Medical Image of the Week: Remote Calvarial Renal Cell Metastases

Figure 1. Contrast enhanced axial MRI image shows the metastatic lesion in the right skull with mass effect and midline shift.

Figure 2. Coronal Image shows the extensive calvarial metastatic lesion and its mass effect.

A 57-year-old woman with past medical history significant for clear cell renal carcinoma and radical nephrectomy 9 years prior was admitted to our hospital for headache and left hemiparesis with associated numbness. Symptoms were progressive and had begun about 5 days prior to her presenting to our emergency department. Neurologic exam was significant for reduced strength in her left upper and lower extremities as well as well as sensory deficit to fine touch and vibratory sensation in her left arm. Her gait was unsteady and she was unable to ambulate without assistance. Her right calvarium was grossly enlarged and asymmetrical with softening of the underlying boney structures. 

MRI of the brain showed a 10 cm x 5 cm mass that was obliterating the calvarium and invading the dura mater (Figure 1).  There was mass effect with shift of the midline structures from right to left by approximately 6.5 mm (Figures 1 and 2). This was biopsy proven to be metastatic renal cell carcinoma. Additional smaller calvarium lesions were also seen. At least 3 and possibly 4 parenchymal metastatic deposits are seen in the left occipital lobe. Renal cell carcinoma has been well described to recur after long periods of remission, up to 33 years (1).

She was initially treated with intravenous dexamethasone with resolution of symptoms after 48 hours. Palliative radiation is being provided at this time.

Anthony Witten MD, Hem Desai MD, Ryan Wong MD and Joao Ferreira MD

Department of Internal Medicine

University of Arizona College of Medicine

Tucson, AZ USA

Reference

1. Parada SA, Franklin JM, Uribe PS, Manoso MW. Renal cell carcinoma metastases to bone after a 33-year remission. Orthopedics. 2009 Jun;32(6):446. [CrossRef] [PubMed]

Cite as: Witten A, Desai H, Wong R, Ferreira J. Medical image of the week: calvairial renal cell metastases. Southwest J Pulm Crit Care. 2016;12(1):32-3. doi: http://dx.doi.org/10.13175/swjpcc154-15 PDF

Medical Image of the Week: Coffee Bean and Whirlpool Signs

Figure 1. Supine abdominal x-ray demonstrating a large dilated loop of bowel and coffee bean sign (red circle).

Figure 2. Contrast CT abdomen (coronal section) showing markedly dilated sigmoid loop with the swirling mesentery (whirlpool sign) (red circle).

A 79-year-old woman with a history of Parkinson’s disease presented with altered mental status, poor oral intake, and multiple episodes of nausea and vomiting. An abdominal x-ray demonstrated dilated loops of bowel and the coffee bean sign concerning for sigmoid volvulus (Figure 1). The coffee bean sign occurs when a thick “inner wall” represents the double wall thickness of opposed loops of bowel while the thinner outer walls due single thickness. A contrast CT abdomen showed dilated sigmoid loop and whirlpool sign confirming sigmoid volvulus (Figure 2). She underwent a total colectomy with ileorectal anastomosis and full recovery.

Brittany Bartolome MS3¹, Choua Thao MD², Yaser Dawod MD², and Carmen Luraschi MD³

¹University of Nevada School of Medicine, Reno, NV USA

²Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas, NV USA

³Division of Pulmonary and Critical Care, University of Nevada School of Medicine, Las Vegas, NV USA

Cite as: Bartolome B, Thao C, Dawod Y, Luraschi C. Medical image of the week: coffee bean and whirlpool signs. Southwest J Pulm Crit Care. 2016;12(1):30-1. doi: http://dx.doi.org/10.13175/swjpcc002-16 PDF