Images You Should Know 6/5/2020 A Rapid Review of Key Course Images You have seen most of these during the course. On the exam they will give you more clinical context, which will make image recognition easier. But… this is mostly a review! Blood Smears 1. What Are These Images? Both Are Same Organism 1. Morula of Ehrlichia Chaffeensis in a Monocyte 2. What Are These Images? (Both Are Same Organism) 2. Morula of Anaplasma in Neutrophils 3. What Is This Image? 3. Borrelia in Peripheral Smear 4. What Is This Gram Negative Rod in the Peripheral Blood of a Splenectomized Septic Patient Licked by a Dog? Wald, Images in Hematology, Am. J. Hematol. 83:879 Researchgate.net 4. Capnocytophaga canimorsus Wald, Images in Hematology, Am. J. Hematol. 83:879 Researchgate.net 5. What Are These Images in an HIV-Infected Patient in the US (CD4=20 cells/uL) with Septic Shock? All Are Same Organism 5. Histoplasma in Leukocytes (Peripheral Smear) 6. What Are These Images from a Skin Biopsy of a Recent Immigrant from Brazil with Fever and Hepatosplenomegaly? 6. Leishmania Note Difference Between Leishmania (kinetoplast and nucleus) and Histoplasma in Image 5 (nucleus only) Visceral Leishmania would be in bone marrow, liver, spleen while cutaneous or mucocutaneous would be in skin or mucous membranes. Leishmania would not be seen in blood smears, unlike histoplasma. 7. What Is This Image in a Patient Who Develops Renal Failure After a Prodrome of Diarrhea and Abdominal Pain? 7. Schistocytes, Helmet Cells, and Thrombocytopenia Hemolytic Uremic Syndrome (HUS) or Thrombotic Thrombocytopenic Purpura (TTP) Schistocytes No Platelets 8. What Is This Image in a Patient with a Non-Specific Febrile Illness? 8. Atypical Lymphocytes EBV and…Many Other Viral and Non Viral Organisms 9. What Two Different Organisms are Demonstrated in These Images from Travelers Who Returned from East Africa (left) and Brazil (right)? 9. Trypanosoma brucei rhodesiensis Trypanosoma brucei rhodesiensis Trypanosoma cruzi (Sleeping Sickness, e.g., East Africa) (Chagas Disease, e.g., Brazil) Peripheral Smear Peripheral Smear 10. What Is This Image in a Febrile Person Who Has Only Resided on the Eastern Seaboard of the US? 10. Babesia in Erythrocytes 11. What Is This Image in a Traveler Who Returned from a Trip That Included West Africa and Asia? 11. Band Form Plasmodium malariae (Asia and West Africa) or knowlesii (Asia) 12. What Is This Image in a Traveler Who Returned from Malarious Areas? 12. Gametocyte Falciparum Malaria 13. What Is This Image in a Traveler Who Returned from Africa? 13. Vivax Malaria Schizont Xrays 14. What Are These Serial Images in a Patient with Lymphoma and Resolving Neutropenia? 14. Halo (left) and Crescent (right) Signs Neutropenia (left) and Resolving Neutropenia (right) Probably Aspergillus The above is aspergillus which is different from… To the left is the reverse halo sign due to mucor or… Cryptogenic organizing pneumonia COP 15. What Is This Image in a COPD Patient with Hemoptysis? 15. Fungus Ball in Pre Existing Cavity Probable Aspergilloma 16. What is Cause of this Bulging, Non Pulsatile Chest Mass in Adult Male with 3 Months of Fever, Weight Loss, Dyspnea, and Cough? Caceres corner no 34 http://blog.myesr.org/caceres‐corner‐case‐no‐34/ 16. Empyema Extending Through the Parietal Pleura into Surrounding Tissues Many Causes: TB, Actinomyces, Staph, Molds Caceres corner no 34 http://blog.myesr.org/caceres‐corner‐case‐no‐34/ 17. What is the Cause of Fever and Chills in this Male Who Had a Sudden Neurologic Event One Week After a Radiofrequency Ablation for Recurrent Arrhythmias? 17. Left Atrial Esophageal Fistula Due to Radiofrequency Ablation Complications Include Air Embolus Causing Stroke and Bacteremia Due to Draining Oral Flora Desai et al, Journal of the American College of Cardiology Volume 71, Issue 11 Supplement, March 2018 18. Why Does This Patient with a Severe Sore Throat Have Pulmonary Embolic Lesions? 18. Lemierre’s Syndrome Usually Fusobacterium Bacteremia On the first image, note the clot in the jugular system (red arrow) (the blue arrow shows complete filling with dye or contralateral jugular Image on right shows sagital view of jugular system with clot 19. What Is This Image in an AIDS Patient? 19. Primary Effusion Cell Lymphoma in HIV 20. What Is This Image in a Previously Healthy Patient with Fever and Chills and Dysuria? Sireineni et al, https://abdominalkey.com/uroradiology/ 20. Eggshell Calcifications of the Bladder Chronic Schistosoma Hematobium with Hydroureter Sireineni et al, https://abdominalkey.com/uroradiology/ 21. What Is the Cause of 5 Days of Abdominal Pain Associated with Fever, Nausea, and Vomiting in this 70 Year Old Diabetic? Sireineni et al, https://abdominalkey.com/uroradiology/ 21. Emphysematous Cystitis Due to Gas Forming Organism, Usually E. coli or Klebsiella and Responds to Medical Therapy Sireineni et al, https://abdominalkey.com/uroradiology/ 22. What Is This Image in a Previously Healthy Patient with Fever and Chills? 22. Emphysematous Pyelonephritis Due to Gas Forming Bacteria 23. What Is This Image in a Patient with Fever and Dysuria and a Renal Biopsy Showing Lipid Laden Macrophages? 23. Xanthogranulomatous Pyelonephritis 24. What Is This Image in a Healthy Patient with Severe Diarrhea? 24. Pneumatosis Intestinalis Emergent Surgery Unnecessary If No Clinical Sepsis, i.e., Unexplained Hypotension, Hyperlactemia, Metabolic Acidosis, and If No Portal Gas, Bowel Obstruction, Signs of Peritonitis or Perforation 25. What Is This Image in a Neutropenic Patient with Abdominal Pain ? 25. Typhlitis in Neutropenic Patient 25. Note Differences Appendicitis vs Typhlitis Normal appendix Appendicitis with Appendicolith Contrast is seen filling a normal appearing An enlarged appendix (solid arrows) is seen appendix (arrows) demonstrating a thin wall with an appendicolith (dashed arrows) at the base Appendicitis Perforated appendicitis The appendix (solid arrows) is abnormally The appendix (solid arrows) is abnormally dilated dilated and demonstrates a thickened with a thickened enhancing wall. Small pockets of enhancing wall and no filling with contrast. extraluminal air (dashed arrows) indicate perforation. http://www.massgeneral.org/imaging/news/radrounds/january_2006/ 26. What Is This Image in an AIDS Patient (CD4=10 cells/uL) Who Just Started ART? 26. Mycobacterium Avium IRIS Syndrome in HIV/AIDS Could Also Be Other Mycobacteria, Fungi, Lymphoma 27. What Are These Images in a Patient with Resolving Neutropenia? Cornely et al. Clinical Liver Disease, Vol 6, No 2, August 2015 Fontanilla, https://radiopaedia.org/cases/hepatic-candidiasis-on-contrast-enhanced-ultrasound 27. Hepatosplenic Candidiasis in Resolving Neutropenia Cornely et al. Clinical Liver Disease, Vol 6, No 2, August 2015 Fontanilla, https://radiopaedia.org/cases/hepatic-candidiasis-on-contrast-enhanced-ultrasound 28. What Is This Image in a Healthy Patient with Fever and Acutely Aberrant Behavior? http://www.med.harvard.edu 28. Herpes simplex Encephalitis Temporal Lobe http://www.med.harvard.edu 29. What Are These Images in a Patient with Rheumatoid Arthritis and Progressive Confusion? 29. JC Encephalitis (Also known as PML-Progressive Multifocal Leukoencephalopathy) 30. What Is This Image in a Recent Stem Cell Transplant Recipient? 30. Posterior Reversible Encephalopathy Syndrome (PRES) 31. What Is the Cause of 3 Week Decline in Mental Function in An Afebrile Patient With No Other Medical Issues and Hyperintensity of the Cortex, Pulvinar and Dorsomedial Thalamic Nuclei, and Basal Ganglia? 31. Creutzfeldt–Jakob Disease The location “Pulvinar” Should Be a Clue CSF Will Show 14-3-3 and Tau Proteins A. Normal FLAIR image for comparison B. Grade 2 hyperintensity of pulvinar C. Grade 3 hyperintensity of pulvinar D. Grade 4 hyperintensity of pulvinar The pulvinar sign refers to bilateral FLAIR hyperintensities involving the pulvinar thalamic nuclei, which is classically described in variant Creutzfeldt‐Jakob disease Collie, American Journal of Neuroradiology September 2003, 24 (8) 1560‐1569; 66 32. What Is This Image in a Healthy Patient with Fever and Facial Pain? 32. Ethmoidal Sinusitis 33. What Is This Image of Unilateral Disease of a Previously Healthy Patient with Fever but No Papilledema or Dysconjugate Gaze? R Itzaak Brook, http://sinusitisunderstood.blogspot.com/p/complications-and-referal.html 31. Orbital Cellulitis/Abscess Due to Ethmoidal Sinusitis Proptosis, Chemosis, Limitation of Extraocular Movement, Visual Loss R Itzaak Brook, http://sinusitisunderstood.blogspot.com/p/complications-and-referal.html 34. What Is This Image of Unilateral Disease in a Previously Healthy Patient with Fever, Ophthalmoplegia, Retinal Hemorrhages, Disc Edema, Vision Loss? Cooper, https://neuro-ophthalmology.Standford.edu. 34. Cavernous Sinus Thrombosis Associated with Sphenoid or Ethmoidal Sinusitis, Facial or Dental Infections Proptosis, Chemosis, Eyelid Edema, Cranial Nerve Palsies, Vision Loss Coronal T1 Image with Enlargement and Enhancement Of Sinus Due To Thrombosis Cooper, https://neuro-ophthalmology.Standford.edu. 35. What Sinus is Infected and What Complication Should be Sought? Interactive CT Sinus Anatomy: http://uwmsk.org/sinusanatomy2/SphenoidAbnormal.html 35. Sphenoid Sinusitis Associated with Cavernous Sinus Thrombosis Cavernous Sinus Thrombosis Sphenoid Sphenoid Sinusitis Sinusitis Cavernous Sinus Thrombosis Interactive CT Sinus Anatomy: http://uwmsk.org/sinusanatomy2/SphenoidAbnormal.html 36. What Is This Image in a Patient with a Severe Sore Throat