PCP Pneumonia

RV positive patient since 16 yrs with recent CD 4 of 109 came with :

Fever with chills since 2mts, dry cough since 1 month, reduced appetite  since 1 month and weight loss of 12 kg over past one month. 

The chest x-ray findings were thought to be related to Koch's and he was started on AKT....

There are coarse reticular opacities in bilateral para hilar and para-cardiac region.Few small cysts were seen in the mid zones.

 Lecopenia was seen ( 1782 /cumm)

Bronchoscopy guided bronchial aspirates revealed PCP organisms. 

Haglund Syndrome

Posterior heel pain



Triad of HS on plain radiograph-

1. Achillis Tendinopathy( thick AT at its insertion with enthesophytes)  
2. Retro-calcaneal bursitis ( Obliteration of Kager's fat pad)
3. Haglund deformity ( bony bump at the posterior superior aspect of the calcaneus)

Ankle Joint osteoarthritis /Talar Osteochondritis dessicans

50 yrs female with ankle Pain since few months. She is known case of OA Knee.

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Subarticular sclerosis along dome of talus on lateral aspect( red arrow)  and subarticular lytic area in the medial aspect.
Irreularity along superior aspect of the neck of talus.

Possibility of osteoarthritis of ankle joint is more likely and is probably secondary to OA Knee with produces undue strain on the ankle joint while walking.


Normal Ankle Joint of another patient for comparison

Etiology of Ankle OA:

• Post traumatic ( most common)- Traumatic ankle injuries that may result in OA include fractures of the malleoli, tibial plafond, talus, isolated osteochondral damage of the talar dome, and ankle ligament injury
• Primary OA, ie, OA with no history of trauma or any kind of secondary or infectious OA, in the ankle is rare.
• Secondary to rheumatoid arthritis and rarely due to hemochromatosis or hemophilia.
• Varus alignment may be a predisposing factor.

Ankle has high resistance cartilage cover and limited range of motions as compared to knee joint so risk of primary OA is less.

Haglund Syndrome with Normal Os Peroneum

A female patient with pain in the posterior aspect of the heel-

Os peroneum is normally located lateral to the cuboid. Accesory Navicular is also noted

Thickening of Achilis tendon at its insertion with enthesophyte and adjacent soft tissue swelling. There is mild  loss of normal retro-calcaneal luceny s/o retro-calcaneal bursitis

Haglund Syndrome:
It is said to be present in cases of patients with heel pain if following signs are present-

1. Achillis insertional site enthesophytes.
2. Insertional Achillis tendinitis,
3. Retro-calcaneal( Kager's fat) and Retro-achillis bursitis.
4. Bone marrow edema in calcaneal tuberosity( MRI)

Predisposing factors: Hind foot varus and pes cavus. 

Those wearing low back shoes are prone for HS-

Os Peroneum:
Located adjacent to calcaneo-cuboid joint( lateral radiograph- 7mm proximal -8mm distal to CC joint, Oblique radiograph- .9mm proximal and 8mm distal to CC jt)
It lies within the peroneus longus tendon.
It can be uni-partite/bi-partite or multi-partite( margins have to be well defined and corticated with minimal i.e. less than 2mm inter-fragment distance).

Fracture of Os Peroneum- os peroneum fragment separation of 6 mm or more or displacement of the proximal Os peroneum fragment by 10 mm or more proximal to the calcaneocuboid joint on a lateral radiograph or by 20 mm or more proximal to the calcaneocuboid joint on an oblique radiograph. It is associated with full-thickness tear of the peroneus longus tendon.

Heel Pain Causes:

The most common causes of heel pain are plantar fasciitis (bottom of the heel) and Achilles tendinitis (back of the heel).
Differential Diagnosis Considerations:

Arthritic -Gout, rheumatoid arthritis, seronegative arthropathy; primary or secondary
osteoarthritis
Infectious -Diabetic ulcer, osteomyelitis, plantar warts
Mechanical 
Plantar—
plantar fasciitis, heel spur, calcaneal stress fracture, medial or lateral
plantar nerve entrapment, heel pad syndrome, foreign body granulomatosis
Posterior—
Achilles tendinopathy, Haglund deformity, retrocalcaneal bursitis, tarsal
coalition, accessory muscles( accesory soleus muscle in posteromedial heel pain), Sever disease (pediatrics)
Neuropathic- Lumbar radiculopathy, nerve entrapment, neuroma, tarsal tunnel syndrome
Trauma
Tumor (rare) -Ewing sarcoma, neuroma
Vascular (rare)

Inflammatory Bowel disease: Crohn's

A 40 yrs female with history of loose non bloody watery stools, weight loss and odynophagia since few months-

The Barium Meal Follow Through Spot compression images reveal eccentric narrowing of the distal small bowel loop with anti-mesenteric pseudosacculations.  The distal ileum stands distinct due to mesenteric fibro-fatty proliferation displacing it from rest of the small bowel. Cecum also shows cobble stone appearance. 

Large bowel colonsocopy upto hepatic flxure reveals serpiginious ulcers with spared normal mucosa giving cobble stone appearance relatively sparing rectum.

Small bowel strictures at two distinct sites involving ileum as detected on Small Bowel Enteroclysis:





There is prestenotic dialation. The strictures are short segment.

Traumatic rupture of Bulbar Urethra. Pelvic bone fractures with peri-prostatic hematoma displacing the bladder upwards: