Objective: Rare disease Background: Nutcracker syndrome and Wilkie's syndrome are rare vascular diseases due to the abnormal course of the superior mesenteric artery originating from the abdominal aorta with reduced angle (<22°) and consequent compression of the left renal vein (nutcracker) and duodenum (Wilkie). Here, we report the case of a patient with a rare combination of these 2 syndromes and with unusual clinical manifestation of post-prandial pain. Case Report: We describe the case of a young male patient with rapid weight loss, coupled with post-prandial abdominal pain, with sub-acute onset, not associated with other symptoms. The ultrasound examination found an aortomesenteric angle of 18° and compression of the left renal vein and left varicocele. A CT study was performed to exclude oncological diseases and/or other pathologies responsible for the pain and weight loss, which confirmed the ultrasound findings and showed compression of the third part of the duodenum. The patient underwent endovascular treatment, with stent placement in the left renal vein, which resolved the vascular compression and of the duodenum, with regression of symptoms. Conclusions: The ultrasound scan promptly highlighted the reduction of the aorto-mesenteric angle and the signs of venous congestion of the left renal vein. Based on this experience, in patients with weight loss and post-prandial pain, in our opinion, diagnostic investigations should also be extended to the study of the aorto-mesenteric angle to confirm or exclude any vascular and/or duodenal compression.

Interstitial Lung Diseases (ILDs) represent a heterogeneous group of pathologies, which may be related to different causes. A low percentage of these lung diseases may be secondary to the administration of drugs or substances. Through the PubMed database, an extensive search was performed in the fields of drug toxicity and interstitial lung disease. We have evaluated the different classes of drugs associated with pulmonary toxicity. Several different high resolution computed tomography (HRCT) patterns related to pulmonary drug toxicity have been reported in literature, and the most frequent ILDs patterns reported include Nonspecific Interstitial Pneumonia (NSIP), Usual Interstitial Pneumonia (UIP), Hypersensitivity Pneumonitis (HP), Organizing Pneumonia (OP), Acute Respiratory Distress Syndrome (ARDS), and Diffuse Alveolar Damage (DAD). Finally, from the electronic database of our Institute we have selected and commented on some cases of drug-induced lung diseases related to the administration of common drugs. As the imaging patterns are rarely specific, an accurate evaluation of the clinical history is required and a multidisciplinary approach—involving pneumologists, cardiologists, radiologists, pathologists, and rheumatologists—is recommended.

Vasculitides represent a heterogeneous group of immune-mediated disorders, characterized by a systemic inflammatory destructive process of the blood vessels resulting either in ischemia or hemorrhage. The organ involved and vessel size influence the pattern of presentation of the pathology. The lung is commonly involved in systemic vasculitides, with heterogeneous clinical, radiological, and histopathological presentations. Primary vasculitides most commonly associated with lung parenchymal involvement include small-vessel antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitides, such as granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA), and microscopic polyangiitis (MPA). Several studies have reported cases of interstitial lung diseases (ILDs) associated with systemic vasculitis, particularly those positive for ANCA associated vasculitis/vasculitidis: AAV. We have selected from our case series different radiological features of pulmonary vasculitis (i.e., solitary or multiple nodules, cavitary lesions, nodules with centrilobular or peribronchial distribution, airspace consolidations, “crazy paving” appearance, interstitial disease), including cases with interstitial lung alterations. Therefore, the aim of this review is to describe the typical clinical manifestations of vasculitides and their main radiologic features (especially AAV).

Vascular compression syndromes are rare alterations that have in common the compression of an arterial and/or venous vessel by contiguous structures and can be congenital or acquired. The best known are the Thoracic Outlet Syndrome, Nutcracker Syndrome, May–Thurner Syndrome, and Dunbar Syndrome. The incidence of these pathologies is certainly underestimated due to the non-specific clinical signs and their frequent asymptomaticity. Being a first-level method, Ultrasound plays a very important role in identifying these alterations, almost always allowing a complete diagnostic classification. If in expert hands, this method can significantly contribute to the reduction of false negatives, especially in the asymptomatic population, where the finding of the aforementioned pathologies often happens randomly following routine checks. In this review, we briefly discuss the best known vascular changes, the corresponding ultrasound anatomy, and typical ultrasound patterns.

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Patient: Male, 55-year-old Final Diagnosis: Dunbar syndrome Symptoms: Epigastric pain • weight loss Medication: — Clinical Procedure: None Specialty: Gastroenterology and Hepatology • Radiology Objective: Rare disease Background: Dunbar syndrome is a rare vascular alteration caused by the abnormal course of the median arcuate ligament of the diaphragm, which in some patients causes chronic compression of the celiac artery and can cause non-specific symptoms such as diarrhea, retro-sternal pain, vomiting, swelling, and nausea, or a typical symptomatic triad with weight loss, post-prandial abdominal pain, and epigastric murmur. Color Doppler ultrasound and duplex Doppler ultrasound provide a complete diagnostic framework of this disease. Case Report: We describe a case of 55-year-old man with post-prandial epigastric pain, significant weight loss, and several episodes of retro-sternal pain. He underwent multidetector computed tomography of the abdomen and color duplex Doppler ultrasound examination of the celiac artery that highlighted stenosis of the celiac artery, more severe in expiratory apnea. The computed tomography showed the typical aspect of the celiac artery, with the “hook sign”. A duplex Doppler ultrasound examination showed a significant increase in peak speed (226 cm/s) due to severe stenosis of the celiac artery by the median arched ligament of the diaphragm. Conclusions: This case is unique due to the severity of the celiac artery stenosis and the unusual clinical presentation of the patient who had frequent episodes of retro-sternal pain. The significant increase in peak velocity in the celiac artery in expiratory apnea, if associated with the typical symptomatology in the absence of other alterations of the splanchnic vessels, can be considered, in our opinion, sufficient for the diagnosis of Dunbar syndrome.

We report the case of a woman with a mass in the anterior and middle mediastinum (a non-small-cell lung carcinoma), determining significant compression of both superior vena cava and right pulmonary artery. The patient developed acute respiratory distress syndrome , necessitating intubation and admission to the Intensive Care Unit . Radiotherapy sessions to reduce the mass effect were attempted, without significant clinical improvement. Due to the persistence of severe hypoxemia, stenting of the superior vena cava and the right pulmonary artery was performed, the latter resulting in a significant improvement of the arterial blood gas parameters, allowing extubation of the patient. In our opinion, stenting of the superior vena cava and the pulmonary artery (or its branches) is an effective and safe treatment; it should be considered in similar cases, especially if other - less invasive - treatments fail.