Yet Another Radiological Halloween

Eric Postal, MD

A radiologist’s Halloween.

Autumn was well underway, and the radiology department’s residents had long since settled into the roles that had been so new and different back in July. Everything was nice, routine, and taken in stride. They shuffled into their daily conference, no expectation of anything unusual.

The attending radiologist conducting the conference had other plans, and told them he’d be presenting a series of unknown cases. Presentation was going to utilize a twist the attending had experienced during his training: A junior resident would look at the images and describe what he saw, and a senior, with his back turned, would try to make the diagnosis purely from what he was hearing. Sometimes, a smidge of relevant clinical history would be provided.

It took the residents awhile to catch on to the common theme of the cases:

Case 1: Patient presented with chlorosis, and during evaluation in ER demonstrated a severe aversion, almost phobic, to water and other liquids. Imaging consistently showed signs of dehydration, but was otherwise unremarkable aside from small dermal facial lesions (ER staff states these appear to be warts on physical exam). Imaging repeatedly shows parts of a large foreign body alongside the patient; technologist states that patient arrived clutching a broom and refused to be parted from it.

Case 2: Patient presents with extensive hypertrichosis. Marked canine-dental hypertrophy, both maxillary and mandibular. There also appears to be enlargement and dorsal protrusion of coccygeal bones. Patient reportedly presents to ER slightly less than once per month, often with altered mental status and combative, requiring considerable usage of restraints. Caution: Allergy to silver.

Case 3: Signs of severe secondary hemochromatosis. Marked hypertrophy of the canines (only maxillary, unlike case #2). Patient noted to exhibit pronounced pallor and is reportedly extremely photosensitive.

Case 4: Patient appears to have acromegaly. Metallic foreign bodies project from both sides of his neck…orthopedic bolts? Mutism noted by technologist and ER staff, although patient was mostly compliant (but did have a short temper and took quite awhile to calm down once agitated).[[{"type":"media","view_mode":"media_crop","fid":"42634","attributes":{"alt":"radiology mystery","class":"media-image media-image-right","id":"media_crop_1419204126669","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4637","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 200px; width: 200px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©venimo/","typeof":"foaf:Image"}}]]

Case 5: Patient is covered in bandaging-material. Appears severely cachectic and dehydrated. Multiple organs are external to the abdominal cavity and imaged alongside the patient, contained in what appear to be jars. Even the brain appears to be absent from the skull.

Case 6: Cannot seem to get diagnostic quality images of tissue by any modality. Yet the sheet wrapped around the patient shows up on images without a problem…appears to have two holes in it for some reason?

Answers (if anyone needs them!) will be posted in a comment to this blog after a few days.