EQ - TEST PAPER I Flashcards
2.A 40-year-old man on the third cycle of chemotherapy for non-Hodgkin’s lymphomapresents with dysphagia and odynophagia. A recent blood count revealed neutropenia.
He is referred for a barium swallow, which shows several linear ulcers with ‘shaggy’ borders’in the upper oesophagus. What is the most likely diagnosis?
A. Candida oesophagitis
B. CMV oesophagitis
C. Post radiotherapy stricture
D. TB oesophagitis
E. Pharyngeal pouch
2.A. Candida oesophagitis
Candida oesophagitis occurs in patients whose normal flora is altered by broad spectrumantibiotic therapy and in patients whose immune systems are suppressed by malignancy, immunosuppressive agents like chemotherapy and radiotherapy, and immunodeficiency states such as AIDS.
When the disease is superficial, the oesophageal mucosa may appear normal radiographically.
Early in the course of Candida oesophagitis, mucosal plaques are the most frequent finding. Later erosions and ulcerations may develop, which together with intramural haemorrhage and necrosis result in the ‘shaggy’ margin seen on esophagograms.
3.A contras! CT scan shows an incidental renal cyst that is hyperdense with thick septationsand a mural nodule. What is the Bosniak classification?
A. Type 1
B. Type 2
C. Type 2F
D. Type 3
E. Type 4
3.D. Type 3
Type 3 cysts have thickened irregular/smooth walls or septa in which measurableenhancement is present. These need surgery in most cases, as neoplasm cannot be excluded. They include complicated haemorrhagic/infected cysts, multilocular cystic nephroma and cystic neoplasms.
Type 2F (F denotes follow-up) cysts may contain multiple hairline-thin septa. Perceived (not measurable) enhancement of a hairline smooth septum or wall can be identified, and there may be minimal thickening of the wall or septa, which may contain calcification that may be thick and nodular. There are no enhancing soft-tissue components; totally intrarenal non enhancing high-attenuation renal lesions (>3 cm) are also included in this category. These lesions are generally well marginated and are thought to be benign but need follow-up.
Type 1 is a benign simple water attenuation cyst with a hairline-thin wall that does not contain septa, calcifications, or solid components and does not enhance.
Type 2 is a benign cystic lesion that may contain a few hairline septa in which perceived (not measurable) enhancement might be appreciated; fine calcification or a short segment of slightly thickened calcification may be present in the wall or septa. Uniformly high-attenuation lesions (<3 cm) that are sharply marginated and do not enhance are included in this group.
No intervention is needed.
Type 4 are clearly malignant cystic masses that can have all of the criteria of Type 3 but also contain distinct enhancing soft-tissue components independent of the wall or septa; these masses need to be removed.
- A 75-year-old woman is admitted under the physicians with confusion and dementia. She has a history of spontaneous intracranial haemorrhage and has been diagnosed with amyloid angiopathy. The most specific MR sequence for diagnosis of multifocal intracranial cortical subcortical microhaemorrhages in cerebral amyloid angiopathy is:
A. T1W spin echo
B. STIR
C. T2W spin echo
D. Gradient echo
E. FLAIR
- D. Gradient echo
Cerebral microbleeds are increasingly recognised neuroimaging findings, occurring with cerebrovascular disease, dementia, hypertensive vasculopathy, cerebral amyloid angiopathy and normal ageing. Recent years have seen substantial progress in developing newer MRI methodologies for microbleed detection.
Hemosiderin deposits in microbleeds are super-paramagnetic and thus have considerable internal magnetisation when brought into the magnetic field of MRI, a property defined as magnetic susceptibility. Among available pulse sequences, T2*-weighted GRE MRI is most sensitive to the susceptibility effect.
- An obese 25-year-old man presents with atypical chest pain. Cardiac MR demonstrates asymmetrical hypertrophy of the interventricular septum, primarily affecting the anteroinferior portion. What is the most likely diagnosis?
A. Hypertrophic obstructive cardiomyopathy
B. Restrictive cardiomyopathy
C. Myocardial infarction
D. Dilated cardiomyopathy
E. Constrictive pericarditis
- A. Hypertrophic obstructive cardiomyopathy
Hypertrophic cardiomyopathy (HCM) is defined as a diffuse or segmental left-ventricular hypertrophy with a non-dilated and hyperdynamic chamber, in the absence of another cardiac or systemic disease explaining the degree of cardiac muscle hypertrophy. Dyspnoea on exertion is the most common symptom because the key functional hallmark of hypertrophic cardiomyopathy is an impaired diastolic function with impaired LV filling in the presence of preserved systolic function. Systolic dysfunction occurs at end-stage disease.
Asymmetric involvement of the interventricular septum is the most common form of the disease, accounting for an estimated 60%-70% of the cases of HCM. Other variants include apical, symmetric, midventricular, mass-like and non contiguous
HCM is typically associated with hypertrophy of the muscle to 15 mm or thicker and a ratio of thickened myocardium to normal left ventricular basal myocardium of 1.3-1.5. With MRI and multidetector computed tomography (CT), apical HCM has a characteristic spadelike configuration of the I.V cavity at end diastole, appreciated on vertical long-axis views
- A 65-year-old diabetic with a history of alcohol excess is referred for a barium swallow following a history of dysphagia. The study shows several small, thin, flask-shaped structures along the cervical oesophagus oriented parallel to the long axis of the oesophagus. What is the most likely diagnosis?
A. Feline oesophagus
B. Pseudodiverticulosis
C. Glycogenic acanthosis
D. Traction diverticulum
E. Idiopathic eosinophilic oesophagitis
- B. Pseudodiverticulosis
Oesophageal intramural pseudodiverticulosis is a condition of unknown cause characterised by flask-shaped outpouchings of the mucosa that extend into the muscular layer and show characteristic findings on oesophagograms. They are dilated excretory ducts of deep oesophageal mucous glands resulting from obstruction of excretory ducts by plugs of viscous mucus and desquamated cells or by extrinsic compression of the ducts by periductal inflammatory infiltrates and fibrotic tissue.
It occurs in all age groups predominantly in the sixth and seventh decades with slight male preponderance. It has been reported as a separate entity or in association with diseases such as diabetes, peptic strictures and oesophagitis.
- A 21-year-old woman with infertility undergoes US that shows a 2-cm right adnexal mass with posterior acoustic enhancement. Another multilocular cyst is seen in the left ovary. Further evaluation with MR shows multiple small lesions in both the ovaries and pouch of Douglas, which were hyperintense on fat-suppressed T1W images with shading sign on T2W images. What is the likely diagnosis?
A. Dermoid
B. Endometrioid carcinoma of the ovary
C. Endometriosis
D. PCOS (polycystic ovarian syndrome)
E. Pelvic inflammatory disease
- C. Endometriosis
Endometriosis is a common multifocal gynaecologic disease that manifests during the reproductive years, often causing chronic pelvic pain and infertility. The ovaries are among the most common sites (20%-40% of cases). It manifests either as superficial fibrotic implants or as chronic retention cysts with cyclic bleeding (endometriomas). Endometriomas are thick-walled cysts with a dark, dense content that represents degenerated blood products. The cysts may be solitary or multiple, and they are bilateral in 50% of cases. Endometriomas may include peripheral nodules (blood clots) or fluid-fluid levels; in the latter, the non-dependent portion represents
the freshest bleeding. A multilocular-appearing endometrioma may consist of multiple contiguous cysts. Endometriomas are a marker of severity of deeply infiltrating endometriosis. On MRIs, cystic cavities can appear as simple fluid, with high signal intensity on T2-weighted and low signal intensity on T1 -weighted images. They also may show high signal intensity on 11-weighted and T1-weighted fat-saturated images because of their haemorrhagic content.
The shading sign, a common and unique feature of endometriomas, represents old blood products, which contain extremely high iron and protein concentrations. These haemorrhagic cysts typically show high signal intensity on T1-weighted images and low signal intensity on T2-weighted images. However, endometriomas also may show’ variable signal intensity on T2-weighted images.
- A young man presents to the ENT clinic with deepening of the voice. Going through his history and clinical notes, the consultant reviews a recent plain radiograph report of his
hands, which describes cystic changes in the carpal bones along with enlarged phalangeal tufts and metacarpals. What is the next appropriate imaging investigation?
A. CT brain pre- and post-contrast
B. MRI brain
C. MRI pituitary pre- and post-contrast
D. Chest X-ray
E. Lateral view of the skull
- C. MRI pituitary pre- and post-contrast
The clinical history along with the radiographic findings points towards acromegaly, and in this case evaluating the pituitary gland for the presence of an adenoma along with correlating biochemistry blood profile would be appropriate investigations.
Osseous enlargement of the vertebrae with increased AP diameter can occur with premature loss of disc space. Expansion of the terminal phalangeal tufts and metacarpals contribute to the clinical finding of ‘spadelike hands’. Other features include increased heel pad thickness >25 mm, premature OA, posterior vertebral scalloping, prognathism (elongated mandible), sellar enlargement and enlarged paranasal sinuses, mostly frontal sinus. In the case of pituitary macro adenomas, compression of the optic chiasm can often result in visual field defects.
- A 77-year-old man with gradual onset dementia shows multifocal abnormalities on cranial CT and MRI. He has been recently diagnosed with amyloidosis. All of the following conditions may be present in central nervous system amyloidosis, except:
A. Occurrence in elderly patients
B. Multifocal subcortical intracranial haemorrhages
C Cerebral and cerebellar atrophy
D. Non-communicating hydrocephalus
E. Typical occurrence in normotensive patients
- D. Non-communicating hydrocephalus
Cerebral amyloid angiopathy (CAA) is an important cause of spontaneous cortical-subcortical intracranial haemorrhage (ICH) in the normotensive elderly.
On imaging, multiple cortical- subcortical haematomas are recognised.
Prominence of the ventricular system and enlargement of the sulci representing generalised cerebral and cerebellar atrophy are non-specific imaging findings.
CAA should be considered in the broad differential diagnosis of leukoencephalopathy (high signal intensity of white matter at T2-weighted MRI), especially if associated with cortical- subcortical haemorrhage or progressive dementia.
Leukoencephalopathy may or may not spare U-fibres.
- A 33-year-old woman with recurrent episodes of optic neuritis with waxing and waning upper limb weakness is referred for an MRI brain with high suspicion of demyelination. All of the following are MR features of acute multiple sclerosis (MS) lesions of the brain, except
A. High signal intensity on FLAIR
B. ‘Black hole’ appearance
C. Incomplete ring-like contrast enhancement
D. Increase in size of lesion
E. Mass effect
- B. ‘Black hole’ appearance
MS lesions can occur anywhere in the central nervous system but are most common in the periventricular white matter.
Typical lesions are ovoid, with the long axis perpendicular to the ventricles.
They are better seen on PD and FLAIR than on T2-weighted images because of increased lesion-CSF contrast.
Lesions of the corpus callosum, at callososeptal interface and subcallosal striations are characteristic.
FLAIR is less sensitive than T2-weighted images to infratentorial lesions occurring in the brain stem and middle cerebellar peduncles.
In the acute phase, lesions show increase in size and solid or ring enhancement with IV contrast, which can persist up to 3 months, but generally resolve in weeks.
Large acute lesions, with associated oedema, mass effect and incomplete ring enhancement can mimic glioma (tumefactive MS).
MS lesions show reduced magnetisation transfer ratio (MTR), reflecting decreased myelin content. MTR is also reduced in normal-looking white matter, representing occult tissue damage. Such occult tissue damage is also detected by diffusion tensor imaging, showing reduced fractional anisotropy.
Low-signal lesions on T1 -weighted MRI (black holes), brain and spinal cord atrophy are seen in established MS.
- A 30-year-old woman presents with shortness of breath and fatigue. CT shows enlargement of the right atrium, right ventricle and pulmonary artery and normal appearance of the left atrium. What is the most likely diagnosis?
A. VSD - Ventricular Septal Defect
B. ASD - Atrial Septal Defect
C. Bicuspid aortic valve
D. Coarctation of the aorta
E. Mitral valve disease
- B. ASD - Atrial Septal Defect
- Which of the following characteristics is typical of prostate cancer?
A. Low on T1 High on T2
B. Low on T1 Low on T2
C. Isointense on T1 High on T2
D. High on T1 High on T2
E. Isointense on T1 Isointense on T2
- B. Low on T1 Low on T2
On T1-weighted MRI, the normal prostate gland demonstrates homogeneous intermediate to low signal intensity.
T1-weighted MRI has insufficient soft-tissue contrast resolution for visualising the intraprostatic anatomy or abnormality.
The zonal anatomy of the prostate gland is best depicted on high resolution T2-weighted images.
Prostate lias a homogenous low-signal background on T1 weighted images. On T2-weighted images, prostate cancer usually demonstrates low signal intensity in contrast to the high signal intensity of the normal peripheral zone.
Low signal intensity in the peripheral zone, however, can also be seen in several benign conditions, such as haemorrhage, prostatitis, hyperplastic nodules, or post- treatment sequelae (e.g., as a result of irradiation or hormonal treatment).
- An eccentric expansile lesion in the metaphysis of the humerus is noted incidentally following a routine plain radiograph investigation in a young patient following a rugby tackle. MRI performed for further characterisation shows multiple cystic spaces, some with blood fluid level, with an intact low signal periosteal rim. What is the diagnosis?
A. Unicameral bone cyst
B. Aneurysmal bone cyst
C. Eosinophilic granuloma
D. Enchondroma
E. Fibrous dysplasia
- B. Aneurysmal bone cyst
Aneurysmal bone cysts or ABCs are most commonly seen between the first and third decades of life.
They are typically a metaphyseal lesion and are often located in the humerus, femur, or tibia.
The presence of fluid-fluid levels along with bone expansion, a narrow zone of transition and metaphyseal location in a long bone is characteristic.
Note that fluid-fluid levels can also be found in giant cell tumours, telangiectatic osteosarcomas and simple bone cysts, but the other associated locations and characteristics of the lesion would tend to be different from an ABC.
Eosinophilic granulomas are associated with Langerhans cell histiocytosis.
Enchondromas are typically located in the small long bones of the hands and in the proximal humerus and femur with non-expansile characteristics.
Fluid-fluid levels are not typically associated with fibrous dysplasia, which takes on the commonly described ‘ground glass’ appearance.
- A 34-year-old woman with previous history of upper limb weakness that resolved spontaneously and optic neuritis was referred for an MRI brain. MRI confirms the presence of bilateral periventricular hyperintensities on FLAIR with abnormal signal in the corpus callosum and middle cerebellar peduncles. MRI also shows signal abnormality in the right optic nerve. Which portion of the optic nerve does Multiple sclerosis (MS) most commonly affect?
A. Intra-orbital.
B. Intracanalicular.
C. Intracranial.
D. Chiasmatic.
E. All portions arc equally susceptible.
- A. Intra-orbital
Typically, findings of optic neuritis in MS are seen in the retrobulbar intra-orbital segment of the optic nerve, which appears swollen, with high T2 signal. High T2 signal persists and may be permanent; chronically the nerve will appear atrophied rather than swollen. Contrast enhancement of the nerve is best seen with fat-suppressed T1-weighted coronal images, in >90% of patients if scanned within 20 days of visual loss.
- A middle aged woman presents with cough and haemoptysis. Her chest X ray reveals a large ovoid mass in the right lower lobe. She has a known history of Osler-Weber-Rendu syndrome. What is the most appropriate next imaging investigation that you will organise?
A. MRA of the pulmonary artery
B. CTPA
C. CTPA with portal phase images covering the liver
D. Chest HRCT
E. Conventional pulmonary angiography
- C. CTPA with portal phase images covering the liver
Hereditary haemorrhagic telangiectasia, also called Osler-Weber-Rendu syndrome, is an uncommon genetic disorder characterised by arteriovenous malformations in the skin, mucous membranes and visceral organs. The brain, gastrointestinal tract, skin, lung and nose are the primary sites affected. It is associated with the classic triad of epistaxis, telangiectasias and a family history.
Pulmonary AVMs are often discovered initially as a solitary pulmonary nodule or mass on plain chest films. If a pulmonary AVM is suspected, further imaging evaluation should be CT or conventional pulmonary angiography. Although conventional angiography is the gold standard, considering its invasive nature CT is considered a better method of diagnosis. This is more important when screening for AVM.
Portal venous-phase liver images are often obtained at the same time, in case the lesion does turn out to be a solid nodule.
- A nursing home resident is found to have a lung tumour and undergoes CT staging of the chest and abdomen. This reveals a discrete lesion medial to the second part of the duodenum with a fluid-fluid level. What is the most likely diagnosis?
A. Duplication cyst
B. Duodenal diverticulum
C. Duodenal web
D. Annular pancreas
E. Adenocarcinoma of the duodenum
- B. Duodenal diverticulum
Duodenal diverticulosis is a common entity first described by Chomel in 1710. Its prevalence varies depending on the mode of diagnosis. Diverticula are found in 6% of upper gastrointestinal series, 9%-23% of ERCP procedures and 22% of autopsies. Its occurrence has no sex predilection, and the age range for detection varies from 26 to 69 years. Duodenal diverticula may be congenital or acquired, with the latter being more common. Congenital or true diverticula are rare, contain all layers of the duodenal wall, and may be subdivided into intraluminal and extraluminal forms.
The CT appearance of a duodenal diverticulum includes a saccular outpouching, which may resemble a mass-like structure interposed between the duodenum and the pancreas that contains air, an air-fluid level, fluid, contrast material, or debris. A periampullary diverticulum may simulate a pseudocyst or tumour.
- Which of the following is false?
A. Skene cyst Lateral to external urethral meatus
B. Nabothian cyst Lateral to the endocervical canal
C. Gartner’s dust cyst Posterolateral aspect of the upper vagina
D. Bartholin’s cyst Posterolateral aspect of the vagina
E. Urethral diverticulum Posterolateral aspect of mid-urethra
- C. Gartner’s duct cyst Posterolateral aspect of the upper vagina
Multiple paraurethral Skene’s glands are related to the female urethra. There are paraurethral ducts that drain into the distal urethral lumen.
Nabothian cysts are retention cysts in the cervix related to chronic cervicitis.
Gartner’s duct cysts are found at the anterolateral aspect of the proximal third of the vaginal wall.
Bartholin’s gland cysts affect the posterolateral aspect of the lower vaginal wall.
Urethral diverticulum occurs at the posterolateral aspect of the mid-urethra.
- A 31-year-old man who is known to the gastroenterologist and rheumatologist presents to the ophthalmology department with visual disturbances. A pelvic radiograph done a year ago in the emergency department showed whiskering of the ischial tuberosities and greater trochanters, with symmetrical sclerosis of both sacroiliac joints. What is the most likely diagnosis?
A. Reiter syndrome
B. Behcet’s syndrome
C. Ankylosing spondylitis (AS)
I). Rheumatoid arthritis
E. Systemic lupus erythematosus (SLE)
- C. Ankylosing spondylitis (AS)
AS is characterised by the hallmark of bilateral and symmetrical sacroiliac joint involvement, though there may be unilateral involvement in the early stages of disease. Other common findings include periostitis with whiskering of the pelvic bones and the typical ‘bamboo’ spine appearance from syndesmophyte formation. Up to 10% of AS cases are associated with inflammatory bowel disease, and iritis is common in up to 40% of patients. Ninety-six percent of patients are HLA-B 27 positive, the antigen associated with the other seronegative spondyloarthropathies of psoriasis, Reiter’s syndrome and inflammatory bowel disease-associated spondyloarthritis.
Behcet’s syndrome affects the chest and gastrointestinal tracts and doesn’t involve the skeleton primarily.
- A 3 year-old presents as acutely unwell with a maculopapular rash, lymphadenopathy and erythema of her palms. Her white cell count is normal, and a specific cause for her symptoms is not found. She improves on immunoglobulins and supportive treatment. A follow-up echocardiogram shows cardiomegaly and a coronary artery aneurysm. What is the
likely diagnosis?
A. Takayasu arteritis
B. Kawasaki arteritis
C. Moyamoya syndrome
D. Henoch-Schönlein purpura
E. Churg-Strauss syndrome
- B. Kawasaki arteritis
Kawasaki disease is a systemic vasculitis that is more severe in small and medium arteries, and veins to a lesser extent, with inflammatory’ lesions in virtually all organs. It is a leading cause of acquired heart disease in childhood. The aetiology of KD remains unknown, although the clinical presentation - self-limiting illness manifested by an abrupt onset of fever, rash, exanthema, conjunctival injection and cervical adenopathy - and the epidemiological features - a seasonal peak in winter and spring, age distribution and a geographic wave-like spread of illness during epidemics - strongly suggest an infectious cause.
Fever is usually the first sign of KD. Rash is non-specific and mostly maculopapular. Cervical lymphadenopathy is the last common of the main manifestations. Cardiovascular complications include coronary artery aneurysms, myocarditis, pericarditis with pericardial effusion, systemic arterial aneurysms, valvular disease, mild aortic root dilatation and myocardial infarct.
Takayasu arteritis (TA), also known as pulseless disease, is a granulomatous large vessel vasculitis that predominantly affects the aorta and its major branches, with increased prevalence in Asian women <50 years of age.
Churg Strauss syndrome is a small-to-medium vessel necrotising pulmonary vasculitis, affecting patients in the third and fourth decades with asthma, eosinophilia and systemic symptoms like purpura and arthralgia.
Moyamoya disease is an idiopathic, non-inflammatory, non-atherosclerotic, progressive vasculo- occlusive disease involving the circle of Willis, typically the supraclinoid internal carotid arteries.
It has a bimodal age distribution, affecting children and adults. In children, ischaemic strokes are most pronounced, whereas in adults haemorrhage from the abnormal vessels is more common.
- A taxi driver has had recurrent episodes of abdominal pain. On CT, a lesion is seen within the head of the pancreas. Pancreatic duct dilatation is noted with a normal CBD and atrophy of the body and tail of the pancreas. ERCP demonstrates thick mucous material discharging from the bulging papilla. What is the most likely diagnosis?
A. Mucinous cystadenocarcinoma
B. Serous cystadenocarcinoma
C. Main duct IPMN (Intraductal Papillary Mucinous Neoplasm)
D. Pancreatic pseudocyst
E. Pancreatic adenocarcinoma
- C. Main duct IPMN (Intraductal Papillary Mucinous Neoplasm)
IPMNs are a group of neoplasms in the biliary duct or pancreatic duct that causes cystic dilatation from excessive mucin production and accumulation. The true incidence of IPMNs is unknown because many are small and asymptomatic. However, in a series of 2,832 consecutive CT
scans of adults with no history of pancreatic lesions, 73 cases of pancreatic cysts (2.6%) were identified. Many of these cases likely were IPMNs, given that IPMNs account for 20%-50% of cystic pancreatic neoplasms. There are three main types of pancreatic IPMNs: main duct, branch duct and combined. A main duct IPMN commonly causes dilatation of the papilla, with bulging of the papilla into the duodenal lumen. Filling defects caused by mural nodules or mucin may be seen at MRCP or ERCP. At CT and MRI, filling defects caused by mural nodules enhance, while filling defects caused by mucin do not enhance.
- A known MS patient has presented to the neurologist with clinical features of involvement of the spinal cord. An MRI of the whole spine has been requested with a view towards assessment of the cord for possible multiple sclerosis (MS) plaques. MS lesions in the spinal cord occur most commonly in the
A. Cervical segment.
B. Thoracic segment.
C. Lumbar segment.
D. Sacral segment.
E. All segments are equally affected.
- A. Cervical segment
MS can show multiple lesions in the spinal cord. Typical spinal cord lesions in MS are relatively small and peripherally located.
They are most often found in the cervical cord and are usually less than two vertebral segments in length.
- A neonate presents with non-bilious vomiting with a palpable upper abdominal lump. Which of the following US findings would not be in keeping with pyloric stenosis?
A. Pyloric muscle thickness 3.5 mm
B. Target sign
C. Pyloric canal length 14 mm
D. Antral nipple sign
E. Cervix sign
- C. Pyloric canal length of 14 mm
Ultrasound is the modality of choice because of its advantages of directly visualising the pyloric muscle and no ionising radiation. The hypertrophied muscle is hypoechoic, and the central mucosa is hyperechoic. Normal measurements of the pylorus are as follows:
Pyloric muscle thickness (i.e., the diameter of a single muscular wall on a transverse image): <3 mm (most accurate)
Length (i.e., longitudinal measurement): <15-17 mm
Pyloric volume: <1.5 cc
Pyloric transverse diameter: <13 mm
Abnormal features on US includes target sign (hypoechoic ring of hypertrophied pyloric muscle around echogenic mucosa centrally on cross section), cervix sign (indentation of muscle mass on fluid-filled antrum on longitudinal section) and antral nipple sign (redundant pyloric channel mucosa protruding into gastric antrum). Other features include increased antral peristalsis and delayed gastric emptying.
Infantile pyloric spasm also shows increased peristalsis and delayed gastric emptying with pyloric muscle thickness between 1.5 and 3 mm.
- A 60-year-old heavy smoker presents with haematuria. US KUB shows a midline fluid-filled cavity with mixed echogenicity and calcification adjacent to the bladder wall. CT shows a focal low-attenuation enhancing mass along a cord-like structure extending from the bladder to the umbilicus. What is the most likely diagnosis?
A. Complex urachal cyst
B. Vescico urachal diverticulum
C. Urachal adenocarcinoma
D. Transitional cell carcinoma
E. Urachal rhabdomyosarcoma
- C. Urachal adenocarcinoma
Urachal adenocarcinoma is characteristically located at the dome of the bladder in the midline or slightly off midline. Ninety percent of masses occur close to the bladder, with the remainder along the course of the urachus or at the umbilical end. A midline, infra-umbilical, soft-tissue mass with calcification is characteristic and is considered to be urachal adenocarcinoma until proved otherwise. Eighty percent of urachal cancers are adenocarcinoma. At CT, the tumour is mixed solid
and cystic in 84% of cases and solid in the remainder. CT is the most sensitive modality for calcification, which is present in 72% of cases and is more commonly peripheral than stippled. On T2-weighted MRI, focal areas of high signal intensity from mucin are highly suggestive of urachal adenocarcinoma. The solid portions of the tumour are isointense to soft tissue on T1-weighted images and enhance with intravenous contrast material.
- A 3-year-old child with shortness of breath is diagnosed with tetralogy of Fallot. All of the following abnormalities may be associated with this condition, except
A. Transposition of great vessels (TGA)
B. Patent ductus arteriosus (PDA)
C. Anomalous origin of coronary arteries
D. DiGeorge syndrome
E. Right-sided aortic arch
- A. Transposition of great vessels (TGA)
A number of associated features can occur in patients with Tetralogy of Falot (TOF).
Right sided aortic arch is the most common variant, known as Corvisart syndrome.
Coronary artery anomalies, such as the left anterior descending artery arising from the right coronary artery (whose course may run directly across the right ventricular outflow tract) can occur.
Other associations include patent ductus arteriosus, multiple ventricular septal defects and complete atrioventricular septal defect.
Approximately 15% of patients have extracardiac anomalies, including chromosomal abnormalities such as Down’s syndrome, DiGeorge syndrome and Alagille syndrome.
@#e 44. A 40-year old woman presents to her GP with right upper quadrant pain and is referred for an ultrasound of the abdomen. The scan demonstrates a thickened gall bladder wall with several intramural small echogenic foci showing ‘comet tail artefacts’. A few gallstones
are also noted. What is the most common diagnosis?
A. Xanthogranulomatous cholecystitis
B. Strawberry gallbladder
C. Porcelain gallbladder
D. Gallbladder adenomyomatosis
E. Acute cholecystitis
- D. Gallbladder adenomyomatosis
Adenomyomatosis is a benign hyperplastic cholecystosis. Tt is a relatively common condition, identified in at least 5% of cholecystectomy specimens. There is no definite racial or sex predilection. Most diagnoses are made in patients in their fifties, but the age range is wide and case reports exist of paediatric adenomyomatosis. Adenomyomatosis is most often an incidental finding, has no intrinsic malignant potential, and usually requires no specific treatment.
It frequently coexists with cholelithiasis, but no causative relationship has been proved. Adenomyomatosis occasionally produces abdominal pain, and in some cases cholecystectomy may be indicated for relief of symptoms. Cholesterol accumulation in adenomyomatosis is intraluminal, as cholesterol crystals precipitate in the bile trapped in Rokitansky-Aschoff sinuses, intramural diverticula lined by mucosal epithelium. Gallbladder wall thickening and intramural diverticula containing bile with cholesterol crystals, sludge, or calculi are the radiologic correlates of the distinctive multimodality imaging features of adenomyomatosis.
US is a primary modality for biliary imaging, and adenomyomatosis of the gallbladder is frequently identified at sonography. The non-specific finding of gallbladder wall thickening is well demonstrated with US, as are sludge and calculi, when present. Echogenic intramural foci from which emanate V-shaped comet tail reverberation artefacts are highly specific for adenomyomatosis, representing the unique acoustic signature of cholesterol crystals within the lumina of Rokitansky-Aschoff sinuses.
- A 46-year-old American man who has come to the UK on a holiday trip arrives at the AED with worsening shortness of breath. Chest X-ray shows bilateral asymmetrical calcified mediastinal and hilar nodes, and chronic pulmonary histoplasmosis is provisionally diagnosed. The worsening symptoms are attributed to fibrosing mediastinitis. All the following conditions can occur as complications of fibrosing mediastinitis, except
A. SVC syndrome
B. Pulmonary arterial hypertension
C. Pulmonary venous stenosis
D. Tracheal stenosis
E. Aortic stenosis
- E. Aortic stenosis
Chronic histoplasmosis may lead to two well-described complications: fibrosing mediastinitis and broncholithiasis.
Fibrosing mediastinitis is a fibrotic immune response to histoplasma antigens. The abnormal fibrosing process encases and narrows vital mediastinal structures, which can lead to superior vena cava syndrome, precapillary pulmonary arterial hypertension from pulmonary arterial stenosis, post-capillary pulmonary arterial hypertension owing to pulmonary vein stenosis, atelectasis from bronchial obstruction, tracheal stenosis, or dysphagia from oesophageal obstruction.
The imaging appearance can mimic infiltrating metastatic disease or lymphoma; however, the presence of mediastinal calcifications often provides a clue to the diagnosis.
Broncholithiasis results from erosion of a calcified hilar lymph node into an adjacent bronchus.
Affected patients present with chronic cough and haemoptysis and even occasionally with lithoptysis.
Typical imaging features include endobronchial calcification with atelectasis of the associated pulmonary segment or lobe.
- A 70-year-old pensioner has been referred for an abdominal ultrasound as part of a routine medical examination. He is fit and well with no significant past medical history. The scan demonstrates a small focal well-defined hyperechoic area in the right lobe
of the liver showing posterior acoustic enhancement. The most likely differential diagnosis is
A. Metastasis
B. Fatty infiltration
C. Liver cyst
D. FNH (Focal nodular hyperplasia)
E. Capillary haemangioma
- E. Capillary haemangioma
The classic haemangioma is an asymptomatic lesion that is discovered at routine examination or autopsy. At US, the typical appearance is a homogeneous, hyperechoic mass with well-defined margins and posterior acoustic enhancement.
The CT findings consist of a hypoattenuating lesion on non-enhanced images. After intravenous administration of contrast material, arterial-phase CT shows early, peripheral, globular enhancement of the lesion. The attenuation of the peripheral nodules is equal to that of the adjacent aorta. Venous-phase CT shows centripetal enhancement that progresses to uniform filling. This enhancement persists on delayed-phase images.
At MRI, haemangiomas are characterised by well-defined margins and high signal intensity on T2-weighted images, which is identical to that of cerebrospinal fluid. Specificity is improved by using serial gadolinium-enhanced gradient-echo imaging. The gadolinium intake is similar to the intake of iodinated contrast material during enhanced CT. With T2-weighted spin-echo and dynamic gadolinium enhanced T1-weighted gradient-echo sequences, the sensitivity and specificity of MRI are 98% and the accuracy is 99%. The imaging features of a haemangioma depend on its size; typical haemangiomas are mostly less than 3 cm in diameter.
- Of the normal uterus signal on MR, which is correct?
- B. High on T2 Intermediate on T2 Low on T2
On T1-weighted images, normal pelvic musculature and viscera demonstrate homogenous low-to-intermediate signal intensity. Zonal architecture is best demonstrated on T2-weighted MRI.
T2 signal reflects the water content, which is highest in the endometrium, intermediate in the myometrium and least in the junctional zone.
- Which of the following is false regarding bronchopulmonary sequestration?
- D. Symptomatic First 6 months Adulthood Bronchopulmonary sequestration
- A 25-year-old music teacher has recently been diagnosed with inflammatory bowel disease. She has an MRI small bowel study for evaluation of her disease status. Regarding features of Crohn’s versus ulcerative colitis on cross-sectional imaging, which of the following options is false?
- E. Skip lesions Yes Yes
In patients with proved or suspected Crohn’s disease, cross-sectional images should be analysed specifically for the presence and character of a pathologically altered bowel segment (wall thickness, pattern of attenuation, degree of enhancement, length of involvement), stenosis and prestenotic dilatation, skip lesions, fistulas, abscess, fibrofatty proliferation, increased vascularity of the vasa recta (comb sign), mesenteric adenopathy and other extra intestinal disease involvement.
- A 30-year old weight-lifter presents with swelling in the right groin. Which of the following is false?
- A. Direct inguinal hernia The hernial sac lies lateral to the inferior epigastric artery and above the pubic tubercle.
There are several sites on the abdominal wall prone to herniation.
The first site is the deep inguinal ring, where an indirect inguinal hernia occurs. Here, herniated structures enter the inguinal canal lateral to the inferior epigastric artery and superior to the inguinal ligament, extending for a variable distance through the inguinal canal.
A second site of herniation is at the inferior aspect of the Hesselbach’s triangle, where a direct inguinal hernia usually occurs. This weakened area is just lateral to the conjoint tendon and medial to the inferior epigastric artery, in contrast to the indirect inguinal hernia, which originates lateral to the inferior epigastric artery.
A third weakened area is inferior in relation to the inguinal ligament and lateral to the lacunar ligament, where a femoral hernia occurs, typically medial and adjacent to the femoral vessels. The fourth area is at the lateral margin of the rectus abdominis muscle, superior to the inferior epigastric artery as it crosses the linea semilunaris, where a spigelian hernia occurs, indirect inguinal hernias are most common regardless of sex; femoral hernias are more common in women.
- A 42-year-old man presents with a high-grade fever, splenomegaly and abdominal pain. CT chest and abdomen done to look for a source of sepsis show multiple small cavitating lesions in both lungs with areas of hypo-attenuation in the spleen and kidneys. Which of the following is the most likely diagnosis?
A. Sarcoidosis
B. Carcinoid heart disease
C. Amyloidosis
D. infective endocarditis
K. Rheumatic heart disease
- I). Infective endocarditis
Extracardiac Complications of Infective Endocarditis
