The accuracy of ultrasonography-guided FNAC at our institution was comparable to that reported in the literature. There appears to be very low probability of malignancy in sonographically benign nodules with initial non-diagnostic FNAC results.
Toxic encephalopathy is a wide spectrum of encephalopathy secondary to insult from toxic substances, with variable clinical presentations from minor cognitive impairment to severe neurological dysfunction and death. Methadone-induced toxic encephalopathy is an extremely rare form of toxic encephalopathy which typically demonstrates abnormal imaging findings in the dentate nuclei or cerebellum. This is a report of methadone-induced toxic encephalopathy in two toddlers secondary to accidental ingestion. They were brought in unconscious to the emergency department of a tertiary hospital and were found to be cyanotic and pulseless, requiring cardiopulmonary resuscitation and mechanical ventilation. Magnetic resonance imaging (MRI) of the brain of both patients showed similar findings of symmetrical hyperintense foci in bilateral cerebellar hemispheres on T2-weighted and fluid-attenuated inversion recovery (FLAIR) sequences. These areas also demonstrated diffusion restriction on diffusion weighted imaging (DWI). Blood and urine toxicology results confirmed the presence of methadone in both patients. As the exact substance of accidental ingestion may not be known at the time of presentation, early radiological diagnosis of methadone-induced encephalopathy may prompt early initiation of treatment to prevent further life-threatening complications, particularly in vulnerable pediatric population.
M e d i c a l E d u c a t i o n CASE PRESENTATION A 56-year-old man presented to the emergency department (ED) with a three-day history of pain in the epigastric and right hypochondrial regions of the abdomen. The pain was aggravated by deep inspiration and movement. There was no nausea, vomiting or associated gastrointestinal symptom. Physical examination revealed tenderness in the same regions as reported. There was no guarding or rebound tenderness. The patient had normal vital signs. Laboratory tests revealed mild leucocytosis of 11.33 × 10 9 /L (normal range 3.82-9.91 × 10 9 /L). Liver function test and serum amylase and renal panel showed normal results. An erect chest radiograph showed no subphrenic free air. Intravenous tramadol was administered for pain relief, but the pain persisted despite a period of observation. Computed tomography (CT) of the abdomen and pelvis (Fig. 1) was subsequently performed to evaluate for acute abdomen. What do these images show? What is the diagnosis?
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