A swollen tender, painful thyroid left lobe

This female patient has an acute swollen tender and painful left side of neck. 

Just did an ultrasound scan and found this:

What is the diagnosis?

de Quervains thyroiditis of left lobe 

with colloid cyst of right lobe. 

The colloid cyst is not the cause of the symptoms of pain and tenderness; the left lobe lesion is the chief culprit. 

What is this odd sounding disorder?

De Quervain's thyroiditis is a self-limiting inflammatory condition of the thyroid gland that affects the left lobe in some cases. 

It is also called subacute thyroiditis. 

The condition usually presents with symptoms of pain, tenderness, and swelling in the affected area.

Ultrasound and color Doppler findings in de Quervain's thyroiditis affecting the left lobe of the thyroid in this case include:

• Hypoechoic (dark) areas within the thyroid gland
• Swollen left lobe thyroid 
• Increased blood flow within the thyroid gland on color Doppler imaging
• Thickened capsule of the affected lobe
• Enlarged lymph nodes in the surrounding area

Management of de Quervain's thyroiditis: typically involves the use of non-steroidal anti-inflammatory drugs (NSAIDs) to control pain and inflammation. In some cases, steroids may be necessary to reduce inflammation and swelling. The condition usually resolves on its own within a few months, and long-term prognosis is excellent.

In summary, de Quervain's thyroiditis is also called subacute thyroiditis and here is affecting the left lobe of the thyroid, in this case can be identified on ultrasound and color Doppler imaging, with characteristic findings including hypoechoic areas, increased blood flow, and thickened capsule. Treatment involves NSAIDs and steroids, and prognosis is typically good with complete resolution of symptoms.

For more visit:

Sonography of subacute thyroiditis

This calculus is huge, is it a staghorn?

Let's have a look at the ultrasound images of the right kidney:

The right kidney shows a totally different picture.

There's a very large, almost huge renal stone and its filling up most of the right renal pelvis and partially entering the calyces.

It's also a good practice to take transverse sections of the calculus. This helps get a complete volume analysis of the calculus. 

Fortunately, there is no hydronephrosis. 

Now have a look at the opposite left kidney:

That's a relief for the poor patient. Just a small pelvic calculus in the left kidney. 

What are the important points about staghorn calculus?
Staghorn calculus is a large branching kidney stone that can partially or completely fill the pelvicalyceal complex (CHLC) of the kidney.

- It can be an accidental ultrasound or X-ray finding or be detected during a targeted examination of the patient.

- The reason for contacting a urologist is usually pain in the lumbar region, the discharge of small concretions, changes in urine tests.

- Staghorn calculi are radiopaque and conform to the renal pelvis and calyces, which are often to some degree dilated.

- When viewed on bone windows on CT scan they have a laminated appearance, due to alternating bands of magnesium ammonium phosphate and calcium phosphate .

- Treatment options include percutaneous nephrolithotomy (PCNL), shock wave lithotripsy (SWL), and ureteroscopy (URS) .

- The prognosis depends on the size and location of the stone as well as any associated infections . 

For more on this visit:

Sonography of renal calculi

Mitral leaflet thickened in elderly male

This anterior mitral valve leaflet definitely appears thickened. 

Incidental finding on routine echo study:

An incidental finding of thickened anterior mitral valve leaflet is not an uncommon finding and is usually seen incidentally. It is of little clinical significance if it is not associated with more than mild regurgitation or "leakage" of the mitral valve, restriction in opening of the valve or mitral stenosis or other structural heart disease.

Conclusion:

In the case above: the color Doppler echo shows normal flow across the mitral valve. 

Hence, this finding of mildly thickened anterior mitral valve leaflet may not be significant. 

View the full echo video here:

Echo video of mitral AML thickening

References:

(2) Rare aneurysm of anterior mitral valve leaflet-a case report. https://pubmed.ncbi.nlm.nih.gov/31775814/ 

(3) Rare aneurysm of anterior mitral valve leaflet-a case report. https://pubmed.ncbi.nlm.nih.gov/31775814/ 

(4) An incidental finding of mitral valve network - PubMed. https://pubmed.ncbi.nlm.nih.gov/20849475/ 

(5) The Mitral Valve in Hypertrophic Cardiomyopathy | Circulation. https://www.ahajournals.org/doi/full/10.1161/circulationaha.111.035568 

(6) Mitral valve disease - Symptoms and causes - Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/mitral-valve-disease/symptoms-causes/syc-20355107 

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My kid has a swelling below the ear

This kid of 10 years has a swelling below the left ear pretty tender too on touch. 

The anguished mother wanted an ultrasound scan. 

This is what we found:

Ultrasound and color Doppler are useful tools for evaluating parotid gland lesions.

These are our findings on sonography of the salivary glands:

1. Ultrasound shows enlargement, heterogeneity, and hypoechoic foci of the affected left parotid salivary gland.

2. Color and power Doppler show increased vascularity and prominent vessels within the gland.

3. In this case, the left parotid gland shows signs of parotitis, while the right parotid and submandibular glands are normal.

What is the final diagnosis here?

# The possible causes of unilateral parotitis include mumps, Castleman's disease, or salivary gland tumors.

# Further investigations such as MRI or biopsy may be needed to confirm the diagnosis.

What is parotitis?

Parotitis is an inflammation of the parotid gland that can be caused by viral, bacterial, or autoimmune diseases.

Management and prognosis of parotitis:

Management of parotitis depends on the underlying cause. For bacterial infections, antibiotics are usually prescribed. For viral infections, antivirals may be used. For other causes, such as salivary stones, tumors, or autoimmune diseases, surgery or other treatments may be needed. Symptomatic relief can be achieved by using painkillers, sialogogues (substances that stimulate saliva production), warm compresses, and gland massage. Oral hygiene and hydration are also important to prevent complications.

Prognosis: of parotitis varies depending on the severity and cause of the condition. Most cases of acute parotitis resolve within a few weeks with appropriate treatment. However, some cases may lead to complications such as abscess formation, facial nerve palsy, sepsis, or chronic recurrent parotitis. Chronic parotitis may require long-term management and may affect the quality of life of the patient. 

For more on this visit:

Sonography of salivary glands

Reference:

Parotitis: Parotid Gland Swelling Causes, Symptoms & Treatment. https://my.clevelandclinic.org/health/diseases/23577-parotitis-parotid-gland-swelling 

(2) Suppurative parotitis in adults - UpToDate. https://www.uptodate.com/contents/suppurative-parotitis-in-adults 

(3) Parotitis Treatment & Management - Medscape. https://emedicine.medscape.com/article/882461-treatment 

Prostatomegaly and it's grades etc

The above ultrasound images show a case of grade 2 prostatomegaly or benign prostatic hypertrophy/ BPH.

Findings: 

= significant enlargement of the prostate

= significant residual urine > 90 ml

= no back pressure changes on the kidneys as yet 

= normal urinary bladder at present 

What is prostatomegaly?

Prostatomegaly, or an enlarged prostate gland, is a common condition that affects many men as they age. It can cause a range of symptoms, such as difficulty urinating, frequent urination, and urinary tract infections. One way doctors diagnose and classify the severity of prostatomegaly is through grading.

Grading:

Prostatomegaly is graded on a scale of 0 to 4, known as the prostate-specific antigen (PSA) grading system. This system is based on the size of the prostate gland, as measured by a doctor during a physical exam, as well as the PSA levels in the blood.

Grade 0: A normal prostate gland measures less than 20 grams and has a PSA level of less than 4 ng/mL. This indicates no sign of prostatomegaly.

Grade 1: A slightly enlarged prostate gland measures between 20 to 30 grams and has a PSA level of less than 4 ng/mL. This is considered mild prostatomegaly.

Grade 2: A moderately enlarged prostate gland measures between 30 to 50 grams and has a PSA level of 4 to 10 ng/mL. This is considered moderate prostatomegaly.

Grade 3: A severely enlarged prostate gland measures between 50 to 100 grams and has a PSA level of 10 to 20 ng/mL. This is considered severe prostatomegaly.

Grade 4: A very severely enlarged prostate gland measures over 100 grams and has a PSA level of over 20 ng/mL. This is considered very severe prostatomegaly.

Important points:

It is important to note that the severity of symptoms experienced by an individual with prostatomegaly does not always correlate with the grade of the condition. For example, someone with a Grade 1 prostatomegaly may experience more severe symptoms than someone with Grade 2. This is why it is essential to discuss any symptoms or concerns with a doctor to determine the appropriate treatment plan.

Management of prostatomegaly:

Treatment for prostatomegaly may include medications, such as alpha blockers or 5-alpha reductase inhibitors, or surgery, such as a transurethral resection of the prostate (TURP). In some cases, lifestyle changes, such as limiting caffeine and alcohol intake, can also help manage symptoms.

In conclusion:  prostatomegaly is a common condition among men and is graded on a scale of 0 to 4 based on the size of the prostate gland and PSA levels. However, the severity of symptoms does not always correlate with the grade of the condition. It is important to discuss any concerns or symptoms with a doctor to determine the appropriate treatment plan.

For more on this visit:

Sonography of BPH and prostatomegaly

A case of PCOD or polycystic ovary disease

This lady is 30 years old and has irregular menses. This is what her ultrasound imaging of the pelvis:

ultrasound findings: 

for PCOD in this 30-year-old female with ovaries of 11 cc volume each include:

The Rotterdam consensus defined the polycystic ovary as having 12 or more follicles, measuring between 2 and 9 mm (FNPO), and/or an ovarian volume (OV) >10 cm.

Ovary size and volume is frequently determined with ultrasound. The normal, adult, non-pregnant, mean ovary volume of women who are not postmenopausal is 6-7 mL.

Thus this patient has an ovarian volume of 11 cc each. 

Final diagnosis: PCOD 

Management:

Management advice in such a case includes:

- Ensuring proper weight management. Even a 5% reduction in weight can help a lot in treating the disease. Thus, PCOD patients must exercise on a regular basis and maintain a healthy diet¹.

- An ultrasound can check the appearance of your ovaries and the thickness of the lining of your uterus. If you have a diagnosis of PCOS, your provider might recommend more tests for complications.

Diet advisable in this lady is:

A healthful PCOD diet can include natural, unprocessed foods high-fiber foods fatty fish, including salmon, tuna, sardines, and mackerel kale, spinach, and other dark leafy greens¹. Women suffering from PCOD/PCOS are insulin resistant. Hence they should follow a diabetic diet. Their diet should be rich in fiber and low in carbs and processed foods.

In general people on a PCOS diet should avoid foods already widely seen as unhealthful. These include refined carbohydrates such as mass-produced pastries and white bread fried foods such as fast food fries margarine red or processed meats.

PCOS vs PCOD:

PCOD (Polycystic Ovarian Disease) and PCOS (Polycystic Ovary Syndrome) are two different conditions that affect ovaries in women during childbearing years. Here are some key differences between them:

- The primary difference between PCOD and PCOS is that PCOS is a more severe condition than PCOD.

- PCOD is a structural change in the ovaries which show multiple unhealthy or abnormal small cysts. Hence the term polycystic ovary. 

Such women may have little/ few or no symptoms as compared to PCOS where multiple symptoms are present. 

- When it comes to symptoms, there are many overlaps between them. However, a key differentiator is that PCOD symptoms rarely show up at an early age. They are typically visible only later in life. On the other hand, PCOS symptoms show up early, usually during teenage years.

- Also, the incidence of PCOD is far more than PCOS. UNICEF study suggests:

9 % of women have PCOS in India whilst 22% of women have PCOD. 

For more on this visit:

Sonography of ovaries in PCOD

A renal cyst with calcific mural nodule

Findings on sonography:

Multiple cysts (2 in number) of the left kidney are present. 

There's also a simple hepatic cyst of the left lobe. 

Left lower pole renal cyst of 3 cms with calcific mural nodule seen on ultrasound imaging.

Calcification of the mural nodule can be a sign of a potentially malignant cyst. 

Color Doppler ultrasound shows no vascularity within the cyst.

A left lobe of liver simple cyst also seen, which is typically benign and may not require treatment.

Analysis of the cyst:

Left renal complex cyst:

Presence of a calcific nodule within the cyst is concerning, as it can be a sign of a potentially malignant lesion.

The size of the cyst is also an important factor to consider, as larger cysts are more likely to harbor malignancy. In this case, the cyst measures 3 cm, which is a moderate size that warrants further evaluation.

The shape and borders of the cyst are also important to evaluate. A cyst with irregular borders or a complex internal structure may be more concerning for malignancy. Additionally, the presence of any solid components within the cyst, such as the calcific nodule in this case, can increase the risk of malignancy.

Further imaging studies such as CT or MRI may be recommended to better characterize the cyst and determine the optimal management strategy.

How to classify this renal cyst:

The Bosniak classification system is the most commonly used ultrasound classification system for renal cysts. It was developed by Dr. Morton Bosniak in 1986 and later revised in 2019. It divides renal cysts into different grades based on their complexity, risk of malignancy, and the need for follow-up.

The Bosniak classification system includes the following grades:

Bosniak I cysts: Simple cysts with a thin, smooth wall and no septations, calcifications, or solid components. They have a negligible risk of malignancy and do not require follow-up.

Bosniak II cysts: Cysts with a few thin septations, calcifications, or a slightly thicker wall. They have a low risk of malignancy and may require follow-up imaging.

Bosniak IIF cysts: Cysts with thicker septations, multiple septa, and/or calcifications. They have an intermediate risk of malignancy and usually require follow-up imaging.

Bosniak III cysts: Cysts with thick, irregular septations, nodularity, or a solid component. They have a high risk of malignancy and should be surgically removed or biopsied.

Bosniak IV cysts: Cysts with a clearly defined solid component or masses with enhancing solid components. These cysts have a high risk of malignancy and should be surgically removed or biopsied.

What is the Bosniak grade for this complex cyst?

The renal cyst in this case could be classified as Bosniak II cyst. This is because it has a small mural calcific nodule, which is considered a feature that slightly increases the complexity of the cyst, but not enough to classify it as a Bosniak III cyst. A Bosniak II cyst has a low risk of malignancy, but may require follow-up imaging.

The 2nd simple left renal cyst is a Bosniak grade I.

For more on this visit:

Sonography of renal complex cysts