Correct answer is: Dermoid cyst

Dermoid cysts account for 15% of all ovarian neoplasms and predominate in young women, being the most common ovarian neoplasm in patients younger than 20 years. Ultrasound is the preferred imaging modality. Typically, an ovarian dermoid is seen as a unilocular cystic adnexal mass with some mural components. The spectrum of sonographic features includes: a diffusely or partially echogenic mass with posterior sound attenuation owing to sebaceous material and hair within the cyst cavity; an echogenic interface at the edge of the mass that obscures deep structures (the tip of the iceberg sign); mural hyperechoic or Rokitansky nodule (dermoid plug); echogenic shadowing calcific or dental (tooth) components; fluid-fluid levels; multiple thin echogenic bands caused by the hair in the cyst cavity; the dot-dash pattern (dermoid mesh); no internal vascularity on color Doppler; intracystic floating balls sign (uncommon, but characteristic).

Discussion

Among the alternatives, the diagnosis of dermoid cyst should be considered because ovarian serous or mucinous cystadenoma/cystadenocarcinoma is usually only a serious consideration if the typical features of dermoid cyst are absent. Carcinoma also tends to occur in an older age group than dermoid cysts. Ovarian dysgerminomas are rare ovarian tumors that occur predominantly in young women in the 2nd to 3rd decades. Approximately 10-20% of cases occur in pregnancy. On ultrasound, they may be seen as a septated ovarian mass with varying echotexture. Color Doppler ultrasound may show prominent flow signal within the fibrovascular septa. Fibromas occur at all ages but are most frequently seen in middle-aged women, and on ultrasound manifest as solid, hypoechoic masses with ultrasound beam attenuation. As such, they may appear similar to a pedunculated subserosal uterine fibroid. However, the sonographic appearance can be variable, and some tumors can have cystic components, although rarely.

Take home message

Knowing the ultrasound aspects of dermoid cysts is important because they are benign lesions that grow slowly (1-2 mm per year) and, therefore may not need surgery. The most common complication is ovarian torsion, which occurs in 3-16% of dermoid cysts. Many recommend annual follow-up for lesions <7 cm to monitor growth. Tumors larger than 7 cm should be resected.

References

1. Outwater EK, Siegelman ES, Hunt JL. Ovarian teratomas: tumor types and imaging characteristics. Radiographics. 21 (2): 475-90
2. Adusumilli S, Hussain HK, Caoili EM et-al. MRI of sonographically indeterminate adnexal masses. AJR Am J Roentgenol. 2006;187 (3): 732-40.
3. Gürel H, Gürel SA. Ovarian cystic teratoma with a pathognomonic appearance of multiple floating balls: a case report and investigation of common characteristics of the cases in the literature. Fertility and sterility. 90 (5): 2008.e17-9.
4. Acién P, Ruiz-Maciá E, Acién M, Martín-Estefanía C. Mature ovarian teratoma-associated limbic encephalitis. Journal of obstetrics and gynaecology : the journal of the Institute of Obstetrics and Gynaecology. 35 (3): 317-9.
5. Patel MD, Feldstein VA, Lipson SD et-al. Cystic teratomas of the ovary: diagnostic value of sonography. AJR Am J Roentgenol. 1998;171 (4): 1061-5
6. Park SB, Kim JK, Kim KR et-al. Imaging findings of complications and unusual manifestations of ovarian teratomas. Radiographics. 28 (4): 969-83.
7. Moomjian LN, Clayton RD, Carucci LR. A Spectrum of Entities That May Mimic Abdominopelvic Abscesses Requiring Image-guided Drainage. (2018) Radiographics : a review publication of the Radiological Society of North America, Inc. 38 (4): 1264-1281.

Correct answer is: Passive hepatic congestion.

Discussion

The figures show a slightly enlarged liver with regular contours and blunt edges. The liver echogenecity is homogeneous. There are no focal lesions. Enlarged hepatic veins, measuring 1.3 to 2 cm near the IVC. Enlarged portal vein with a diameter of 1.5 cm and without thrombi.

Passive hepatic congestion, also known as congested liver in cardiac disease, describes the stasis of blood in the hepatic parenchyma, due to impaired hepatic venous drainage, which leads to the dilation of the central hepatic veins and hepatomegaly. Passive hepatic congestion is a well-studied result of acute or chronic right-sided heart failure.

The spectrum of sonographic features includes enlargement of the right hepatic lobe and the right hepatic vein measures about 9 mm (normal caliber < 6 mm), increases up to 13 mm with pericardial effusion, dilated IVC/hepatic veins, hepatomegaly, ± ascites.

Expected findings related to alternative answers

Among the alternatives, the diagnosis of congestive hepatic congestion should be considered by the patient history and the imaging findings. Budd-Chiari syndrome refers to the clinical picture that occurs when there is partial or complete obstruction of the hepatic veins. It is characterized on imaging by ascites, caudate hypertrophy, peripheral atrophy and prominent collateral veins. Hepatic veno-occlusive disease (VOD), also known as sinusoidal obstruction syndrome (SOS), is a condition arising from occlusion of the hepatic venules. Ultrasound is the imaging modality of choice which may show: hepatomegaly; portal vein abnormalities, such as portal vein dilatation, portal venous pulsatility, hepatofugal portal venous flow; gallbladder wall thickening (> 6-8 mm); and ascites. Acute hepatitis is a clinical diagnosis and the spectrum of sonographic features includes hepatomegaly (most sensitive sign) >15.5 cm at the midclavicular line; starry sky appearance; gallbladder wall thickening; periportal edema; accentuated brightness of the portal veinous walls; overall decreased echogenicity.

Take home message

Knowing the ultrasound aspects of hepatic congestion is important because it allows the clinician to direct the treatment to the basic cause – the heart failure.

References

1. Zakim D, Boyer TD. Hepatology. Saunders. ISBN:0721648363.
2. McNaughton DA, Abu-Yousef MM. Doppler US of the liver made simple. RadioGraphics 2011; 31(1): 161–188.
3. Gore RM, Mathieu DG, White EM et-al. Passive hepatic congestion: cross-sectional imaging features. AJR Am J Roentgenol. 1994;162 (1): 71-5.
4. Murphy FB, Steinberg HV, Shires GT et-al. The Budd-Chiari syndrome: a review. AJR Am J Roentgenol. 1986;147 (1): 9-15
5. Bayraktar UD, Seren S, Bayraktar Y. Hepatic venous outflow obstruction: three similar syndromes. World J. Gastroenterol. 2007;13 (13): 1912-27
6. Brancatelli G, Vilgrain V, Federle MP et-al. Budd-Chiari syndrome: spectrum of imaging findings. AJR Am J Roentgenol. 2007;188 (2): W168-76

Correct answer is: Medial tibial plateau stress fracture.

Discussion

Stress fractures of the lower limb are not an uncommon finding in runners. This may be due to an increase in load or training errors. They may also occur due to decreased bone density of individuals without necessarily any increase in loading.

Our patient indicated an increase in loading along with tenderness over medial tibial plateau. On ultrasound assessment oedema of the fat layer overlying bone was noted along with periosteal haematoma which is shown as a hypoechoic line overlying the bone cortex (this is nicely shown in video 1 and Image 4). Swelling and oedema of the overlying fat can be noted on Image 1 between the medial collateral ligament and tibia. Clinical history and examination along with ultrasound findings are strongly indicative of stress fracture.

Image 4- Medial tibial plateau transverse view. Tibia (open white arrow), deep fascia (white arrow), periosteal haematoma (black arrow). Associated fat oedema can be noted overlying periosteal haematoma.

Image 3- PDFS MRI sequence showing bone marrow oedema of tibial plateau consistent with stress fracture.

Expected findings related to alternative answers

1. A) Pes anserine bursitis-very rare to occur in isolation and swelling in this region can usually be attributed to one of the other 3 possible answers.
2. B) Medial meniscal tear-clinically would present with pain and tenderness centred more over medial joint line rather than pes anserine region. Fluid and oedema uncommonly seen tracking down towards the pes anserine region due to a related meniscal cyst with or without rupture. Periosteal haematoma would not be present.
3. D) Pes anserine bursitis may occur in patients with systemic arthropathy. This would result in localised swelling of tissues between medial collateral ligament (MCL) and pes anserine (unlike our current case which shows swelling under MCL).

Correct answer is: Know infant hip anatomy

Discussion

In this image, we can see a Type IV Graf dislocated hip with a poor bony roof, a flattened superior bony rim and with the cartilaginous roof pressed downwards. The angles are immeasurable in this case. By simply knowing the anatomy you are able to diagnose the hip dislocation.

We cannot measure the angles and draw the lines in this case because it is a decentered joint. Before a hip sonogram can be evaluated you must identify the anatomical structures in a methodical way (chondro-osseous junction, femoral head, synovial fold, joint capsule, acetabular labrum, cartilage acetabular roof, bony socket and osseous rim) (1). In order to reach a diagnostic and measurable sonogram the three landmarks must be present (the formed acetabular roof, bony part of the acetabular roof and bony rim: turning point from concavity to convexity).

One of the main advantages of the Graf method is that it can be used as a criterion of improvement, stagnation or worsening of the condition during the follow-up of patients treated with Pavlik harness (2, 3). In this case, the infant had a dislocated hip, and after 3 weeks of treatment, this is the sonographic result:

In 6 weeks, 9 weeks and 12 weeks, the favorable evolution of the case can be observed, starting from a type IV to a type Ia hip, or from a dislocated hip to a mature hip.

Image 5: The first step: anatomical identification. Subtitles:
1-Femoral head
2-Large trochanter
3-Bony roof
4-Medial border of the Ilium
5-Labrum
6-Cartilaginous acetabular roof
7-Joint capsule
8-Synovial fold
9-Triradiate cartilage

Take home message

Through accurate analysis of the pathological changes in the cartilage and bony socket it is possible to state the severity of the pathology affecting the hip joint, even before the confirmation by the fourth step (the measurement with alpha and beta angles). Always remember the order of assessment: the first step is the anatomical identification, the second step is checking the three landmarks, the third step is the description of the structures (bony socket, bony rim and cartilaginous acetabular roof), and finally, the last one is the angles’ measurement that it must coincide (be congruent).

References

1. GRAF, Reinhard.Hip sonography: diagnosis and management of infant hip dysplasia. Springer Science & Business Media, 2006.
2. KOSAR, Pinar et al. Follow‐up SonographicResults for Graf Type 2a Hips: Association With Risk Factors for Developmental Dysplasia of the Hip and Instability.Journal of Ultrasound in Medicine, v. 30, n. 5, p. 677-683, 2011.
3. JUDD, Julia; CLARKE, Nicholas MP. Treatment and prevention of hip dysplasia in infants and young children.Early human development, v. 90, n. 11, p. 731-734, 2014.

Correct answer to Q1 is:

1. B-line artefacts
2. Irregular pleural line and very small amount of free fluid located peripherally
3. Multiple small consolidations in all lung regions

Correct answer to Q2 is:

1. SARS-CoViD-19 infection

Discussion:

Since COVID-19 infection is primarily a respiratory disease the expectation would be that lung imaging would be essential for the diagnosis (1,2). The typical sonographic signs using lung US (LUS) identified in the course of COVID-19 infections include features of the pleura and pleural space (1), findings of interstitial pneumonia (2) and specific artefacts (3) (1,3-5). The signs are specific when there is a very high “a priori” probability of COVID-19 with cough and dyspnea (1). The initial lung involvement often posterior-basal may become extensive with involvement of the entire lung as shown in this patient. In later stages mixed and much less specific image patterns can be observed including the so-called white lung and bacterial pneumonia superinfection. US also allows detection of complications including pneumothorax, not only in ventilated patients, and pulmonary embolism (5).

Ultrasound signs and differential diagnoses

Pleura

• Thickened, irregular (coarse) and fragmented pleural line.
• Small amount of superficially located pleural fluid (sign of severity). More extensive pleural effusions are not typical.

Lung

• Consolidations, multiple. Very small consolidations often posterobasally, initially. Later in various distributions and possibly involving the entire lung.

Artefacts

• B-lines (initially discrete, later multifocal and confluent), alveolar-interstitial syndrome, so-called „white lung“ (ARDS).
• Respiratory dependent lung sliding (A-artefact), combined with B-line artefacts (mixing A and B patterns).

Differential diagnoses and complications

• Chronic heart insufficiency (BLA, larger pleural effusion than in CoViD-19).
• Bacterial pneumonia (typically larger consolidations than in CoViD-19).
• Pulmonary embolism (initially no vascularity)

Conflicts of interest

“The authors declare no conflict of interest.”

Image(s): Confluent curtain like B-line artefacts (BLA) intercostally using 5 MHz curved array transducer (a). Thickened and irregular pleura line and tiny amount of pleural fluid using 5 MHz curved array transducer (b) and 10 MHz transducer revealing much more details (c). The corresponding computed tomography image is also shown (d). C: Consolidation. FF: free fluid. White arrow: Pneumo-alveolo-bronchogram.

References

1. Piscaglia F, Stefanini F, Cantisani V, Sidhu PS, Barr R, Berzigotti A, Chammas MC, et al. Benefits, Open questions and Challenges of the use of Ultrasound in the COVID-19 pandemic era. The views of a panel of worldwide international experts. Ultraschall Med 2020;41:228-236.
2. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med 2020;382:727-733.
3. Dietrich CF, Mathis G, Cui XW, Ignee A, Hocke M, Hirche TO. Ultrasound of the pleurae and lungs. Ultrasound Med Biol 2015;41:351-365.
4. Dietrich CF, Mathis G, Blaivas M, Volpicelli G, Seibel A, Atkinson NS, Cui XW, et al. Lung artefacts and their use. Med Ultrason 2016;18:488-499.
5. Dietrich CF, Mathis G, Blaivas M, Volpicelli G, Seibel A, Wastl D, Atkinson NS, et al. Lung B-line artefacts and their use. J Thorac Dis 2016;8:1356-1365.

Correct answer to Q1 is:

1. B-line artefacts
2. Irregular pleural line and very small amount of free fluid located peripherally
3. Multiple small consolidations in all lung regions

Correct answer to Q2 is:

1. SARS-CoViD-19 infection

Discussion:

Since COVID-19 infection is primarily a respiratory disease the expectation would be that lung imaging would be essential for the diagnosis (1,2). The typical sonographic signs using lung US (LUS) identified in the course of COVID-19 infections include features of the pleura and pleural space (1), findings of interstitial pneumonia (2) and specific artefacts (3) (1,3-5). The signs are specific when there is a very high “a priori” probability of COVID-19 with cough and dyspnea (1). The initial lung involvement often posterior-basal may become extensive with involvement of the entire lung as shown in this patient. In later stages mixed and much less specific image patterns can be observed including the so-called white lung and bacterial pneumonia superinfection. US also allows detection of complications including pneumothorax, not only in ventilated patients, and pulmonary embolism (5).

Ultrasound signs and differential diagnoses

Pleura

• Thickened, irregular (coarse) and fragmented pleural line.
• Small amount of superficially located pleural fluid (sign of severity). More extensive pleural effusions are not typical.

Lung

• Consolidations, multiple. Very small consolidations often posterobasally, initially. Later in various distributions and possibly involving the entire lung.

Artefacts

• B-lines (initially discrete, later multifocal and confluent), alveolar-interstitial syndrome, so-called „white lung“ (ARDS).
• Respiratory dependent lung sliding (A-artefact), combined with B-line artefacts (mixing A and B patterns).

Differential diagnoses and complications

• Chronic heart insufficiency (BLA, larger pleural effusion than in CoViD-19).
• Bacterial pneumonia (typically larger consolidations than in CoViD-19).
• Pulmonary embolism (initially no vascularity)

Conflicts of interest

“The authors declare no conflict of interest.”

Image(s): Confluent curtain like B-line artefacts (BLA) intercostally using 5 MHz curved array transducer (a). Thickened and irregular pleura line and tiny amount of pleural fluid using 5 MHz curved array transducer (b) and 10 MHz transducer revealing much more details (c). The corresponding computed tomography image is also shown (d). C: Consolidation. FF: free fluid. White arrow: Pneumo-alveolo-bronchogram.

References

1. Piscaglia F, Stefanini F, Cantisani V, Sidhu PS, Barr R, Berzigotti A, Chammas MC, et al. Benefits, Open questions and Challenges of the use of Ultrasound in the COVID-19 pandemic era. The views of a panel of worldwide international experts. Ultraschall Med 2020;41:228-236.
2. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X, et al. A Novel Coronavirus from Patients with Pneumonia in China, 2019. N Engl J Med 2020;382:727-733.
3. Dietrich CF, Mathis G, Cui XW, Ignee A, Hocke M, Hirche TO. Ultrasound of the pleurae and lungs. Ultrasound Med Biol 2015;41:351-365.
4. Dietrich CF, Mathis G, Blaivas M, Volpicelli G, Seibel A, Atkinson NS, Cui XW, et al. Lung artefacts and their use. Med Ultrason 2016;18:488-499.
5. Dietrich CF, Mathis G, Blaivas M, Volpicelli G, Seibel A, Wastl D, Atkinson NS, et al. Lung B-line artefacts and their use. J Thorac Dis 2016;8:1356-1365.

Correct answer is: Leukemia

Image Findings:

The examination revealed an enlarged, heterogeneous right testicle, with a normal epididymis. Also, a small homogenous fluid collection, corresponding to a hydrocele was seen (Figure 1 and 2). The color Doppler study showed a pattern of hypervascularity.

Discussion

Leukemia is a cancer of the body’s blood-forming tissues, such as the bone marrow and the lymphatic system. Leukemia can affect adults and children. In acute lymphocytic leukemia, the brain and the spinal cord and the testes in boys are known as sanctuary sites of cancer. Sanctuary sites are extramedullary anatomic locations that have historically been difficult to penetrate with systemic chemotherapy. In the testes, the finding of an enlarged firm testicle and hyperactivity on color Doppler similar to inflammatory findings, should remind the physician of leukemia of the testis.

Teaching Points

Although an enlarged testicle due to leukemia is a rare ultrasound finding, it is important to remember this diagnosis when dealing with a patient with a previous history of leukemia. The differential diagnoses include inflammatory diseases, but the clinical finding of a painless testicle is very important, as this indicates leukemia more than inflammation.

References

1. https://radiopaedia.org/articles/leukaemia-testicular-manifestations-1?lang=us
2. Kocakroc E, Bhatt S, Dogra V S; Ultrasound Evaluation of Testicular neoplasms. Ultrasound Clinics (2), 27-44, 2007.
3. Dogra V, Gottlieb RH, Oka M et al. Sonography of scrotum. Radiology, 227:18-36, 2003.
4. Hortsman WG, Melson GL, Middleton WD et al. Testicular tumors: findings with color Doppler US. Radiology, 185: 733 -37, 1992.