Cysticercosis-MRI

Cysticercosis, or neurocysticercosis, is the most common parasitic infestation of the central nervous system worldwide. Humans develop cysticercosis when they ingest eggs or larvae of the tapeworm Taenia solium. The eggs and larvae are usually found in fecally-contaminated water and undercooked pork. The larvae of T. solium are able to invade tissue, and enter the bloodstream. From there, they are able to spread to many organs (skeletal muscle, heart, eye, brain, spinal cord) and form cysts in tissue called cysticerci. This case shows numerous cysts in all the paraspinal muscles and conus medullaris.

Case by-Dr.Sumer K Sethi, MD
Consultant Radiologist ,VIMHANS and CEO-Teleradiology Providers
Editor-in-chief, The Internet Journal of Radiology
Director, DAMS (Delhi Academy of Medical Sciences)

Dr Jaya Shankar, MD
Consultant Radiologist ,VIMHANS

Batman For Sale

Just saw this at the town market of Boac, Marinduque. Each Batman is 40 pesos. I love toy balloons and the kid in me told me to buy one. I did. Shot with a Nikon D40 and Sigma 14mm 2.8 @f5.6.

A Flagellante Interview 2

Here's my second interview with one of the flagellantes in Gasan, Marinduque. Again, this short film is unedited and contains graphic scenes not suitable for sensitive people and minors. Do not try this at home!

Chance equivalent fracture

Findings

Subtle kyphosis at L2/L3 with bipedicle fracture and L1-L3 right transverse process fractures


Diagnosis: Chance equivalent fracture


Key points

Thoracolumbar junction fractures are classified based on mechanism of injury as determined by middle column.
Chance fractures result from anterior hyperflexion, usually across a lap belt.
There is often a horizontal fracture through the vertebral body, pedicles, lamina, and spinous process.
Chance equivalent occurs when the injury is primarily ligamentous.
Chance equivalent may demonstrate mild widening of the posterior intervertebral disc space, facet widening, or splaying of spinous processes.
In both Chance and Chance equivalent, infrequently (20%) there is a neurologic deficit.
50% of the time there is an associated bowel injury.
Almost always occurs at L2 or L3.
Usually this is an unstable fracture.
If there is a neurologic deficit, the patient will likely need surgery. Otherwise they can often be treated with a brace.

A Memorable Third Day in Marinduque

In my third day of my Marinduque tour, I was finally able to get a decent room in Boac Hotel. Yes! Apparently, one of the people who was supposed to reserve the room did not push with the reservation. And so, since I earlier notified the Boac Hotel that I'll get the earliest vacated room, the owner texted me that there is already a vacant room. I immediately took it the following morning.

Although my new hotel room is by no means any better than even the cheap motels in Cubao, it had at least a full-size bed, an air-conditioner, a private toilet and bath, a cable television, and 24-hour room service. In exchange, I had to pay 800 pesos a day, which I consider to be still very cheap. Well, I'm supposed to be on a holiday, so every luxury is welcome, as long as my budget permits me. After all, I can always borrow money from my parents later if I get short. I always make it a point to live within my means, even if I had to borrow to do it :)

After settling my things in my new room, I decided to take a shower, as it was very hot even in the morning. While rubbing my face with soap, I noticed that something was crawling on the ceiling. Half-blinded by the soap, I saw that it was a large house spider almost as big as a child's palm, and with an egg sac in its belly. I quickly grabbed my towel and escaped from the bathroom, with soap and bubbles all over my body. I dried myself with the towel, scrubbing the soap off my body.

Dressing up, I went to the hotel lobby to ask the janitor to remove the spider. The janitor laughed as if it was only a trivial matter to him. But it was a big problem for me, as I will never enter that bathroom again knowing that the spider may be just anywhere inside. I accompanied him to my bathroom and said that I'll give him twenty pesos if he could remove the spider there. And so he entered the bathroom while I anxiously waited if he could catch my nemesis.

The janitor caught the spider with his bare hands, even playing with it, as it crawled in his arms. I almost ran away had I not thought that my reputation as a brave man was at stake here. I threw him the 20 warning him not to get near me. I made sure that he let the spider escape outside lest it got back to my room. Afterwards, I continued my shower, but still opening my eyes wide, lest the spider had some relatives.

Fortunately, I did not see one.

And so I went to my continuation of my exploration of Marinduque. The province, even at the new millenium, still retains an air of rural ambience. Even from the poblacion, one can see the lovely slopes of mountains from beyond. I felt that maybe this is the kind of place where I'm really at home. Yes I miss the hub, noise, and activity in Cubao, but the countryside is ultimately where I'm going to retire when I grow old.

With my backpack containing my digital camera, I walked the town towards the countryside: through creeks, hills, beaches, and ricefileds. For me, there is no more beautiful experience than to behold God's lovely artwork as revealed in nature.

But sometimes, even in this most lovely and serene setting, a misfortune can happen.

As I was wading myself through the ricefields to shoot some colorful landscapes, I felt that I stepped onto something soft and warm. My whole left foot (adorned with my new Adidas), was completely submerged in a carabao dung. I love carabaos, you know. But to have my foot completely in its dung is a complete disaster.

Pulling my left foot up, I noticed that it was now colored yellow-green. Although it is not as smelly as a human waste, the dung in itself is not very pleasant to smell. What's more, its totally embarassing because I'm sure a lot of people will laugh at me if they see how stupid can one get into a carabao dung.

But I had no choice. Wiping my foot into the foliage in side by side motion, I was able to get most of the dung off my foot. Fortunately, one of the nearby shacks had a pump well (Poso), and there I washed myself. The shack owners also told me not to get too deep into the ricefields as there are known to be snakes there.

I went back to town riding in tricycle, and then sneaked back into my hotel room. I placed my Adidas shoe in the shower faucet and let the water do its job. I later bought a brush with a long handle to remove the remaining particles.

Oh what a day....I guess I need to rest a bit...

Congenital epulis

Findings

A homogeneous mass extends from the left maxillary alveolar ridge. The signal intensity of this lesion is isointense to muscle on T1 (Figure 1 and Figure 5) and hyperintense to muscle on T2 weighted images (Figure 2, Figure 3, and Figure 6). Mild enhancement is seen after gadolinium administration (Figure 4 and Figure 7).
The findings are consistent with congenital epulis or congenital gingival granular cell tumor.


Diagnosis: Congenital epulis


Congenital epulis or congenital gingival granular cell tumor is a rare tumor of newborns. These soft tissue tumors appear as erythematous, round masses that arise from the gingival mucosa. Two-thirds arise from the alveolar ridge of the maxilla, but these lesions may also be found in relation to the mandible. The size at birth ranges from a few millimeters to a few centimeters. Epulides are more often found in females with a female-to-male ratio of 8:1.

Although these lesions do not grow after birth, the treatment is surgical excision. No reported cases of tumor recurrence or malignant transformation have been reported. Resection is important due to the risk of oral and airway obstruction during the newborn period. A few cases of spontaneous regression have been reported in the literature.

Histologicaly these tumors are similar to granular cell tumors that originate in other locations. Epulides are composed of a group of un-encapsulated large cells with eosinophilic cytoplasm that are connected by dense fibrous connective tissue and plexiform array of vessels. The exact origin of these lesions is unknown, but is felt to be from messenchymal cells.

Congenital epulis may first present on prenatal ultrasound screening. The differential consists of hemangiomas, lymphangioma, fibroma, and teratomas. The MRI characteristics of this lesion allow for differentiation from other head and neck lesions found in the newborn. Hemangiomas appear as solid masses that are hypervascular and may be multiple. Lymphangiomas are cystic in nature whereas the lesion presented in this case is solid. Fibromas usually appear dark on T2 images. Teratomas contain multiple tissue types and may have calcifications, cystic areas, and fat.

Good Friday Scenes in Gasan 2008

Gasan is a lovely quiet town in Marinduque island that becomes a pilgrimage site every Holy Week. The town is known for the flagellants who cut their skins and whip themselves as a form of sacrifice to atone for their sins. Afterwards, the men wash their wounds in the nearby sea. You can check out my post about it called A Bloody Ritual in Gasan here.

A panoramic view of the sleepy town of Gasan

At late afternoon on Good Friday, the women of Gasan participate in a peculiar ritual called Prusisyon ng Pupua, where they cover Pupua plants around their heads and walk barefooted around the town. This is followed by a procession of religious mannequins.

For those of you who wish to get a feel what Good Friday is like in Gasan, please see the photos below, and be sure click each picture to enlarge.

The main road of Gasan

Gasan Bay

Good Friday in Gasan

Epiglottitis

Findings

Severe thickening of the epiglottis and aryepiglottic folds


Diagnosis: Epiglottitis


Key points

Epiglottitis is acute swelling of the epiglottis and the surrounding soft tissues including the arytenoids and the aryepiglottic folds. The spectrum of epiglottitis has significantly changed over the past 2 decades with the introduction of the Hib vaccine in 1985. Prior to 1985, the disease primarily occurred in children aged 2-7. Other bacteria (Staph and Strep), trauma and thermal injury can cause epiglottitis.
Radiology plays an important role in confirming epiglottitis but in any patient with the possible diagnosis, a bedside radiograph should be obtained and consultation with ENT or Anesthesia should be done to insure proper airway management.
Radiographic signs: the classic finding is the thumb sign which is a thickened epiglottis protruding from the anterior wall of the hypopharynx. It is important to remember that a negative radiograph does not rule out epiglottitis, especially in the early stages of presentation.

A Flagellante Interview

This is my interview with one of the flagellantes in Gasan, Marinduque. The interview was shot March 21, 2008 (Good Friday). A word of caution: Please be advised that the following video contains graphic scenes that may not be suitable for sensitive people and minors.

Pilocytic astrocytoma

Findings

CT shows a mixed cystic-solid mass in the left basal ganglia extending into the left anterior thalamus and left cerebral peduncle. There is associated mild effacement of the left foramen of Monroe with symmetric mild hydrocephalus involving the lateral ventricles. MR confirms the CT findings and demonstrates mild enhancement of the solid portion of the mass with essentially no surrounding edema.

Differential diagnosis of supratentorial partially cystic, partially solid mass in a child:
- Pilocytic astrocytoma
- PNET (primitive neuroectodermal tumor)
- Hemorrhage


Diagnosis: Pilocytic astrocytoma


Key points

Pilocytic astrocytomas are the most common infratentorial neoplasm in the pediatric age group and are classified as WHO grade I.
They typically are round, well defined, and have a solid center piece and cystic peripheral portion.
60% occur in the posterior fossa, but they can also occur in the hypothalamus or along the optic pathways.
On unenhanced CT they are hypodense. Postcontrast, the solid portion enhances.
Calcification is uncommon (<10%); a cystic component is very common (60-80%); hemorrhage is rare.
Pilocytic astrocytomas have an excellent prognosis (5 year survival >90%).

A Bloody Ritual in Gasan

I went to Gasan, Marinduque on Good Friday, to personally witness the bloody ritual of the flagellantes who cut their skins as a form of penitence. Coming from Boac, I arrived in Gasan at exact 2pm. Gasan is a peaceful sloping hill town bounded on the west by sea, and on the east by mountains.

Arriving as a complete stranger, I was told by the locals that the flagellants were already at the Gasan old cemetery. I immediately proceeded there to document their Good Friday Bloody Ritual.

At the old cemetery, I found some fifty bleeding flagellants, still cutting their skins with razor blades. Some older men act as "cutters" making small breaks into the flagellants' arms, chest, back, and legs. The flagellants then hit their wounds with small bundles of sticks to numb the pain.

As I witnessed the ghastly ritual, I became extremely curious and went closer because the men were very friendly and seemed to enjoy being photographed. In my carelessness, I became too close so that some of theirblood splattered on my arms, shirt, and pants. I retreated and apologized for being too close, but the men, ever friendly, just smiled at me, and told me that the bloodstains on my shirt can be easily removed with Zonrox.

It was the very first time that I had personally witnessed a group of people purposely hurt themselves and seemed to be enjoying it, as all of them are smiling and even sharing some jokes. Some of them were even drinking Tawak, a drink concoction made from a mixture of indigenous roots, peppers, secret prayers, and Tanduay.The Tawak was supposedly magical and can make the drinker immune from the venoms of poisonous snakes and bugs.

The very strong and spicy Tawak

As I came to know some of the men, I asked them what their purpose was for doing this ritual. They said that it was an old tradition in Gasan, and a way to atone for their sins. The bloodletting is just small sacrifice compared to the agony suffered by the Lord on the same Friday that he was tortured and crucified.

After a few hours of cutting their skins, they then proceeded to the nearby sea to wash their wounds.

The old Gasan cemetery where the bloody ritual is traditionally held every Good Friday



The Flagellants

My shirt and pants that had been smeared by the flagellants' blood