Methanol Overdose
Submitted by GPH on Wed, 2011-06-08 08:53
Methanol Overdose
This is an interesting yet very sad case.
The patient in his early 40s presented to ER with decreased level of consciousness. The patient remained comatose and had to be intubated for airway protection.
His laboratory studies revealed a profound anion gap metabolic acidosis and a significantly elevated serum osmolarity and osmolal gap.
Methanol overdose was suspected and the patient was immediately given Fomepizole IV and started on Bicarbonate drip.
The patient had a long history of alcohol abuse. His initial CT head revealed a diffuse brain atrophy unusual for his young age. Note a diffuse volume loss and enlarged ventricles on the upper image above. Prolonged and severe alcohol abuse is known to cause brain atrophy.
Despite aggressive medical management the patient remained acidotic so hemodialysis treatment was initiated.
Several hours after the admission the patient “blew his pupils” - his pupils became large and unresponsive to light.
Repeat CT head revealed diffuse cerebral edema due to Methanol overdose. Note almost complete collapse of the ventricles and absence of gyri and sulci(bottom image above). This appearance of the brain is very similar to a brain of the patient suffering from a severe anoxic encephalopathy.
Subsequently, the patient was pronounced brain dead based on clinical criteria and confirmatory test (nuclear brain perfusion scan).
Bilateral Cerebral Aneurysms
Submitted by GPH on Wed, 2011-04-27 10:42
Bilateral Cerebral Aneurysms
This is a very unfortunate case. A young gentlemen presented to ER after he was found unresponsive at home. No history of trauma/injury was reported.
CT head revealed massive sub arachnoid hemorrhage (not well visualized on the above image) as well as left hemisphere intracerebral hemorrhage (labeled blood).
CT angiography of the brain revealed large bilateral aneurysms - right one still intact and well seen and the left one is collapsed by the blood clot.
The patient had progressive deterioration in his neurological status and subsequently was declared brain dead.
Mediastinal Goiter
Submitted by GPH on Mon, 2011-04-25 08:58
Mediastinal Goiter
The patient in her mid-80’s presented with progressively worsening shortness of breath and wheezing. Her chest XR revealed mediastinal mass - labeled by black arrows on the upper image.
CT chest showed a large mediastinal mass (labeled goiter on the bottom image) almost completely collapsing the airways - labeled with small white arrows.
The patient underwent thoracotomy with mediastinal mass resection as well as total thyroidectomy.
Post-operatively the patient was taken off the ventilator with no difficulties. The patient was started on hormone replacement therapy (thyroid hormone) after the pathology was confirmed.
Contrast Extravasation
Submitted by GPH on Fri, 2011-04-08 07:41
Contrast Extravasation
The trauma patient was undergoing CT angiography of the chest to rule out major vascular injury. Immediately after the intravenous contrast administration the patient was noted to have swollen arm. Contrast extravasation (spread of contrast outside the vascular system) was the likely cause.
The XR of the arm confirmed...the contrast extravasation (ever wonder why healthcare is so expensive in America?).
The XR did show though a very nice distribution of the contrast along the fascial planes (see image above).
Contrast extravasation is not a mere inconvenience (causing pain and swelling). In some cases it could lead to muscle and tissue necrosis and even a limb loss.
The patient did fine and went home in a few days. No injury, by the way, was found on the CT scan.
Blastomycosis
Submitted by GPH on Wed, 2011-04-06 12:05
Blastomycosis
This unfortunate gentleman presented to medical attention complaining on weight loss, cough and night sweats.
His Chest XR revealed a likely “mass” in the left lung (black arrow on the upper image above).
CT chest showed a necrotic mass in the same location (bottom image).
Bronchoscopy with lavage and subsequent fungal culture confirmed the diagnosis of Blastomycosis.
The patient was started on antifungal agent with clinical improvement in his condition.
Old Rib Fractures
Submitted by GPH on Thu, 2011-03-31 13:31
Chronic Rib Fractures
If someone comes in to your ICU falling from stairs while in a drunken stupor and you see the above chest XR - you know the patient has done it before.
The image above demonstrates old healed rib fractures in a patient with chronic alcoholism.
Falling from the standing height could cause significant injuries and even lethal head trauma. For many alcoholics it could be a “recurrent medical condition”
I once admitted a patient three times for the same problem... falling from the bar stool.
Post-ERCP Cholangiogram
Submitted by GPH on Sun, 2011-03-27 13:29
Post-ERCP Cholangiogram
This is a cholangiogram image of the patient who had undergone ERCP for cholelithiasis and common bile duct obstruction. On pre-ERCP images the level of the bile duct obstruction was clearly visible.
The above images were taken by injecting contrast through the external biliary drain. Now, you can see the contrast filling the biliary ducts and duodenum (labeled CBD and duodenum respectively).
Subsequently, the external drain was removed and the patient underwent open cholecystectomy.
