Ans. 1. (a) Hyper secreting Adenoma

18

RADIOLOGY

1. What is the most probable diagnosis of the given investigation?

Thyroid cartilage

Sternal Notch

Right

a. Hyper secreting Adenoma b. Graves diseasec. Aberrant thyroid d. Papillary Carcinoma

Ref: Essentials of Nuclear Medicine Imaging, 6th Edition

The given image is of Thyroid ScanThyroid Scan

• Functional Scan• Agent used – Tc-99m Pertechnetate• Dose - 3--5 mCi

Patterns of Thyroid Scan1. Normal Scan –

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2. Mutli-nodular Goiter

3. Hypersecreting Adenoma

217RADIOLOGY

Ans. 2. (a) Pulmonary venous hypertension

4. Cold nodule

2. Which of the following is not a finding in the given chest X-ray?

a. Pulmonary venous hypertensionb. Narrow vascular pediclec. Decreased pulmonary blood flowd. Right atrial enlargement

Ref: Chest X-ray Made Easy, Pg – 108

Findings in the given CXR – • Narrow vascular pedicles

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Ans. 3. (c) Renal Angiomyolipoma

• Cardiomegaly• Hyperlucent lung fields• Oligaemic lung fields

The above given findings are suggestive of Pulmonary Arterial HypertensionNote :Pulmonary Venous Hypertension is  suggested  by Plethoric  lung fields with prominent hilar vessels.

3. A 50 year old banker female underwent a routine workup for insurance purposes. The USG showed complex exophytic mass in her kidney. A CT Scan abdomen was done to further evaluate the mass as given below. Which of the following is the most probable diagnosis?

a. Parapelvic Cystb. Renal Cell Carcinomac. Renal Angiomyolipomad. Renal Cyst

Ref :Genitourinary Imaging By Satomi Kawamoto, Katarzyna J. Macura; P – 108• Renal angiomyolipomas (AMLs) are a type of benign renal neoplasm and are

composed of vascular, smooth muscle and fat elements.• Angiomyolipomas are often found incidentally when the kidneys are imaged for

other reasons, or as part of screening.• Angiomyolipomas are members of the perivascular epithelioid cells tumour group

(PEComas) and are composed of variable amounts of three components; blood vessels (-angio), plump spindle cells (-myo) and adipose tissue (-lipo).

219RADIOLOGY

Ans. 4. (c) Toxic megacolon

• Radiologic Findings –◊Mostly small lesions <5 cm in diameter◊Many have a large exophytic component (25%)◊Calcifications not common (6%)◊Plain film findings ◊Mass of fat lucency is lesion is large enough◊CT findings Well-marginated, cortical-based, heterogeneous tumor predominantly of

fat density (<-20 HU)Variable enhancement (smooth muscle, vessels)

4. A patient presented to the emergency department with fever and pain abdomen. He had a history of diarrhea with fever and pain abdomen. There was associated prolonged history of diarrhea and abdominal distension on examination was present. An X-ray abdomen was performed which is given below. Which of the following is the most probable diagnosis?

a. Volvulus b. Intestinal perforationc. Toxic megacolon d. Pneumatosisintestinalis

Ref :Fundamentals of Diagnostic Radiology - Page 678; Schwartz Principles of Surgery 10th Ed; P-1197

The given case is of Toxic Megacolon which is evident by a presentation of acute abdominal pain associated with fever and a past history of diarrhea for several months along with the given radiograph showing dilated entire colon with loss of haustrations

www.aim4aiims.in 220with increased diameter.Toxic Megacolon

• Toxic megacolon is the clinical term for an acute toxic colitis with dilatation of the colon.

• The dilatation can be either total or segmental.• The affected area of bowel loses all tone and contractility.• The  patient will  have  progressive  abdominal  distension,  significant  discomfort 

and fever.NOTE:Perforation – X-ray will show gas under the diaphragm.

Pneumatosis intestinalis – X-ray will show gas within the bowel wall.

Ans. 1. (b) PDR

10OPTHALMOLOGY

1.Which of the given disease correctly corresponds to the given fluoresceinangiography image:

a. NPDR b. PDRc. Familial dominant drusen d. Birdshot retinopathy

Explanation:This picture shows Fundus Fluorescein Angiography (FFA) of a patients.

Features seen in this picture are

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73OPTHALMOLOGY

Ans. 2. (c) Staphyloma

a. Diffuse leak along superior arcade ( red circle) suggestive of NVEb. Multiple CNP (capillary non perfusion ) areas (yellow circle) c. Multiple pin pointed leaks ( green circle) suggestive of dot and blot hemorrhage

Above all findings suggestive of PDRIn NPDR, there will be no diffuse leak as circled in red circle.

PathologicPatternsofFluorescence

Pattern Cause Example Appearance on an-giogram

Hyper fluorescence Leakage AMD (CNVM)Neovascular tissueCSCR

Hyperfluorescence in-crease with time (both intensity of dye and size of lesion)

Staining Scar

Scleral show

Amount of dye visible increasesSize of lesion stays constant

Pooling Pigment epithelial defectTumor

Dye accumulating in a fluid-filled space (well-defined border, elevation o clinical exam)

Window defect Loss of RPERPE tear Drusen

Normal fluorescence of choroid accentuated (most apparent early, fades late)

Hypo fluorescence Blockage BloodPigmentFibrous tissue

Fluorescence of dye blocked by opaque medium

Nonperfusion Vascular occlusion

Coloboma

Vessels do not fill properly Absence of tissue/vessels

AMD, age-related macular degeneration; CNVM, chorodial neovascular membrane; CSCR, central serous chorioretinopathy; RPE, retinal pigment epithelium.

2.Themost likelycauseofbulgingofcornea inapatientofacutecongestiveglaucomais?a. Keratoconus b. Descemetocelec. Staphyloma d. Decreased corneal thickness

www.aim4aiims.in74Explanation:A staphyloma is an abnormal protrusion of the uveal tissue through a weak point in the eyeball. The protrusion is generalily black in colour, due to the inner layers of the eye. It occurs due to weakening of outer layer of eye (cornea or sclera) by an inflammatory or degenerative condition. It may be of 5 types, depending on the location on the eyeball (bulbus oculi). ANTERIOR (corneal) staphyloma In the anterior segment of the eye, involving the cornea and the nearby sclera. It is an ectasia of pseudocornea ( the scar formed from organised exudates and fibrous tissue covered with epithelium) which results after sloughing of cornea with iris plastered behind, it is known as anterior staphyloma. INTERCALARY staphyloma It is the name given to the localised bulge in limbal area, lined by the root of the iris. It results due to ectasia of weak scar tissue formed at the limbus, following healing of a perforating injury or a peripheral corneal ulcer. There may be associated secondary angle closure glaucoma, may cause progression of the bulge if not treated. Defective vision occurs due to marked corneal astigmatism. Treatment consists of localised staphylectomy under heavy doses of oral steroids. CILIARY Staphyloma As the name implies, it is the bulge of weak sclera lined by ciliary body, which occurs about 2–3 mm away from the limbus. Its common causes are thinning of sclera following perforating injury, scleritis & absolute glaucoma. it is part of anterior staphyloma EQUATORIAL staphyloma On the equator of the eye (region circumferencing the largest diameter orthogonal to the visual axis). Its causes are scleritis & degeneration of sclera in pathological myopia. It occurs more commonly in the regions of sclera which are perforated by vortex veins. POSTERIOR staphyloma Posterior staphyloma beneath the optic disc (right eye) In the posterior segment of the eye, typically diagnosed at the region of the macula, deforming the eye in a way that the eye-length is extended associated with myopia (nearsightedness). It is diagnosed by ophthalmoscopy, which shows an area of retinal excavation in the region of the staphyloma.

Ciliary

Anterior

Intercalary

Equatorial

Posterior

lens

75OPTHALMOLOGY

Ans.3.(d)Intraocularantibniotic

3.Apatient onpost opday 5 after cataract surgerydeveloped the followingcomplication.Treatmentincludea/e:

a. Pars plana vitrectomy b. Topical antibioticc. Intravenous antibiotic d. Intraocular antibiotic

Explanation:Signs present in this picture are,

• Diffuse congestion• Corneal edema• Hypopyon

All this signs along with recent history of cataract surgery suggestive of endophthalmitis

EndophthalmitisIt is an inflammation of the internal layers of the eye resulting from intraocular colonization of infectious agents and manifesting with an exudation into vitreous cavity.It can be exogenous or endogenous.ClassificationPost surgical endophthalmitis

a. Fulminant (<4 days) • Gram negative bacteria• Streptococci• Staphylococcus Aureus

b. Acute (5-7 days)• Staph. Epidermidis• Coagulase negative cocci

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1. Delayed entry• Bleb related

2. Delayed onset• P. acne• Fungi• Staph epidermidis

Symptoms and signs in endophthalmitis• Pain• Rapid diminution of vision • Absent fundus glow• Anterior chamber reaction• Pupillary membrane• Hypopyon

ConfirmationofdiagnosisAll unexpected inflammatory response following intraocular surgery should be considered endophthalmitis unless proven otherwise.

Treatment Three most important determinant in outcome following endophthalmitis are-

a. Duration b. Virulence and loadc. Pharmacokinetics and spectrum of activity1. ANTIMICROBIAL THERAPY

a. Intravitreal antibiotics in post-surgical endophthalmitisb. Intravenous antibiotics in post-surgical bacterial endophthalmitis found to be

poor intraocular penetration.c. Topical and subconjunctival antibiotic can be considered

2. ANTI-INFLAMMATORY THERAPY: ROLE OF CORTICOSTEROIDS3. PARS PLANA VITRECTOMY

Close differential of endophthalmitis in a post surgical patient is TASS (Toxic Anterior Segment Syndrome)

77OPTHALMOLOGY

Ans.4.(a)Pterygium

TASS ENDOPHTHALMITISTiming The day after sx, 12-48 hrs Usually >2 day after surgery,

commonly 4-7 daysMild to moderate pain More pain (25% no pain)

Discharge Watery PurulentLid edema No Yes

Conjunctival chemosis

No Yes

Corneal edema Limbus to limbus Localized or segmental

4. Identify the given pathology:

a. Pterygium b. Pinguiculac. Chemical injury d. Fibrodysplasia

Explanation:PINGECULA

A

A. Pinguecula B. Pinguecula with calci�cation

B

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Ans. 5. (a) Myopia

C. Pinguculitis

C

PTERYGIUM

A. Pterygium showing cap, head and body B. Stockers line in pterygium

C. Pseudopterygium secondary to chemical burn 5. Identify the refractive error:

a. Myopia b. Hypermetropia c. Compound astigmatism d. Mixed astigmatism

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79OPTHALMOLOGYExplanation:

Myopia corrected by minus lens Hyperopia correct by plus lens

(A) Simple hyperopic astigmatism; (B), (E) simple myopic astigmatism; (C) compound hyperopic astigmatism; (D) compound myopic astigmatism; (E) mixed astigmatism

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Ans. 6. (b) Myasthenia Gravis

6.ApatientpresentedwithdroopingofrightuppereyelidasshowninimageA.ThepatientwasgivenacertaindrugafterwhichtheconditionimprovedasshowninimageB.Whichofthefollowingisthepossiblediagnosis?

BeforeDrug AfterDrug

a. Tolosa-Hunt syndrome b. Myasthenia gravisc. Trigeminal neuralgia d. Multiple sclerosis

Explanation:

The image shows the Tensilon test used for the diagnosis of Myasthenia Gravis. The Tensilon test is used to diagnose Myasthenia Gravis. Patients positive for the disease should show an improvement in muscular strength following administration of Tensilon - Edrophonium - IV. Edrophonium is a very short acting Anticholinesterase and therefore increases the effective amount of acetylcholine at the neuromuscular junction in patients with Myasthenia Gravis.

Pathogenesis of Myasthenia Gravis

Axon

Mitochondria

Vesicle

A Normal

Nerve

terminal

Muscle

AChE

AChR

B MG

THE NEUROMUSCULAR JUNCTION

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81OPTHALMOLOGYImportant points in myasthenia gravis

1. Most sensitive test: EMG (decremental response)

2. Most specific test: Antibody against Ach Esterase antibody

3. Treatment of Myasthenic crisis: Plasmapheresis and IVIG

4. Indications for thymectomy in MG

a. Anti < 15 years and > 55 years

b. Anti MuSK positive

c. Generalized MG

OssermanclassificationofMyastheniaGravis(MG)

● Occular MG ● Generalized MG

● Bullbar weakness ● Respiratory weakness/ crisis