient with both complications presented 7 hours after a motorcycle accident. These were detected incidentally on a scout film for CT for lumbar fractures and both resolved entirely and simultaneously after chest tube insertion in the right pleural space.

Radiological imaging of a massive dermoid in the male pelvis.

A dermoid cyst, arising from the posterior aspects of the prostate and seminal vesicles, and extending into the pelvis to masquerade as a full bladder, must be exceedingly rare. Ultrasound, computed tomography and especially magnetic resonance imaging (MRI) proved to be invaluable in making the diagnosis, and MRI in particular was very useful in providing an anatomical road map for surgery.

Simultaneous detection of esophageal and gastric carcinomas.

The case histories of six patients are presented where the diagnosis of carcinoma of the esophagus and the stomach was made at the same time by barium studies. The clinical history was elusive in two patients. In four of the six patients, histological proof of squamous carcinoma of the esophagus and adenocarcinoma of the stomach was obtained, but in the other two biopsy of the gastric lesion was not possible because of the extensive esophageal cancer.

Computed tomography of the breast: a valuable adjunct to mammography in selected cases.

Computed tomography (CT) is not often used for the further assessment of a mass in the breast. In the case presented it proved to be invaluable in demonstrating a very posterior breast mass previously suboptimally demonstrated on mammography, not palpable clinically, and not visualized on ultrasound examination. The predicament of a very posterior breast mass is highlighted and it is suggested that present-day routine craniocaudal and oblique views may not be adequate to show such a mass even if meticulous attention to radiographic technique is given. If the supine-oblique view with balloon compression cannot be obtained, CT in the prone position with the breasts dependent may be the best alternative. Fine needle aspiration biopsy can be performed under CT guidance in such cases.

Chest radiographs of neonates with respiratory failure caused by congenital syphilis.

Congenital syphilis still occurs in newborn babies and the prevalence has increased in recent years, especially in developing countries. This has led to an increase in the number of babies with congenital syphilis requiring intensive care for respiratory failure. The early recognition of this disease could lead to the institution of timely and appropriate treatment. In this study the radiological picture of syphilitic pneumonitis is described in 20 neonates admitted to our neonatal intensive care unit requiring ventilation for respiratory failure. The radiological picture of the babies with syphilis was compared to 20 babies with other causes of respiratory distress. The radiological picture in 17 babies demonstrated a coarse nodular pattern in addition to band-like opacities radiating from the hilar regions. The nodular opacities became confluent on follow-up radiographs. In 13 cases, the proximal humeri showed changes typical of congenital syphilis. Two of the three babies with syphilis who did not have the typical chest radiological picture had bony involvement visible on the chest radiograph. Both the sensitivity and specificity of radiographic diagnosis were 75% with a positive and negative predictive value of 75%. The diagnosis of congenital syphilitic pneumonitis can therefore be suspected on chest radiographs and should be included in the differential diagnosis of any baby who presents with an interstitial pattern on chest radiography.

Vanishing pleural fluid collections in cardiac failure simulating lung tumours.

Vanishing fluid collections in interlobar fissures, associated with congestive cardiac failure, are uncommon but well-recognized. Previous studies have highlighted the occurrence of solitary vanishing 'tumours', but in the study reported here 7 out of 12 consecutive patients presented with more than one interlobar fluid collection simulating pulmonary tumours. In most cases a lateral radiograph confirmed the correct diagnosis and in all cases follow-up radiographs demonstrated resolution of all pleural fluid collections. In one case ultrasound was helpful. Making the correct diagnosis is very important in order to prevent inappropriate investigations and treatment such as biopsy or surgery. It is suggested that unusual pleural fluid collections may be more common in communities where pleural disease following stab wounds or tuberculosis are more prevalent.

Atypical fat necrosis of the breast: the 'mycetoma' appearance.

A very unusual appearance of fat necrosis in the breast is described. The low density/hypo-echoic rim and high density/hyperechoic central part are shown on mammography and ultrasound, respectively. The mass had the appearance of a 'mycetoma' in a cavity in the lung. The radiological diagnosis of fat necrosis was confirmed by histopathology.

Stab wounds of the heart: two new signs of pneumopericardium.

The diagnosis of a small traumatic pneumopericardium may be difficult and differentiation from a left medial pneumothorax or pneumomediastinum is important. Two new signs which only occur in pneumopericardium are described: the "transverse band of air" sign on the frontal radiograph representing air in the transverse sinus of the pericardium, and the "triangle of air" sign as noted on the lateral radiograph. If there is still doubt, a left-side-down decubitus radiograph will establish the diagnosis.

Mucocele of the surgically isolated esophagus.

A large esophageal mucocele causing chest pain developed in a 26-year-old woman who had undergone esophageal bypass surgery and gastric interposition because of involvement by scleroderma. Computed tomographic (CT) scans showed the mucocele as an elongated mediastinal mass which spontaneously reduced in size during conservative management. The clinical and radiological features of this unusual postsurgical complication are herein reviewed.

Localized loss of the infrabronchial descending aortic interface as a normal variant.

Localized loss of the aortic interface may occur as a normal variant or may be due to an adjacent mass or opacification. The former category is divided into four types depending on position and length of loss of interface. The findings on conventional chest radiographs are correlated with computed tomographic findings.