Case in Point Winners

Case in Point gives users the opportunity each day to work through a subspecialty case developed by a community of residents, their mentors and expert subspecialty editors. Each month, we sift through thousands of reviews by the Case in Point® community to find the best cases.

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A radiologist views the ACR Case in Point case of the day on a laptop screen and takes notes on a notepad to his right.

2024 Case of the YearDisseminated miliary tuberculosis

Review the case and learn more with the authors Q&A.

Congratulations to all case contributors! The College could not maintain such a high level of quality without a steady supply of incredible cases.

Thank you to our Case in Point Associate Editor, Muhammad Aziz, MD, for editing this case.

Review the case

This case was particularly interesting due to the unusual diagnosis of someone in the United States, as well as the diffuse involvement of nearly every organ system. It was not difficult to choose. We started discussing it and we decided to select this unique case. We had a large collection of multiple images, along with a full history and many helpful pieces of information to share.

Keep thinking outside the box, always consider travel outside the country when a diagnosis doesn’t seem to fit the patient’s current living scenario. Tuberculosis (TB) in the USA is rare, and miliary tuberculosis is the rarest presentation of active tuberculosis. This case is also unique because it does not present the typical signs associated with military TB in the chest; however, it has manifested in many other organs.

The impressive multisystem involvement includes pericardial effusions and prostatitis. There is no doubt that radiology is important for diagnosis and treatment; however, in this case, I discovered how challenging it can be to rely on other diagnostic techniques to confirm a diagnosis. The patient was solely diagnosed and treated based on radiology and clinical judgment, as all other labs and biopsies returned inconclusive results.

Our staff helped us work with the inpatient team at our institution for a collaborative, multidisciplinary approach with ultimately allowed for the imaging studies and the confirmatory lab test. Senior staff provide independence for us in completing the case, trusting our judgment and providing final review and polishing of our case.

Throughout residency, Case in Point has been a staple of our program. It is the most popular platform among radiologists to publish cases and has a strong reputation among our senior staff, which helps improve our career development. Case in Point does a great job of showing classic, can’t miss, cases as well as zebras to keep the differential diagnosis healthy. It provides a platform for allowing us to see our peers’ work/efforts at other institutions and see work from past graduates of our own institution. When we see a case with a familiar face at the end, it’s always a topic of discussion.

Ahmed Elarabi, DO
LT, MC, USNR
General Medical Officer
Department of Family Medicine
Naval Medical Center Portsmouth
Portsmouth, VA

Rob Nottingham, DO
LCDR, MC, USN
Staff Radiologist
General Radiology
Naval Hospital Jacksonville
Jacksonville, FL

Van Thong Ho, MD
Diagnostic Radiology
Naval Medical Center Portsmouth
Portsmouth, VA

Case and Point is a big library of radiology cases and images, designed to attract physicians interested in radiology and encourage them to become regular readers. I don’t have a specific type of case that I prefer, but I gravitate towards more unique or rare cases, similar to the one I presented.
Ahmed Elarabi, DO
LT, MC, USNR, General Medical Officer
Department of Family Medicine, Naval Medical Center Portsmouth

I am still a regular reader of Case in Point, although not as much as I was in residency. My favorite cases are the bread-and-butter diagnoses that present on a non-classic modality.
Rob Nottingham, DO
LT, MC, USN, Staff Radiologist
Naval Hospital Jacksonville

Lineup of images from case in point winners

2023 Case of the YearSuperior Mesenteric Artery Syndrome

Check out the case and then learn more with the authors Q&A.

Congratulations to all case contributors. The College could not maintain such a high level of quality without a steady supply of incredible cases.

Thank you to our Case in Point Associate Editor, Paul Hill, MD, for editing this case.

Review the case

We selected this case because of its unique presentation and associated findings. The patient’s medical managing team was surprised when we communicated to them the finding of suspected gastric outlet obstruction on abdominal radiograph and recommended placement of an enteric tube with order for immediate cross-sectional imaging. They told us that the working diagnosis was constipation and were planning to treat it conservatively with enema. Follow-up computed tomography (CT) confirmed the upper gastrointestinal (GI) obstruction and revealed the underlying cause to be superior mesenteric artery (SMA) syndrome. The team was then able to elicit a history of significant rapid weight loss from the mother.

Reading plain radiographs is an art that needs to be mastered by all radiologists. New trainees should be aware of the subtle, but information-laden clues to diagnosis that can show up on plain films and direct next steps of management.

We learned that prior cases have been published on the accepted normal aortomesenteric angle and distance along with the range of these values that are diagnostic for SMA syndrome. Also, coexistence of SMA and nutcracker syndrome is rare even though they share similar pathophysiology.

We were excited when our Attending, Dr. Hammill, agreed with our diagnosis. However, we were confused with the liver and splenic ischemic foci apparent on CT as this is not a phenomenon ever described to be associated with SMA syndrome. Dr. Hammill directed our attention to the compression of the retroperitoneal vascular structures including branches of the celiac artery by the markedly distended stomach.

Case in Point is a valuable resource that enriches our residency education because we know we will not be directly exposed to every diagnosis during training. When we can review a variety of cases shared by others on the Case in Point platform, we are more confident that we will recognize them when they come up in the future.

It was thrilling to see on follow-up imaging that the ischemic foci on the liver and spleen resolved after gastric decompression. It was also comforting that the patient could achieve relief with conservative management of refeeding and weight gain.

Hadassah Stein, MD
PGY-1, Intern Year Radiology Resident
Internal Medicine
Mather Hospital at Northwell
Port Jefferson, NY

Temitope Soyemi, MBBS
PGY-5, Radiology Resident
Department of Radiology
SUNY Downstate
Brooklyn, NY

Patrick Hammill, MD
Diagnostic Radiologist
Department of Radiology, Diagnostic Imaging
Kings County Hospital Center
Brooklyn, NY

We especially appreciate cases that challenge us to identify and click on the abnormality. They help train the eyes to pick out abnormalities and the mind to identify patterns. The annotations on images also help to pinpoint exactly what is being described in the text.
2023 Case in Point Winner Authors