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Visual Diagnosis Part 6

10/23/2023

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Visual Diagnosis Part 6

Boxer's Fracture

A boxer's fracture is the break of the 5th metacarpal bones of the hand near the knuckle.
Occasionally it is used to refer to fractures of the 4th metacarpal as well.
Classically, it occurs after a person hits an object with a closed fist.
The knuckle is then bent towards the palm of the hand.

Tapioca Pearls

Tapioca pearls appear as “marble-like objects” in ultrasound and CT scan.

Prostatic Abscess

Common symptoms of prostate abscess include frequent urination, pain while urinating, difficulty with urination, or retaining urine.
Physical findings include a purulent urethral discharge, painful digital rectal examination, and possible fluctuant areas in the prostate.
Patients who develop febrile urinary tract infections following a prostate biopsy should be considered high risk for developing a prostatic abscess.

Hampton Hump

Hampton hump refers to a dome-shaped, pleural-based opacification in the lung most commonly due to pulmonary embolism and lung infarction.
It can also result from other causes of pulmonary infarction, such as vascular occlusion due to angio-invasive aspergillosis.

Emphysematous Cholecystitis

Emphysematous cholecystitis is a rare form of acute cholecystitis where gallbladder wall necrosis causes gas formation in the lumen or wall.
It is a surgical emergency, due to the high mortality from gallbladder gangrene and perforation.

ABDOMINAL AORTIC ANEURYSM

The risks of ABDOMINAL AORTIC ANEURYSM (AAA) include advanced age, male gender, smoking, HTN, and family history.
AAA can be asymptomatic, or it may present with abdominal pain back pain, or shock.
Treatments of AAA include surveillance for small aneurysms, and surgical repair, or endovascular stent grafting for larger aneurysms.
Screening, early detection, and monitoring are crucial to prevent AAA rupture.
The absolute lifetime risk of rupture of AAA is 20% for a diameter of 5 cm, 40% for a diameter of 6 cm, and 50% for a diameter of 7 cm.

Diverticulitis

Diverticulitis is a condition where small pouches or pockets called diverticula, which form in the lining of the colon, become inflamed or infected.
Symptoms of right-sided diverticulitis can mimic those of acute appendicitis.
CT findings of diverticulitis include pericolic fat stranding, thickening of the affected colon wall, and the possible presence of abscesses or bowel perforations.
CT can also reveal the presence of diverticula.

Severe or recurring diverticulitis may require hospitalization and surgery.
Complications of diverticulitis include abscesses, bowel obstruction, perforation, and diffuse peritonitis.

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Tension pneumothorax, bulla, and gastrothorax

10/23/2023

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Tension pneumothorax, bulla, and gastrothorax

Tension pneumothorax, tension bulla, and tension gastrothorax are three distinct medical conditions that share similar manifestations and similar characteristics on chest X-rays.
Clinical diagnosis in the acute setting can be challenging since they all present with respiratory distress, chest pain, and tachycardia.
On Chest X-Ray, large radiolucent air-filled cavity is seen almost occupying the hemithorax, causing mediastinal shift and tracheal deviation.
The air-filled cavities are free of lung markings and may represent an massive intrapleural gas, a giant pulmonary bulla, or a distended stomach.

Tension Pneumothorax

Tension pneumothorax occurs due to the progressive accumulation of intrapleural gas in the thoracic cavity caused by a valve effect during inspiration and expiration.
Tension pneumothorax may be associated with rib fractures and subcutaneous emphysema in the setting of trauma.

Tension Bullae

Tension bullae are air-filled sacs in the lung that become enlarged and under pressure, causing compression of surrounding lung tissue.
A rapidly expanding bulla may resemble the same clinical presentation as tension pneumothorax.

Tension Gastrothorax

Tension gastrothorax is a rare life-threatening condition caused by mediastinal shift due to a distended stomach herniating into the thorax through a diaphragmatic defect.
The stomach is distended with trapped air due to one way valve mechanism created by the collapsed pylorus and kinking of the gatro-oesophagal junction.

Diagnosis:

Tension pneumothorax requires immediate chest decompression.
Patient should not be sent to CT scan before chest tube insertion.
CT scan of tension bullae may show intact diaphragms and massive bullae with thin-wall septae.
The wall of the bullae may sometimes be misinterpreted as a pleural line and can be confused with pneumothorax on a chest X-ray.
CT scan is the best way to evaluate the diagnosis of tension gastrothorax, with identification of communication between the stomach and thorax.
Chest CT scans can show the stomach herniated through the diaphragmatic defect with significant distension with or without air-fluid level.

Treatment:

Treatment of tension pneumothorax, tension bulla, and tension gastrothorax are different.
Tension pneumothorax requires needle decompression or finger thoracostomy, followed by chest tube insertion.
Tension bullae may be observed with O2 supplement, but surgical resection may be necessary in severe cases.
Tension gastrothorax requires nasogastric tube decompression of the stomach and surgical repair of the diaphragm.

Take Home Message:

Tension pneumothorax, tension bulla, and tension gastrothorax are three distinct medical conditions that share similar manifestations and similar characteristics on chest X-rays.
Clinical diagnosis in the acute setting can be challenging since they all present with respiratory distress, chest pain, and tachycardia.
CT scan plays a major role in differential diagnosis.
Tension pneumothorax requires needle decompression or finger thoracostomy, followed by chest tube insertion.
Tension bullae may be observed with O2 supplement, but surgical resection may be necessary in severe cases.

Tension gastrothorax requires nasogastric tube decompression of the stomach and surgical repair of the diaphragm.

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Amiodarone Side Effects

10/23/2023

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Amiodarone Side Effects

Amiodarone is a potent antiarrhythmic agent that is used to treat ventricular arrhythmias and atrial fibrillation.
However, its administration in certain conditions can be catastrophic.

Here are six conditions in which healthcare providers should avoid administering amiodarone or use with extreme caution:

Arrhythmias secondary to prolonged QT interval: Amiodarone can prolong the QT interval, which can lead to torsades de pointes, a life-threatening arrhythmia.
Atrial fibrillation associated with left atrial thrombus or A-fib with unknown onset: Amiodarone treatment is associated with an increased risk of stroke in patients with A-fib, which may be the result of thrombus dislodgement and embolization.
Atrial fibrillation in preexcitation or WPW syndrome: Amiodarone can cause a paradoxical increase in conduction through the accessory pathway, leading to ventricular fibrillation.
Arrhythmias due to digoxin toxicity: Digoxin levels increase significantly after coadministration with amiodarone. This increase occurs because of the inhibition of digoxin secretion from renal tubules and the inhibition of the P-glycoprotein membrane transporter system.
Atrial fibrillation in hyperthyroidism: Thyroid toxicity is the most common complication that requires intervention. Amiodarone can cause hypothyroidism or exacerbate hyperthyroidism[3]. Hyperthyroidism may result from an excess of iodine or acute thyroiditis. Hypothyroidism is two to four times more common than hyperthyroidism.
VT mimics due to hyperkalemia, Na-channel blocker toxicity, and accelerated idioventricular rhythm: Amiodarone can worsen wide complex tachycardias mimicking ventricular tachycardia such as severe hyperkalemia, sodium-channel blocker toxicity, and AIVR.

Amiodarone is associated with several serious side effects that require careful monitoring and management:
Pulmonary toxicity

The most serious potential adverse effect of amiodarone therapy is pulmonary toxicity, which may result from direct drug-induced phospholipidosis or immune-mediated hypersensitivity.
The most common clinical presentation is subacute cough and progressive dyspnea, with associated patchy interstitial infiltrates on chest radiographs and reduced diffusing capacity on pulmonary function tests.
A much less common presentation is adult respiratory distress syndrome (ARDS).

Hyperthyroidism

Amiodarone can cause hyperthyroidism by inhibiting the conversion of thyroxine (T4) to triiodothyronine (T3) in peripheral tissues.
This can lead to symptoms such as weight loss, palpitations, and tremors.

Hypothyroidism

Amiodarone can also cause hypothyroidism by causing thyroiditis or by inhibiting the release of thyroid hormones.
This can lead to symptoms such as fatigue, weight gain, and cold intolerance.

Liver toxicity

Amiodarone can cause liver toxicity, which is usually mild and evidenced only by abnormal liver enzymes
However, in rare cases, it can cause severe liver injury, including acute liver failure.

Optic neuropathy

Amiodarone can cause optic neuropathy, which is a rare but serious side effect that can lead to vision loss.

Proarrhythmia

Amiodarone can cause proarrhythmia, which is the development of new or worsened arrhythmias.
This can occur due to the drug's effects on cardiac repolarization.

Bradycardia

Amiodarone can cause bradycardia due to the drug's effects on the sinus node.

Amiodarone is also associated with several minor side effects:

Nausea, anorexia, and constipation.
Corneal microdeposits.
Photosensitivity.
Blue discoloration of skin.

It is important to note that the frequency of most adverse effects is related to the total amiodarone exposure (i.e., dosage and duration of treatment). Therefore, physicians must use the lowest possible dosage of amiodarone and, if possible, discontinue treatment if adverse effects occur. If any of these minor side effects persist or become bothersome, patients should consult their healthcare provider.

Some of the drugs that commonly interact with amiodarone include:

Digoxin.
Warfarin (Coumadin).
Simvastatin (Zocor).
Sildenafil (Viagra).
Cyclosporine (Sandimmune).
Antiarrhythmic.
Quinolones.
Antidepressants.

Take Home Message

In conclusion, it is important for healthcare providers to know that amiodarone has many side effects, and there is also the potential for interacting adversely with other medications.
Patients receiving amiodarone should chronically have baseline testing done to facilitate future monitoring of hepatic, thyroid, pulmonary, and ophthalmologic toxicity.
Patients on warfarin will also need close monitoring of their INR.

All providers, including physicians, nurses, and pharmacists, should be aware of the risks associated with amiodarone administration and take appropriate precautions to ensure patient safety.

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Shark Fin Sign for STEMI

10/23/2023

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Shark fin sign for STEMI

The shark fin sign is indicative of severe myocardial injury and is associated with a large burden of myocardial ischemia, its recognition is crucial for timely diagnosis and management of STEMI.
The shark fin sign is also known as ‘lambda waves', 'giant R waves', or 'triangular waves’.
The ECG pattern consists of complexes formed by the blurring together of QRS and T-wave due to extreme ST-deviation.
The shark fin sign is associated with STEMI of the left main coronary artery or proximal left anterior descending artery.
The shark fin sign can also be found in takotsubo cardiomyopathy, which is associated with hemodynamic instability and shock.
Figure 1 is an ECG from Doctor Smith’s ECG Blog, showing shark fin sign of massive infero-posterior STEMI in a 75-year-old man who collapses to the ground in cardiac arrest while shopping.
Figure 2 is another ECG from Doctor Smith’s ECG Blog, showing shark fin sign of STEMI due to occlusion of the left main coronary artery in a 55-year-old lady who presents with severe chest pain.
Figure 3 is an ECG originally published in Dr. Wang's Atlas of Electrocardiography, showing shark fin sign of STEMI. Note that, the shark fin ST-elevation in leads V4 and V5 could easily be mistaken for a wide-complex tachycardia on ECG rhythm strips.
This is an ECG published in ”Circulation“, showing shark fin sign in a 54-year-old female with septic shock, who was finally proved to be due to takotsubo cardiomyopathy. In a critically ill patient with shark fin sign on ECG and septic shock, takotsubo cardiomyopathy needs to be considered, and takotsubo cardiomyopathy should be included in the differential diagnosis for patients with sepsis and ST elevation that mimics STEMI.

Take Home Message

In conclusion, the shark fin sign is an uncommon ECG pattern and is associated with high-risk conditions such as sub-occlusion of the left main coronary artery or proximal left anterior descending artery.
It can also be found in takotsubo cardiomyopathy, which is associated with hemodynamic instability and shock.

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How to Read Elbow Radiograph

10/23/2023

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How to Read Elbow Radiograph:

Reading an elbow x-ray can be challenging, especially when trying to identify fractures after an acute elbow injury.
A systematic approach can aid in the radiographic recognition of occult signs of injury.
When reading an adult elbow x-ray, it is important to review the alignment, fat pads for effusion, and bony cortex. Below are the steps to follow when reading an elbow x-ray.

Step number 1:

Alignment: Check the anterior humeral line and the radiocapitellar line.
Anterior Humeral line: This line should intersect the middle third of the capitellum on the lateral view. Fractures usually result in displacement of the capitellum posteriorly (versus anteriorly). Signs of humeral fracture are also commonly subtle; breakage may only be evidenced by an abnormal anterior humeral line.
Radio-capitellar line: This line is drawn through the middle of the radius posteriorly/rostrally and should bisect the capitellum on both the lateral and the AP elbow radiograph. Failure to align properly indicates a radial head dislocation that requires prompt reduction if neuro-vascular compromise is to be avoided.

Step number 2:

Effusion: Check for raised fat pads.
Anterior fat pad evaluation: A visible anterior fat pad can be normal; it is a small radiolucent shadow adherent to the anterior aspect of the distal humerus. An abnormal anterior fat pad is described as a "sail sign" because it is unusually prominent and bows outward to form a triangular shape. After trauma, blood can accumulate in the intraarticular space and push the fat pad anteriorly; a positive sail sign in the setting of trauma is a reliable indication of an intraarticular fracture – even if no fracture line can be identified.
Posterior fat pad evaluation: Radiographic visualization of a posterior fat pad is never normal and always signifies fluid in the intraarticular space. Again, in the setting of trauma, this strongly implies fracture of an articular surface.

Step number 3:

Bone cortex: Check around every bone on the film.
Hourglass sign or figure of eight: Search for an adequate "hourglass sign", or "figure of eight" at the distal humerus. If absent, the study is not a true lateral, and interpretation of steps 1 through 2 is less reliable.
Radial head: Careful inspection of the radial head is paramount since fracture lines are often not visible; look for subtle disruptions in the cortical contour.
Olecranon: Look for fracture lines and subtle disruptions in cortical contour.

Pediatric elbow x-ray:
When reading a pediatric elbow x-ray, it is important to distinguish normal from abnormal anatomy:

Normal anatomy and development: Radiographic evaluation of the skeletally immature elbow requires knowledge of the normal sequence and appearance of the secondary ossification centers of the elbow.
Radiographic evaluation: Assessment of the radiocapitellar joint, anterior humeral line, and Baumann’s angle is important.
Specific injuries: Supracondylar humerus fractures are the most common type of elbow fracture in children. Several radiographic parameters are used to evaluate for the presence of a supracondylar humerus fracture.

CRITOE:
CRITOE is a mnemonic used to determine skeletal age from x-rays of a child's elbow. It stands for:

C: Capitellum
R: Radial head
I: Internal (medial) epicondyle
T: Trochlea
O: Olecranon
E: External (lateral) epicondyle

These letters represent the order in which the secondary ossification centers of the elbow appear and fuse. The appearance of secondary ossification centers of the elbow is predictable, but may vary from patient to patient based on sex, maturity, and may even vary from one extremity to the other. The CRITOE mnemonic can be used to remember the chronologic order of ossification.

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Visual Diagnosis Part 6

Tension pneumothorax, bulla, and gastrothorax

Amiodarone Side Effects

Shark Fin Sign for STEMI

How to Read Elbow Radiograph

AuthorTwitter: @jackcfchong[email protected]

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