1990, The British Journal of Radiology, 63, 138-140
leading to bilateral small calcified glands and sometimes Addison's disease (Wilms et al, 1983). Unilateral disease appears to be uncommon. The finding of a unilateral adrenal mass in a patient with known malignant disease must always raise the possibility of metastasis. We agree with Bernadino et al (1985) that guided biopsy is indicated in these circumstances, if only to exclude metastasis, as in our patient. Acknowledgments We are grateful to Dr C. J. Alcock for his permission to publish clinical details of this patient and to Miss J. Edmonds and Mr S. Ashington for their assistance.
References BERNADINO, GRAHAM,
Case reports MCCLEES, K.,
BAUMGARTNER, B.
R.,
TORRES, W.
E.
GLAZER, H. S., WEGMAN, P. J., SAGEL, S., LEVITT, R. G.
WALTHER, M. M., PHILLIPS, V. M., WHITAKER SEWELL, C , GEDGAUDAS-
&
MCCLENNAN, B. L., 1982. Non-functioning adrenal masses: incidental discovery on computed tomography. American Journal of Roentgenology, 139, 81-85. HAUSER, H., BOTTIKHA, J. G. & WETTSTEIN, P., 1981. Pathology
of the adrenal glands: common and uncommon findings in CT. European Journal of Radiology, 1, 215-226. KENNEY, P. J. & STANLEY, R. J., 1987. Calcified adrenal masses. Urologic Radiology, 9, 9-15. O'BRIEN, W. M., CHOYKE, P. L., COPELAND, J., KLAPPENBACH,
R. S. & LYNCH, J. H., 1987. Computed tomography of adrenal abscess. Journal of Computer Assisted Tomography, 11 (3), 550-551. WILMS, G. E., BAERT, A. L., KINT, E. J., PRINGTO, J. H.
M. E., S. D.,
&
ERWIN, B. C , 1985. CT guided adrenal biopsy: accuracy, safety and indications. American Journal of Roentgenology, 144, 67-69.
&
GODDEERIS, P. G., 1983. Computed tomographic findings in bilateral adrenal tuberculosis. Radiology, 146, 729-730.
Magnetic resonance imaging of the chest in infectious mononucleosis By P. Goddard, MD, FRCR, D. Kinsella, FRCR, *A. W. Duncan, FRCR, *A. Hamilton, MRCP and *F. Carswell, MRCP Bristol Royal Infirmary and *Bristol Royal Hospital for Sick Children, Bristol (Received June 1989 and in revised form August 1989)
Infectious mononucleosis is a disease of young adults, typically presenting with malaise, fever, sore throat and cervical adenopathy (Juel-Jensen, 1983). Non-specific respiratory symptoms may also be present. The diagnosis is confirmed by serological tests for the virus. A case is reported in which the presence of lymphadenopathy as demonstrated by a magnetic resonance imaging (MRI) scan led to the diagnosis of infectious mononucleosis. Case report A 12-year-old patient with a 6-year history of asthma (controlled by becotide and ventolin inhalers (Allen and Hanburys)) complained of lethargy and poor appetite following a recent chest infection. On examination, the only abnormality was an enlarged left cervical node. The chest radiograph (Fig. 1) was normal. As part of a study of pulmonary disease in childhood, an MRI scan was arranged. The chest was imaged in the coronal plane with T,-weighted spin-echo (time to repeat (TR) 500 ms, time to echo (TE) 26 ms) and short tau inversion recovery (STIR) (TR 1500 ms T, 100 ms) pulse sequences. This showed intra- and extra-thoracic lymphadenopathy (Figs 2, 3). The former is seen in the subcarinal and broncho-pulmonary regions; the extra-thoracic lymphadenopathy is present in the left axilla and left supra-clavicular regions. No lung parenchymal abnormality was demonstrated. The appearances were considered likely to be a result of infectious mononucleosis, lymphoma or sarcoidosis. Other possibilities included "cat-scratch fever" and brucellosis. The
138
Figure 1. Normal chest radiograph. There is no evidence of hilar adenopathy. The British Journal of Radiology, February 1990
Case reports
(b) Figure 2. (a) r,-weighted and (b) STIR coronal images in the plane of the carina. The high signal of the broncho-pulmonary nodes (arrows) is well shown on the STIR image. pattern in this case was predominantly of hilar nodal enlargement with other enlarged nodes in the mediastinum, axilla and neck. This pattern would occur in sarcoidosis and infectious mononucleosis, but sarcoid is very uncommon at this age. Lymphoma causes predominantly mediastinal and cervical node enlargement and the hilar component is usually less
marked. In "cat-scratch fever", the nodes near to the area of the cat scratch are largest. On balance, infectious mononucleosis was therefore the most likely diagnosis from the MRI scans. Subsequently, the ELISA test for Epstein Barr nuclear antigen and immunofluorescence tests to the virus capsid antibody were found to be positive.
Figure 3. (a) 7,-weighted and (b) STIR images in a plane anterior to that in Fig. 2. High signal from lymph nodes in the left axilla and left supra-clavicular fossa is seen on the STIR image (arrows). High signal from fat prevents visualization of these nodes on the T] -weighted image. Vol. 63, No. 746
139
Case reports
1990, The British Journal of Radiology, 63, 140-142 Discussion
The accuracy of MRI in the assessment of hilar and mediastinal lymphadenopathy has been previously described (Gamsu et al, 1983; Goddard, 1987). The coronal r,-weighted images allow for the precise anatomical location of enlarged lymph nodes not seen on a chest radiograph. This information is important as different disease processes involve different lymph node groups. For instance, sarcoidosis most commonly affects the broncho-pulmonary and right para-tracheal nodes (Cohen et al, 1983). The advantages of MRI over computed tomography in cases of mediastinal and hilar disease are that coronal images are produced and that ionizing radiation is not required. Also, as flowing blood within the vessels produces a signal void, contrast medium injection is not required for vessel identification (Gamsu et al, 1983). The STIR sequence increases the contrast between tissues with a high water content and surrounding normal tissues (Bydder & Young, 1985). This additional information compensates for the decreased spatial resolution of the STIR sequence; also, as fat gives a high signal on the T, images but a low signal on the STIR sequence, it can readily be distinguished from other tissues. The MRI scans in this case were performed as part of a research protocol. It is not intended that MRI should
be performed in all children with recent chest infections and cervical adenopathy or in whom infectious mononucleosis is suspected. However, this case does illustrate the considerable value of MRI in the anatomical localization of mediastinal mass in children. Acknowledgments We thank the radiographers and secretaries at the Bristol MRI Scanner Centre for their assistance, the trustees of the Bristol MRI Scanner Fund and the Dawn James Trust.
References BYDDER, G. M. & YOUNG, I. R., 1985. MR imaging: clinical
use of the inversion recovery sequence. Journal of Computer Assisted Tomography, 9, 659-675. COHEN, A. M., CREVISTON, S., LIPUMA, J. P., BRYAN, P. J.,
HAAGA, J. R. & ALFIDI, R. J., 1983. NMR evaluation of hilar
and mediastinal lymphadenopathy. Radiology, 148, 739-742. GAMSU, G., WEBB, W. R., SHELDON, P., KAUFMAN, L., CROOKS, L., BIRNBERG, F. A., GOODMAN, P., HINCHCLIFFE, W. A. &
HEDGECOCK, M., 1983. Nuclear magnetic resonance imaging of the thorax. Radiology, 147, 473^78. GODDDARD, P., 1987. Diagnostic Imaging of the Chest (Churchill Livingstone, London), pp. 132 and 154. JUEL-JENSEN, B. E., 1983. Infectious mononucleosis: EpsteinBarr virus disease. In Oxford Textbook of Medicine (Oxford Medical Publishing, Oxford), p. 61.
Galactocele of the breast: radiologic and ultrasonographic findings By Rafael Salvador, MD, Manuel Salvador, MD, Jose A. Jimenez, MD, Manuel Martinez, MD and Lourdes Casas, MD Department of Radiology, Universidad Autonoma, Hospital General Vail d'Hebron, Av. Vail D'Hebron S/N, 08035 Barcelona, Spain (.Received July 1989)
A galactocele is a benign lesion of the breast, denned as an encysted collection of milk products. It is usually found in young women during lactation, although it has also been described in girls and men (VabderschuerenLodeweycky et al, 1979). The quantity of milk is almost always limited, although an excess may sometimes lead to signs of pressure. A case of a galactocele is reported, together with its radiological and ultrasound findings. Case report A 31-year-old woman presented with a breast mass that had been present for 4 years. She had originally detected this mass during a previous period of lactation, after which she had had a further uneventful pregnancy and had breast-fed for 2 months. During all this time the size of the mass had remained unchanged. Physical examination revealed a large, smooth mass, 4 cm in
140
diameter and situated in the upper left quadrant of the left breast. The mass was unattached to muscle or skin. Mammography showed a hypodense mass 4 cm in diameter, with a wall of higher soft-tissue density encompassing small circular components, which had a density greater than the rest of the mass and settled to the bottom when the patient was standing. This latter feature gave the mass an extremely hypodense upper area and a lower area of greater soft-tissue density, separated by an undulating interface (Fig. 1). The appearances were considered to be diagnostic of a galactocele. Ultrasound showed the mass to contain hypoechoic and highly echogenic portions, separated by a wavy line which tended to remain horizontal in recumbent and erect positions. The mass, which was approximately 37 mm in diameter and was bilobulated, had a highly echogenic, 4 mm wall surrounding highly echogenic images with intense distal acoustic shadowing within its dependent part (Figs 2, 3). The mass was punctured with a 19-gauge needle and 15 ml of white fluid containing some fatty and some other compact, clotted material was extracted: this proved to be milk. An The British Journal of Radiology, February 1990
leading to bilateral small calcified glands and sometimes Addison's disease (Wilms et al, 1983). Unilateral disease appears to be uncommon. The finding of a unilateral adrenal mass in a patient with known malignant disease must always raise the possibility of metastasis. We agree with Bernadino et al (1985) that guided biopsy is indicated in these circumstances, if only to exclude metastasis, as in our patient. Acknowledgments We are grateful to Dr C. J. Alcock for his permission to publish clinical details of this patient and to Miss J. Edmonds and Mr S. Ashington for their assistance.
References BERNADINO, GRAHAM,
Case reports MCCLEES, K.,
BAUMGARTNER, B.
R.,
TORRES, W.
E.
GLAZER, H. S., WEGMAN, P. J., SAGEL, S., LEVITT, R. G.
WALTHER, M. M., PHILLIPS, V. M., WHITAKER SEWELL, C , GEDGAUDAS-
&
MCCLENNAN, B. L., 1982. Non-functioning adrenal masses: incidental discovery on computed tomography. American Journal of Roentgenology, 139, 81-85. HAUSER, H., BOTTIKHA, J. G. & WETTSTEIN, P., 1981. Pathology
of the adrenal glands: common and uncommon findings in CT. European Journal of Radiology, 1, 215-226. KENNEY, P. J. & STANLEY, R. J., 1987. Calcified adrenal masses. Urologic Radiology, 9, 9-15. O'BRIEN, W. M., CHOYKE, P. L., COPELAND, J., KLAPPENBACH,
R. S. & LYNCH, J. H., 1987. Computed tomography of adrenal abscess. Journal of Computer Assisted Tomography, 11 (3), 550-551. WILMS, G. E., BAERT, A. L., KINT, E. J., PRINGTO, J. H.
M. E., S. D.,
&
ERWIN, B. C , 1985. CT guided adrenal biopsy: accuracy, safety and indications. American Journal of Roentgenology, 144, 67-69.
&
GODDEERIS, P. G., 1983. Computed tomographic findings in bilateral adrenal tuberculosis. Radiology, 146, 729-730.
Magnetic resonance imaging of the chest in infectious mononucleosis By P. Goddard, MD, FRCR, D. Kinsella, FRCR, *A. W. Duncan, FRCR, *A. Hamilton, MRCP and *F. Carswell, MRCP Bristol Royal Infirmary and *Bristol Royal Hospital for Sick Children, Bristol (Received June 1989 and in revised form August 1989)
Infectious mononucleosis is a disease of young adults, typically presenting with malaise, fever, sore throat and cervical adenopathy (Juel-Jensen, 1983). Non-specific respiratory symptoms may also be present. The diagnosis is confirmed by serological tests for the virus. A case is reported in which the presence of lymphadenopathy as demonstrated by a magnetic resonance imaging (MRI) scan led to the diagnosis of infectious mononucleosis. Case report A 12-year-old patient with a 6-year history of asthma (controlled by becotide and ventolin inhalers (Allen and Hanburys)) complained of lethargy and poor appetite following a recent chest infection. On examination, the only abnormality was an enlarged left cervical node. The chest radiograph (Fig. 1) was normal. As part of a study of pulmonary disease in childhood, an MRI scan was arranged. The chest was imaged in the coronal plane with T,-weighted spin-echo (time to repeat (TR) 500 ms, time to echo (TE) 26 ms) and short tau inversion recovery (STIR) (TR 1500 ms T, 100 ms) pulse sequences. This showed intra- and extra-thoracic lymphadenopathy (Figs 2, 3). The former is seen in the subcarinal and broncho-pulmonary regions; the extra-thoracic lymphadenopathy is present in the left axilla and left supra-clavicular regions. No lung parenchymal abnormality was demonstrated. The appearances were considered likely to be a result of infectious mononucleosis, lymphoma or sarcoidosis. Other possibilities included "cat-scratch fever" and brucellosis. The
138
Figure 1. Normal chest radiograph. There is no evidence of hilar adenopathy. The British Journal of Radiology, February 1990
Case reports
(b) Figure 2. (a) r,-weighted and (b) STIR coronal images in the plane of the carina. The high signal of the broncho-pulmonary nodes (arrows) is well shown on the STIR image. pattern in this case was predominantly of hilar nodal enlargement with other enlarged nodes in the mediastinum, axilla and neck. This pattern would occur in sarcoidosis and infectious mononucleosis, but sarcoid is very uncommon at this age. Lymphoma causes predominantly mediastinal and cervical node enlargement and the hilar component is usually less
marked. In "cat-scratch fever", the nodes near to the area of the cat scratch are largest. On balance, infectious mononucleosis was therefore the most likely diagnosis from the MRI scans. Subsequently, the ELISA test for Epstein Barr nuclear antigen and immunofluorescence tests to the virus capsid antibody were found to be positive.
Figure 3. (a) 7,-weighted and (b) STIR images in a plane anterior to that in Fig. 2. High signal from lymph nodes in the left axilla and left supra-clavicular fossa is seen on the STIR image (arrows). High signal from fat prevents visualization of these nodes on the T] -weighted image. Vol. 63, No. 746
139
Case reports
1990, The British Journal of Radiology, 63, 140-142 Discussion
The accuracy of MRI in the assessment of hilar and mediastinal lymphadenopathy has been previously described (Gamsu et al, 1983; Goddard, 1987). The coronal r,-weighted images allow for the precise anatomical location of enlarged lymph nodes not seen on a chest radiograph. This information is important as different disease processes involve different lymph node groups. For instance, sarcoidosis most commonly affects the broncho-pulmonary and right para-tracheal nodes (Cohen et al, 1983). The advantages of MRI over computed tomography in cases of mediastinal and hilar disease are that coronal images are produced and that ionizing radiation is not required. Also, as flowing blood within the vessels produces a signal void, contrast medium injection is not required for vessel identification (Gamsu et al, 1983). The STIR sequence increases the contrast between tissues with a high water content and surrounding normal tissues (Bydder & Young, 1985). This additional information compensates for the decreased spatial resolution of the STIR sequence; also, as fat gives a high signal on the T, images but a low signal on the STIR sequence, it can readily be distinguished from other tissues. The MRI scans in this case were performed as part of a research protocol. It is not intended that MRI should
be performed in all children with recent chest infections and cervical adenopathy or in whom infectious mononucleosis is suspected. However, this case does illustrate the considerable value of MRI in the anatomical localization of mediastinal mass in children. Acknowledgments We thank the radiographers and secretaries at the Bristol MRI Scanner Centre for their assistance, the trustees of the Bristol MRI Scanner Fund and the Dawn James Trust.
References BYDDER, G. M. & YOUNG, I. R., 1985. MR imaging: clinical
use of the inversion recovery sequence. Journal of Computer Assisted Tomography, 9, 659-675. COHEN, A. M., CREVISTON, S., LIPUMA, J. P., BRYAN, P. J.,
HAAGA, J. R. & ALFIDI, R. J., 1983. NMR evaluation of hilar
and mediastinal lymphadenopathy. Radiology, 148, 739-742. GAMSU, G., WEBB, W. R., SHELDON, P., KAUFMAN, L., CROOKS, L., BIRNBERG, F. A., GOODMAN, P., HINCHCLIFFE, W. A. &
HEDGECOCK, M., 1983. Nuclear magnetic resonance imaging of the thorax. Radiology, 147, 473^78. GODDDARD, P., 1987. Diagnostic Imaging of the Chest (Churchill Livingstone, London), pp. 132 and 154. JUEL-JENSEN, B. E., 1983. Infectious mononucleosis: EpsteinBarr virus disease. In Oxford Textbook of Medicine (Oxford Medical Publishing, Oxford), p. 61.
Galactocele of the breast: radiologic and ultrasonographic findings By Rafael Salvador, MD, Manuel Salvador, MD, Jose A. Jimenez, MD, Manuel Martinez, MD and Lourdes Casas, MD Department of Radiology, Universidad Autonoma, Hospital General Vail d'Hebron, Av. Vail D'Hebron S/N, 08035 Barcelona, Spain (.Received July 1989)
A galactocele is a benign lesion of the breast, denned as an encysted collection of milk products. It is usually found in young women during lactation, although it has also been described in girls and men (VabderschuerenLodeweycky et al, 1979). The quantity of milk is almost always limited, although an excess may sometimes lead to signs of pressure. A case of a galactocele is reported, together with its radiological and ultrasound findings. Case report A 31-year-old woman presented with a breast mass that had been present for 4 years. She had originally detected this mass during a previous period of lactation, after which she had had a further uneventful pregnancy and had breast-fed for 2 months. During all this time the size of the mass had remained unchanged. Physical examination revealed a large, smooth mass, 4 cm in
140
diameter and situated in the upper left quadrant of the left breast. The mass was unattached to muscle or skin. Mammography showed a hypodense mass 4 cm in diameter, with a wall of higher soft-tissue density encompassing small circular components, which had a density greater than the rest of the mass and settled to the bottom when the patient was standing. This latter feature gave the mass an extremely hypodense upper area and a lower area of greater soft-tissue density, separated by an undulating interface (Fig. 1). The appearances were considered to be diagnostic of a galactocele. Ultrasound showed the mass to contain hypoechoic and highly echogenic portions, separated by a wavy line which tended to remain horizontal in recumbent and erect positions. The mass, which was approximately 37 mm in diameter and was bilobulated, had a highly echogenic, 4 mm wall surrounding highly echogenic images with intense distal acoustic shadowing within its dependent part (Figs 2, 3). The mass was punctured with a 19-gauge needle and 15 ml of white fluid containing some fatty and some other compact, clotted material was extracted: this proved to be milk. An The British Journal of Radiology, February 1990
