ObjectivesWe aim to illustrate the multimodal imaging spectrum of hepatic involvement in tuberculosis (TB). Whilst disseminated tuberculosis on imaging typically manifests as multiple small nodular lesions scattered in the liver parenchyma, isolated hepatic tuberculosis remains a rare and intriguing entity.MethodsIndubitably, imaging is the mainstay for detection of tubercular hepatic lesions which display a broad spectrum of imaging manifestations on different modalities. While sonography and computed tomography (CT) findings have been described in some detail, there is a paucity of literature on magnetic resonance imaging (MRI) features. Due to a significant overlap with other commoner and similar appearing hepatic lesions, hepatic tuberculosis is often either misdiagnosed or labelled as indeterminate lesions. This article is a compendium of cases highlighting the spectrum of imaging patterns that can be encountered in patients with isolated primary hepatic tuberculosis as well as disseminated (secondary) disease. Rare patterns of primary disease such as tubercular cholangitis, hypervascular liver masses, and those with vascular complications are also illustrated and discussed.ConclusionsImaging plays a valuable role in the detection of tubercular hepatic lesions. Also, imaging can be helpful in their characterisation and for assessing associated complications.Teaching points• Hepatic TB has myriad imaging manifestations and is often confounded with neoplastic lesions.• Imaging patterns include miliary TB, macronodular TB, serohepatic TB and tubercular cholangitis.• Concurrent splenic, nodal or pulmonary involvements are helpful pointers towards the diagnosis.• Miliary calcifications along the bile ducts are characteristic of tubercular cholangitis.• Histological/microbiological confirmation is often necessary to confirm the diagnosis.

Objective:To assess the performance of mannitol as a luminal contrast as compared to water and positive contrast in evaluation of bowel on multidetector computed tomography (MDCT).Materials and Methods:Three hundred patients were randomly selected for this study and were divided equally into three groups. Each subject received 1500 ml of oral contrast. Group 1 received 3% mannitol in water, group 2 received diluted iodinated positive contrast, and group 3 received plain water without additives. Qualitative and quantitative analysis for distension, fold visibility, and overall image quality were analyzed by actual diameter measurement and point scale system at different bowel levels. One-way analysis of variance (ANOVA) followed by Tukey's HSD Post-hoc test and Pearson's Chi-square (exact test) test were applied.Results:Group 1 showed better results for small bowel distension, intraluminal homogeneity, and visibility of mucosal folds on quantitative and qualitative analysis with statistically significant P value (P<0.001). The ileo-caecal junction distension and mural feature visibility was better with mannitol (P < 0.001). No significant difference in distension of stomach and duodenum was found between the three groups.Conclusion:Mannitol as endoluminal contrast increases the diagnostic accuracy of the investigative studies in comparison to water and iodine-based contrast by producing significantly better bowel distension and visibility of mural features with improved image quality without additional adverse effects.

Background:Pulmonary nocardiosis is a rare but a life-threatening infection caused by Nocardia spp. The diagnosis is often missed and delayed resulting in delay in appropriate treatment and thus higher mortality.Aim:In this study, we aim to evaluate the clinical spectrum and outcome of patients with pulmonary nocardiosis.Methods:A retrospective, 5-year (2009–2014) review of demographic profile, risk factors, clinical manifestations, imaging findings, treatment, and outcome of patients with pulmonary nocardiosis admitted to a tertiary care hospital.Results:The median age of the study subjects was 54 years (range, 16–76) and majority of them (75%) were males. The risk factors for pulmonary nocardiosis identified in our study were long-term steroid use (55.6%), chronic lung disease (52.8%), diabetes (27.8%), and solid-organ transplantation (22.2%). All the patients were symptomatic, and the most common symptoms were cough (91.7%), fever (78%), and expectoration (72%). Almost two-third of the patients were initially misdiagnosed and the alternative diagnosis included pulmonary tuberculosis (n = 7), community-acquired pneumonia (n = 5), lung abscess (n = 4), invasive fungal infection (n = 3), lung cancer (n = 2), and Wegener's granulomatosis (n = 2). The most common radiographic features were consolidation (77.8%) and nodules (56%). The mortality rate for indoor patients was 33% despite treatment. Higher mortality rate was observed among those who had brain abscess (100.0%), HIV positivity (100%), need for mechanical ventilation (87.5%), solid-organ transplantation (50%), and elderly (age > 60 years) patients (43%).Conclusion:The diagnosis of pulmonary nocardiosis is often missed and delayed resulting in delay in appropriate treatment and thus high mortality. A lower threshold for diagnosing pulmonary nocardiosis needs to be exercised, in chest symptomatic patients with underlying chronic lung diseases or systemic immunosuppression, for the early diagnosis, and treatment of this uncommon but potentially lethal disease. Despite treatment mortality remains high, especially in those with brain abscess, HIV positivity, need for mechanical ventilation, solid-organ transplantation, and elderly.

Peripheral nerve sheath tumors are categorized into benign and malignant forms, comprising of neurofibroma and schwannoma in the benign category and malignant peripheral nerve sheath tumors in the malignant category. Magnetic resonance imaging plays an important role in the diagnosis of these lesions. The various imaging features and signs that help to identify and characterize a nerve sheath tumor are, distribution of the tumor along a major nerve, an entering or exiting nerve sign, target sign, a fascicular sign and a split-fat sign.

The presence of a ureter within an inguinal hernia is an extremely rare entity, usually discovered incidentally during herniorrhaphy and may pose a surgical risk. Early preoperative diagnosis is crucial to guide proper surgical approach and to preserve renal function.

SUMMARYMarchiafava-Bignami disease (MBD) is a form of toxic demyelinating disease more often seen in chronic alcoholics. The disease process typically involves the corpus callosum and clinically often presents with altered sensorium, neurocognitive defects or seizures with acute cases often deteriorating to comatose state. The death rate is high. We report a rare case of MBD with complete clinical recovery. A 50-year-old male patient presented in an unconscious state and underwent MRI of the brain which showed significant lesions involving the corpus callosum. Following treatment with thiamine and supportive therapy, he improved clinically and a follow-up MRI revealed significant resolution of the earlier lesions. Diffusion-weighted MRI showed the changes more conspicuously as compared with conventional imaging. The clinical resolution corresponded well with the MRI pattern. The case highlights that diffusion-weighted MRI is an extremely useful tool in evaluation and prognostication of MBD. CASE PRESENTATIONA 50-year-old chronic alcoholic living in isolation presented in an unconscious state to the emergency department. The patient was not a known diabetic or hypertensive, and there was no other significant medical history. On examination, the patient was non-comprehensive and the Glasgow Coma Scale score of the patient was 11/15 with poor word output and localisation to painful stimulus. Laboratory analysis of the patient revealed random blood glucose levels of 95 mg/dL, sodium 107 mmol/L and potassium 4.9 mmol/L. The renal function tests, liver function and other laboratory tests were within normal limits. INVESTIGATIONSCT of the brain which was performed outside the hospital showed subtle hypodensity in the corpus callosum. MRI of the brain showed bilateral subdural hygroma, swollen splenium and posterior body of the corpus callosum with hyperintense signal on FLAIR (fluid attenuation inversion recovery) and T2 images ( figure 1A, B), with diffusion restriction noted as hyperintensity and corresponding hypointensity on ADC (apparent diffusion coefficient) images in the involved region ( figure 1C, D). There was minimal cortical white matter involvement in the left parietal lobe which showed subtle hyperintensity on FLAIR with diffusion restriction ( figure 1E, F).A follow-up MRI following complete clinical recovery revealed a decrease in size of the primary area of involvement with no significant diffusion restriction ( figure 2A-C). Hyperintense signal on diffusion-weighted images was due to T2 shine through as the ADC images were normal. A final diagnosis of Marchiafava-Bignami (MB) disease was considered on the basis of clinical course and MRI findings.

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