Quick one today. Take a look at Patient A and Patient B.
Patient A has a smooth focal indentation of the posterior cervical esophagus.
Patient B has a broader indentation that is also irregular and nodular along its contour.
Patient A has a cricopharyngeal bar, which is a prominence caused by the cricopharyngeus muscle that can cause dysphagia if it gets really prominent. Patient B has esophageal squamous cell carcinoma.
I think these are valid concerns, once again, and must be discussed and hashed out so that everyone is on the same page.
The medical field has a long history of sharing cases for education, and I would say radiology definitely is one of the fields where this is done more often than not, due to the complexity of cases, use of imaging, which is a format that makes it easier to share. I would also say that radiology is quicker to embrace new technologies, including use of the internet and social media, due to reliance on technology to begin with. For example, you can find on twitter, of all places, many case presentations and discussions, many by prominent leaders in the field. Almost all the major radiology societies have some case series for perusal, there’s Radiopaedia as I already mentioned, and the largest community I’m aware of is r/radiology, which I modeled this community after.
I understand there’s a slippery slope between posting educational content and entertainment content. I intend to firmly keep us away from the entertainment side. While I do not want this community to fall into a somber tone, I will not tolerate posts or comments intended to mock or demean a case/patient.
In regards to data harvesting - interesting thought. I had to dig a little bit. There’s definitely been some publications that deal with large medical imaging datasets wherein AI was able to use the high resolution imaging to identify patient features, including 3D reconstruction of the face from the data. The images posted here are: 1) regular .jpgs and not high resolution files like dicom, 2) limited to a couple of images when a full CT can be in the hundreds, and 3) been through photoshop, powerpoint, possibly multiple saves though jpg with degradation each time, or they’re crappy phone camera images of a medical image. I can’t say the risk is absolutely 0, but it’s pretty close - by staying within medical privacy laws and avoiding super rare presentations of things.
However, your concerns have been my concerns too, so I have also reached out to the .world admins for their thoughts. Perhaps they don’t feel comfortable hosting this type of content, or would like to see some other assurances. I will find out and proceed from there.
Yes that's correct, it's the levamisole that presented as demyelination in this case.
Cocaine by itself can also cause problems, which I would categorize in 3 ways:
Sudden-onset issues that are potentially life-threatening. Cocaine is a stimulant, which can raise blood pressure, heart rate, etc. Those effects can cause ischemic stroke, hemorrhagic stroke, rupture of pre-existing aneurysms (with subsequent intracranial hemorrhage), and seizures, all of which can show up on brain imaging.
Long-term issues. These are insidious, subtle changes from repeated use of cocaine, which will damage the brain through neurotoxicity + the long-term results of an accumulation of events from #1.
Complications from cocaine use. I would put levamisole in this category. For other drugs that are more commonly injected (rather than snorted or smoked), brain infections from use of dirty needles would also go into this category.
Thank you for this comment, because it brings up some very important issues, which I hope this reply addresses.
The biggest issue is the matter of patient confidentiality. This is of utmost concern in an online medical community, especially one wherein clinical vignettes are presented. I take extreme care to avoid including any information that can narrow down to a patient, thus breaching confidentiality. Similarly, I expect anyone else commenting or posting here to follow this rule, Rule 4, which was created not just for internet etiquette but literally to prevent illegal breaches of confidentiality. With regards to consent - this is not required for publishing de-identified information, or sites like Radiopaedia with their thousands of cases would not exist. With regards to patient confidential information that cannot be shared - this not only includes the obvious ones such as patient age, DOB, dates of events, addresses, etc etc, but also vaguer information. For example, there are cases that I would never present here online because the disease is so incredibly rare that the disease itself becomes a patient identifier. These types of cases I would formally publish in the literature if need be. For this particular case, I do not think the information presented breaks these rules (or I would not have posted). Cocaine use is fairly common among the demographic in question, and being found in the shower is not that uncommon, although dramatic.
Second, to address the following:
The title is like your a friend but the text is from a medical professional.
This is something that I have been struggling with. This community is growing at an exceptional rate, and visitors seem to be overwhelmingly from a non-medical background. There are comments that frankly say they do not understand certain things, and other comments and questions imply a lack of experience with looking at imaging studies. I have been vacillating between using terminology and sentences that laypeople can understand versus maintaining medical terminology. I think this is why you think I am writing about a friend in the title, but the body of the post is more medically-oriented. For this reason, I have changed the title - it did not need to be so dramatic. In the future, I will be more careful with my wording.
Please let me know if this addresses your concerns. I would also love to hear more input regarding point #2. Should I continue to word cases as if talking to other medical professionals or include more basic terminology so that the general public can understand? The purpose of these cases, and this community in general, is to be an educational resource in terms of what Radiology is and does.
This complication of cocaine use generally manifests as a single episode of demyelination that recovers well with treatment. Of course, the long term depends on how often the cocaine abuse happens.
Patient was a young adult working in finance at a major tech company found to be mute and diaphoretic.
Physical exam notable for fever, tachycardiac, hypertension, awake but not following commands, aphasic, and with hyperreflexia and muscle ridigity. CK peaked to 11,344.
MRI shows multiple ovoid to splotchy confluent lesions in the white matter with diffusion restriction. Lesions also enhanced with hyperperfusion (not shown).
Urine drug test positive for cocaine. Infectious work-up was negative. Steroids were started with good recovery.
Patient denied knowingly taking cocaine but did say weekly use of what they thought was MDMA with friends...
Final diagnosis: Levamisole-induced leukoencephalopathy. Levamisole is an antiparasite medication that is no longer used in the US but still in some other countries. It is a common cutting agent in cocaine. It's neurotoxic effects primarily come from causing demyelination.
I remember this episode quite well because it happened around the time I decided to get into the medical field. In the episode, a young teacher had a first-time seizure while in the middle of teaching. House and team attempted to get a brain MRI, but she got an allergic reaction from the IV contrast. Thereafter, some drama happens, and at some point, they break into her house, find out she's been eating raw pork (wtf?), and diagnose her with the tapeworm infection associated with eating raw pork, cysticercosis (and neurocysticercosis, since it also involved her brain). They took an x-ray of her leg to show all the parasites in the muscles, and then House scolds her for being stupid. I remember thinking that was such as crazy medical story.
The reality is - they could have just repeated the brain MRI minus the contrast part, and the radiologist would have been able to identify neurocysticercosis without issue. House would have complained to Cuddy that she really was wasting his time with these basic cases, and the episode would have lasted 15 minutes tops...
Anyhow, this is a 25 year old Hispanic from jail. Just like the House episode, he presented with first time seizure and headaches.
CT of the head [top] shows a cystic lesion in the left frontal lobe. If one pays attention, one can see a small dot (blue arrow) within the cyst representing the scolex of the tapeworm parasite. Just from the CT appearance, history of seizure, and risk factors of jail (the parasite thrives in areas of low sanitation) and Hispanic (the parasite is endemic to South America), neurocysticercosis is the top possibility. A differential diagnosis of cystic brain tumor is provided to complete the picture.
MR [middle and bottom] shows a cystic lesion again. After giving IV contrast [middle right], one can see the cyst has a thin wall of enhancement (teal arrows). On T2 [bottom left] and especially FLAIR [bottom right], one can see a rim of swollen brain (green arrows) from the inflammation going on around the parasite.
This was diagnosed as neurocysticercosis in the colloidal vesicular stage and antiparasite medication was started.
Oh good to know. I guess I only really caught reddit downtimes in the past.
I like how it looks exactly like reddit's status page, especially considering they just released old.lemmy.world.
Just a standard T2 sequence.
FLAIR would have dark CSF, since that's what FLAIR is designed to suppress - CSF.
MPRAGE is a T1 sequence that's usually done with contrast.
Thank you! Much appreciated.
Yes, cysts can form in bone.
However, this particular entity, aneurysmal bone cyst, is the name of an actual tumor that happens to produce a lot of cysts.
You can see the other case I posted today for what an ABC looks like on MRI - I think you see why it's called an aneurysmal bone cyst. Unfortunately, that appearance is not specific for ABC. That other case did turn out to be cancer.
Bone break! Why so weak? -> Oh, tumor surprise! -> Tumor growing, bad! Make bone weak(er)! -> Fix fix fix. Luckily not a cancer. -> Good.
[Top]: X-ray shows a lucent, bubbly, lesion of the distal femur at the metaphysis. On the frontal view [top right], there is breakage through the medial femoral cortex into the adjacent soft tissues, not a good sign.
[Bottom]: MRI shows a multicystic lesion filling the distal femur containing multiple locules, many with fluid-fluid, fluid-debris, and fluid-hemorrhage levels. The most common lesions with this striking appearance are aneurysmal bone cyst, giant cell tumor, or telangiectatic osteosarcoma. Unfortunately, there is clearly extension of the bone tumor beyond the bone (yellow arrows), which favors a more aggressive neoplasm from that differential diagnosis - this turned out to be telangiectatic osteosarcoma.
5 year old who fell off a slide.
Initial imaging shows a comminuted fracture through the distal humerus, compatible with a supracondylar fracture. Nothing else appreciable here, except maybe in retrospect some lucency of the distal humerus where the fracture is.
4- and 7-month follow-up radiographs shows a growing lucent lesion of the distal humerus, expanding the bone there. It has a multicystic appearance. A diagnosis of large simple bone cyst versus aneurysmal bone cyst was proposed.
12 month follow-up was done after the cyst was opened surgically, its contents scraped off, and the resulting cavity was packed with allograft bone chips. At surgery, this turned out to be an aneurysmal bone cyst.
5 year follow-up shows involution of the cyst cavity with some residual heterogeneity and a bone spur at the anterior aspect of the distal humerus.
Luckily I did bring my flashlight and batteries, otherwise I would have been screwed. I did not plan to stay up so late, but the ascent to the ridge hike took longer than anticipated, and of course, what was a sunny day in the morning progressed to clouds and rainstorm by the afternoon, which continued into the night.
I continued as best as I can. I was acutely aware of the danger of a trip and fall that might break an ankle and hypothermia - some parts of the hike still had snow, and anytime I stopped, I could feel the cold seeping in.
In the end, I reached my car at around 10 PM.
[Left]: Head CT shows left hemispheric volume loss. The injury happened early enough that even the skull is smaller on that side.
[Right]: Brain MRI shows the severe left hemispheric atrophy. Some of the brain gyri have bulbous ends and a thin neck, resembling mushrooms, a shape called ulegyria and consequence of the brain atrophy. The left lateral ventricle is mildly enlarged due to the atrophied brain.
Red arrows point to 2 big gallstones, top one in the gallbladder and bottom one obstructing a small bowel loop, and a small gallstone in the cystic duct.
Red lines point to hernia entry. Red arrow points to where the bowel tapers and becomes obstructed as it enters the hernia sac.
[Left]: Fetal MRI (FIESTA sequence) shows twins joined from their lower chest to the pelvis, but truly fused and sharing a single abnormal pelvic region. Not shown, but there are 3 lower limbs - one of the twins only had a single lower extremity.
[Right]: Postnatal small bowel follow-through (SBFT). It was unclear initially whether the twins shared a single rectum or had their own rectum. Therefore, contrast was administered via nasogastric tube for the twin with the suspected nonfunctional rectum, and serial imaging was performed until it passed into what turned out to be a separate, functional, but small rectum/anus.
I do not know too much about conjoined twins - not my area of expertise, but the general forms to consider are the side of fusion: ventral (front to front), lateral (side to side), dorsal (back to back), or caudal (tail end to tail end). Within these first 3, there are subtypes depending on how far up the fusion goes (head, chest, abdomen/pelvis); by definition, the caudal version obviously is only a lower body fusion. Once this is derived, an additional classification is the number of upper and lower limbs.
No clinical history saved on this one - sorry.
[Right] Small bowel follow-through (SBFT), where the patient drinks barium, and then we wait a bit until that barium is in the small bowel, then we take some pictures. This study is showing a long segment of terminal ileum that is strictured and severely narrowed in fibrostenotic Crohn's (red bracket). This is called the "string sign."
[Left] Coronal CT performed sometime after the SBFT. You can still see some residual barium in the small and large bowels (blue arrows). Red bracket shows the CT appearance of the terminal ileum stricture. On the CT, you can also see that the strictured segment has submucosal fat deposition, the "fat halo sign."
I didn't save any clinical history for these - sorry.
[Top] Patient 1 - Gigantic mass along the lesser curvature of the stomach. Look down at your belly - this mass is about 1/3rd the width from left to right.
[Mid] Patient 2 - CTs showing gently lobulated and undulating wall thickening of the gastric cardiac and fundus. Notice the transition from the normal gastric rugae to the smoother wall thickening where it is infiltrated by lymphoma. There is also mild (aneurysmal) dilation of the stomach where the wall thickening is located.
[Bottom] Patient 2 - PET-CT. The wall thickening is ridiculously hypermetabolic with a max SUV of 21.3. For comparison, the liver is normally in the range of 2-4 mean SUV.
Tuberculosis, sarcoidosis, lymphoma, and metastatic disease - these 4 can look like almost anything.
57 year old with left flank pain for 12 hours. Urine sample 2+ for blood. White count at 14.
[Top]: Coronal CT shows the left kidney is enlarged, with angry-looking, inflamed, surrounding fat. The renal pelvis is dilated (hydronephrosis).
[Bottom]: Axial CT shows a small stone at the very end of the ureter (ureterovesicular junction).
Pretty straightforward case. For the nonmedical visitors, this is what we look for if your doc wants to get a CT for flank pain / kidney stone suspicion. See the other case for an ultrasound version.
Should the instances that responded to you be refederrated? I’m pretty sure I saw some of them on lemmy.world’s block list. I think it would be sad for these small servers to not realize they are, in fact, not connected to the greater fediverse. On the other hand, if you’re an admin, and you don’t know what you’re doing to the point of not knowing your server was infected by hundreds of thousands of bots, maybe it’s too dangerous to refed.