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ECR2016
Minor interventional procedures in tropical diseases
Anbal J. Morillo
Chief, Interventional Radiology
Dept. of Diagnostic Imaging
University Hospital of the Fundacin Santa Fe de Bogot
Wien, Mrz 6, 2016
Presentation
The European Society of Radiology organized a special session for its 28th European
Congress of Radiology (ECR 2016), that expected to receive over 20,000 delegates from
101 countries.
On this occasion, the ECR featured again its ESR meets program (v.i.), where three
national radiological societies were invited. Apart from the Nordic countries and Japan,
Columbia was one of the invited guest countries to show the diversity of the medical
imaging world.
One of the three lectures of that ESR Meets Colombia session was this lecture on minor
interventional procedures in tropical diseases, presented on behalf of the Colombian
Association or Radiology (Asociacin Colombiana de Radiologa - ACR).
The following notes correspond to the transcript of the lecture held on Vienna, on March
6th, 2016.
No conflicts of interest were declared for this lecture
Anbal J. Morillo.
Chief, Interventional Radiology
Department of Diagnostic Imaging
University Hospital of the Fundacin Santa Fe de Bogot
Bogot, Colombia.
This compilation of notes is for educational purposes, where the intention is to disseminate information related or not with radiology
and similar or dissimilar sciences. It is based on bibliographic references, lectures, schematics and experience (not always
synonymous with old age). Any violation of authorship rules is excused by the educational and non-profit intention of this notes.
Internet has proven to be an endless source of references, drawings and photographs. The use of current search engines allows for
such a fast navigation speed that sometimes it is impossible to reconstruct all the visited sites, with the involuntary omission of
some references. All efforts have been made to give adequate acknowledgement to all sources. Although this notes are for free use
and distribution, it is recommended not to use the photographs, figures, schematics, and tables for any purpose different than
personal enlightenment, in order to avoid the propagation of any copyright violation.
Science is permanently evolving. Reading this notes must be done with a critical posture, and complemented with other information
sources. The author is not to be held responsible for consequences resulting from decisions taken based on tis notes.
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ECR 2016
"ESR meets Colombia"
EM 3: Sunday, March 6, 10:30-12:00, Room B
Session objectives:
1. To have a glance of our countries peculiarities not only from a cultural point of view but also on its laws and
management of diseases.
2. To explore new ways of finding solutions to possible problems presented in our profession.
To
To
To
To
Interlude:
The history of radiology in Colombia (5 min)
Show Video
1. To propose possible modifications to conventional biopsy techniques tailored to certain cases where ideal
conditions cannot be met.
2. To present the local experience of a high complexity hospital in Latin America.
3. To determine when a multimodality imaging evaluation prior to biopsy is required.
4. To establish in which cases contrast administration is appropriate before a CTguided biopsy is conducted.
Interlude:
Colombia, magical realism (5 min)
Show Video
Panel discussion: Minor invasive procedures - is there a place for the non-interventional
radiologists? (15 min)
Minor interventional procedures in tropical diseases
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Presentation
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Introduction
In 2014, the nurse in charge of the
Hospital Infectious Control
Committee asked me if I or my team
of interventional radiology would
place an ultrasound-guided central
venous catheter in a patient with
Ebola.
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Awareness
So, apart form being aware, we need
to be prepared for tropical diseases,
especially if we are to perform
invasive procedures to diagnose or
treat them.
A few weeks after that encounter, an
awareness campaign started at our
hospital, with information for our
patients on the possible symptoms
and alerts for travelers arriving from
specific areas in the African
continent. The Mayors Office Health
Secretariat also issued informative
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The World Health Organization includes in the definition of tropical diseases several
facts: they are infectious, they are endemic in certain geographical locations, they
appear in the most underprivileged of populations, and they have significant costs
for developing economies. Tropical diseases are caused by diverse viral, fungal,
parasitic and opportunistic pathogens.
Fungal
Trachoma
Rabies
Trypanosomiasis
Leprosy Taeniasis
Leishmaniases
Parasitic
Opportunistic
Buruli
Treponematoses
Schistosomiasis
Dracunculiasis
Trematodiasis
Cysticercosis
Ebola
Amoebiasis
Zika
Echinococcosis
Strogyloidosis
Chagas
Blastomycosis
Histoplasmosis
Tuberculosis
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Tropical diseases
Tropical diseases
Tropic of Cancer
150 countries
Pop.1000,000,000
Tropic of Capricorn
They were originally thought of as exclusive to that very wide geographical area of
the planet within the Tropic of Cancer and the Tropic of Capricorn, which includes
some 150 countries and an estimated population of one billion.
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Globalisation means that borders are now more easily crossed. Migration is not only
possible by infected human beings, but vectors, mostly arthropods, have been
known to migrate and adapt along with human populations.
Some examples include the West Nile Virus migration into North America; reports of
outbreaks of Dengue and Chikungunya have reached and crossed the latitudes
beyond which these infections were previously seen.
Global trade routes can also favor
the migration of populations and of
several infectious disease vectors,
that become more easily adapted to
climate conditions where they were
not expected to thrive.
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Vector migration
Such is the case of the Aedes egypti mosquito, the
known vector for Yellow Fever, Dengue, Chikunguyna and
Zika, which has been seen in locations remote from the
warmer tropics.
Rhodnius prolixus
triatomine bug
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The tropics
Awareness and preparedness are the
clues for the prevention of epidemics,
especially for deadly threats such as
the one posed by the Ebola virus
disease, but I am not sure if a large,
poster-sized picture of the electron
microscopic appearance of this virus
reaches the general public or is of any
help.
I come from Colombia, right in the middle
of the Tropics. Bogot, its capital city, is
about 5 degrees North of the Equator, but
it rests upon the Andes mountains, at 2600
meters (8300 feet) above sea level. Global
warming and weather phenomena such as
El Nio have also affected our country, and
even though Bogot is now warmer than it
used to be (as seen in a picture of my
Bogot
2546 m /
8350 ft
4.5981 N, 74.0758 W
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Ascaridiasis. Upper right: Barium-filled small intestine demonstrates an intraluminal linear defect
(yellow arrows). Ultrasonography shows a tangle of worms (lower left). The image on the lower right
demonstrates the digestive tract of one of the worms (arrow).
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Splenic candidiasis
F, 28
Neck abscess aspiration and drainage. 28-yr-old female, CT and
fluoroscopic procedure. Courtesy: Dr. Nicols Useche.
As is common in other
indications, we can use
US, CT or fluoroscopic
imaging and
combinations of these
imaging methods to
reach such fluid
collections and to
obtain samples for microbiological
characterization.
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Tropical myositis
Tropical pyomyositis has an unclear pathogenesis.
Muscular trauma or exertion has been postulated, with
myoglobin sequestration as a nurturing agent for
bacteria. Nutritional deficiencies and previous viral or
parasitic infections have also been held responsible.
The most common organism found, Staphylococcus
aureus, is not strictly tropical. Percutaneous
drainage is a very important component of treatment.
Myositis tropicans in the thigh.
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A 39-yr-old male French citizen visiting Colombia got his own taste of the tropics, in
the form of a painful subcapsular hepatic amoebic abscess managed with
percutaneous US-guided drainage due to its imminent rupture.
Just this last week, we saw another young man, this time from Bogot, who had not
travelled to endemic areas in the country, and arrived to our hospital after several
days of pain and fever. CT demonstrated the subcapsular location of the abscess,
with irregularity of its posterior margin and pleural effusion, due to pleural
transgression (yellow arrows). An anterolateral approach was planned (green arrow),
and US-guided drainage of the abscess was performed.
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Pulmonary actinomycosis
75-yr-old male patient with an invasive actinomycosis and an anterior left chest wall abscess,
clearly demonstrated on CT. US-guided needle aspiration and evacuation under local anesthesia
was performed (double arrows).
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Spinal infections
56-yr-old male patient with a postoperative right posterior paraspinal abscess (arrows), amenable to
percutaneous drainage.
Several infectious diseases involve the spine, as in this 56-yr-old male patient with a
posterior paraspinal abscess with easy percutaneous access. Drainage procedures
can be performed under CT or US guidance, sometimes a combination of both
modalities is used.
In most spinal infection
patients, surgical
drainage is the first
choice, because a more
extensive curettage and
hardware extraction can
be performed, but, when
comorbidities are
present, a percutaneous
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Spinal infections
Disk space aspiration and catheter drainage for the treatment of spondylodiscitis.
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Spinal infections
Spondylodiscitis is most
commonly bacterial; MRI is
crucial for diagnosis and for the
depiction of extraspinal
extension.
Contrast enhancement is useful
for the depiction of abscess
formation. CT is most commonly
used as the guidance method for
the aspiration and disk biopsy.
Male, 37-yrs-old. Coronal lumbar spine MRI (left)
shows an abscess on the right psoas muscle (arrow).
Sagittal T2-weighted image (right) shows involvement of
the L1 and L2 vertebral bodies (arrows).
Courtesy:
Dr. Sonia Bermdez
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Spinal infections
involvement, and the associated iliac muscle tuberculous abscess. CT-guidance was
used for both locations (Bottom images, yellow arrows).
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Spinal infections
T2WI
T1WI
T1WI + Gd
STIR
A similar patient, in this case a 66-yr-old veterinarian, with typical MRI findings for
spondylodiscitis. Gadolinium enhancement helped direct the needle and confirm
Brucellosis.
66-yr-old male with Brucellosis. Above: Multiparametric sagittal MRI shows involvement of two
adjacent vertebrae and their corresponding disk (arrows). Below: Transverse gadolinium-enhanced
T1WI (left) shows abnormal signal foci in the disk and right paraspinal space (arrows). On the right, a
CT-guided biopsy needle in the corresponding disk confirmed brucellosis.
Courtesy: Dr. Nicols Useche.
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Histoplasmosis mediastinitis
Occasionally, we need more advanced
interventional techniques, as in a young
female with fibrosing mediastinitis due to
histoplasmosis. Pulmonary artery stenting
was performed in a collaboration with an
interventional cardiology colleague.
Follow-up after 5 years shows adequate patency, with minimal intimal hyperplasia,
without significant stenosis.
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Myasis
A junior staff surgeon from our
hospital went on vacation to the
nearby town of Villavicencio, 72 km
(45 mi) to the Southeast of Bogot,
at our eastern plainlands, that
eventually merge with the amazon
jungle. This is the town where I did
the rural part of my internship,
where I saw my first cases of
malaria, hemorrhagic dengue,
tetanus, tropical myositis and
venomous snake bites. Our surgeon
colleague came to us because he had
a stinging sensation at the base of his big toe, with
72 km
(45 mi)
AJ Morillo 25
Myasis
A high-resolution US
also demonstrated a
small echogenic
unidentified object, but
the patient was sure he
did not suffer from a
direct blow to his toe. In
01/21/2016
01/21/2016
34-yr-old male patient with myasis.
Courtesy: Dr. scar Rivero.
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Zika lymphadenopathy
Enter Zika virus. A recent news report has estimated
37,000 cases in Colombia, of which over six
thousand are pregnant women.
While I was collecting cases for this presentation,
about ten days ago, a 54-yr-old female with Zika
lymphadenopathy arrived to our
hospital because she developed
erythema. The jugulodigastric
lymph node appeared to have
developed a superimposed
bacterial infection, that caused
yugular vein
compression
and pain.
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Zika lymphadenopathy
US guidance was used to puncture and aspirate its purulent contents, that revealed
coccal infection.
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Awareness - preparedness
Tropical diseases are global. More awareness campaigns are needed to recognize
and treat these diseases. Preparedness is also crucial for management and
dissemination control, especially in those cases where propagation is widespread
and epidemics can appear and affect large populations.
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http://ccr2016.org/index.html
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AFP: Colombia registra ms de 37,000 casos de Zika. El Tiempo, Febrero 20 de
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Bandara M, Ananda M, Wickramage K, Berger E, Agampodi S: Globalization of
leptospirosis through travel and migration. Globalization and Health 2014;
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Blechman AB, Wilson BB: Myasis. Medscape. http://emedicine.medscape.com/
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Chauhan S, Jain S, Varma S, Chauhan SS: Tropical pyomyositis (myositis
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Han J-Y, Lee K.N, Lee JK, et al.:An overview of thoracic actinomycosis: CT
features. Insights Imaging 2013; 4: 245-252.
Irfan U: Exotic diseases from warmer climates gain foothold in U.S. Scientific
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Discover magazine, June 1, 2013. http://blogs.discovermagazine.com/
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McNeil DG: Europe: increase in tropical diseases is aided by migration and weak
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Polat KY, Balik AA, Oren D: Percutaneous drainage of hydatid cyst of the liver:
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Preston R: The Hot Zone. A Terrifying true Story. Anchor Books, 1995.
Ramos Pacheco, J. Hydatid disease: multiple locations and radiological features.
Imgenes 2014; 3: 23-31.
Struck D: Climate change drives disease to new territory. Viruses moving North to
areas unprepared for them, experts say. Washington Post Foreign Service. May 5,
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AR2006050401931.html
Walsh B: Infectious disease could become more common in a warmer world especially for plants and animals. Time, Aug 3, 2013.http://science.time.com/
2013/08/02/infectious-disease-could-be-more-common-in-a-warmer-worldespecially-for-plants-and-animals/
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http://ajtmh.org/cgi/doi/10.4269/ajtmh.16-0096
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neglected_diseases/en/
Minor interventional procedures in tropical diseases
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