Ultrasound Images of HIV Cholangiopathy and Cervical Insufficiency

Section VII – Ultrasound

Figure 1A
162. You are shown two ultrasound images (Figures 1A and 1B) from the right upper quadrant of a
30-year-old HIV-positive patient. What is the MOST LIKELY pathogen?

A. Candida
B. Mycobacterium avium-intracellulare
C. Cryptosporidium
D. Coccidioides

1
Diagnostic In-Training Exam 2006


Figure 1B

2 American College of Radiology

Question #162
Findings: Markedly thickened gallbladder wall without gallstones or pericholecystic fluid detected.
Rationales:
C is correct
The above findings are concerning for HIV cholangiopathy. HIV cholangiopathy is an opportunistic
infection of the biliary tree which may occur in individuals with advanced HIV infection. Marked thick-
ening of the wall of the bile ducts and gallbladder is seen. The most common pathogens isolated from
these individuals include Cryptosporidium, CMV, and Microsporidium. Although Candida,
Mycobacterium avium-intracellulare, and coccidioides are pathogens which can infect immunocompro-
mised patients, they are not considered a common cause of HIV cholangiopathy.

3


Figure 2
163. A 20-year-old woman with a normal quadruple screen has a sonogram at 18-weeks
gestational age (Figure 2). What is the MOST appropriate next step?

A. Perform an amniocentesis to assess for trisomy 21
B. Perform a chorionic villous sampling to assess for trisomy 18
C. Perform a fetal survey to assess for morphologic abnormalities
D. No further follow-up is needed


Question #163
Rationales:
The image shows bilateral choroid plexus cysts. Choroid plexus cysts are associated with a low inci-
dence of trisomy 18. When a choroid plexus cyst is visualized it is important to perform a formal fetal
survey to look for morphologic abnormalities such as cardiac abnormalities, clenched fists, and microg-
nathia. A is not correct since amniocentesis is not recommended unless other indications of trisomy 18
are present. In addition the amniocentesis would be to assess for trisomy 18 not trisomy 21. B is not
correct since chorionic villous sampling is performed in the first trimester. D is not correct since it is
important to assess for other findings of aneuploidy.

5


Figure 3
164. You are shown a single image from a 2nd trimester OB ultrasound (Figure 3). What is the
MOST LIKELY diagnosis?

A. Incompetent cervix
B. Placenta previa
C. Placental abruption
D. Nabothian cyst


Question #164
Findings: Single longitudinal image of lower uterine segment from 2nd trimester OB examination
reveals shortening of the cervix and hour glass herniation of membranes through cervical os.
Rationales:
A Correct. The above findings on a 2nd trimester ultrasound are consistent with cervical incompe-
tence.
B. Incorrect. The placenta does not overly the cervix; therefore, there is no placenta previa.
C. Incorrect. There are no subchorionic or retroplacental fluid collections to suggest placental abrup-
tion.
D. Incorrect. A Nabothian cyst arises from the cervix. The visualized fluid collection of vagina clearly
communicates with the endometrial cavity via the cervical os.

7


Figure 4
165. A 28-year-old man presents with mild renal function impairment on routine medical checkup.
You are shown a longitudinal sonogram of the right kidney (Figure 4). What is the MOST LIKE-
LY diagnosis?

A. Medullary sponge kidney
B. Acute pyelonephritis
C. Human immunodeficiency virus-associated nephropathy
D. Autosomal recessive polycystic kidney disease


Question #165
Rationales:
A. Incorrect. Medullary sponge kidney (MSK) is secondary to dilatation or ectasia of the distal collect-
ing ducts and is difficult to identify by ultrasound. When complicated by nephrocalcinosis multiple
echogenic foci can be seen in the medullary pyramids.
B. Incorrect. Pyelonephritis is rare in adult males. Majority of kidneys with acute pyelonephritis are
normal on Sonography and if abnormality is present it is usually a focal lesion and not diffuse
increased echogenicity.
C. Correct. The cortical echogenicity is increased, cortico-medullary differentiation is decreased and
renal sinus fat is decreased. The renal size may be enlarged.
D. Incorrect. Autosomal recessive polycystic kidney disease is bilateral and usually diagnosed in utero
in early second trimester. These children generally succumb to their renal failure. If they survive to
adulthood the kidney will demonstrate increased echogenicity with large renal cysts.

9


Figure 5
166. What kinds of twins are depicted in the sonogram show (Figure 5)?

A. Diamniotic dichorionic
B. Diamniotic monochorionic
C. Monoamniotic monochorionic
D. Conjoined twins


Question #166
Rationales:
The image shows an 8 week pregnancy with a single placenta with thin dividing membranes surround-
ing each embryo consistent with diamniotic monochorionic twins. A is incorrect since there would be a
thick dividing membrane with dichorionic twins at this gestational age. C is incorrect since there should
be no dividing membrane in monoamniotic twins. D is incorrect since the twins are clearly separate.

11


Figure 6
167. You are shown color and spectral Doppler evaluation of the right hepatic artery of a 34-year-old
woman, 72 hours status post liver transplant (Figure 6). Which one is the MOST LIKELY
diagnosis?

A. Normal hepatic artery
B. Hepatic artery stenosis
C. Pseudoaneurysm of hepatic artery
E. Arterio-venous fistula


Question #167
Rationales:
A. Incorrect. Normal hepatic artery resistive index is not less than 0.5.
B. Correct. Hepatic artery stenosis is suspected if resistive index is less than 0.5. A low resistance
arterial waveform can be seen down stream from the hepatic artery stenosis.
C. Incorrect Pseudoaneurysm have typical bidirectional to and fro color flow pattern
D. Incorrect. Arterio-venous fistula has turbulent flow with arterialized waveform in the vein.

13

In ultrasound, which one of the following statements is INCORRECT regarding the advantages
168.
associated with transducer arrays when compared to the single-element transducers?

A. Transducer arrays can be constructed and designed as linear, curved, phased, or annular arrays.
B. Transducer arrays significantly reduce the presence of grating lobes that degrade the lateral
resolution of the ultrasound beam.
C. Transducer arrays enable electronic beam steering.
D. Transducer arrays permit the selection of transmit focal distances.

Question #168
Rationales:
A. Incorrect. The flexibility of designing in various forms is a key advantage of transducer arrays.
These array designs are routinely used in modern systems.
B. Correct. Grating lobes do degrade lateral resolution and are produced by phased array transducers,
but they are not reduced by transducer arrays. If the examinee does not understand what a grating
lobe is he/she ought to be able to identify A, C, and D as true statements regarding transducer arrays
and arrive at B as the incorrect statement.
C. Incorrect. Electronic beam steering is a key feature of transducer arrays.
D. Incorrect. The focal distance of an array transducer may be varied electronically, by changing the
electronic delay sequence; this is a key feature of a transducer array.


Concerning tunica albuginea cysts, which one is TRUE
169.

A. They are intratesticular in location.
B. They are not palpable.
C. They range from 2 mm to 5 mm in size.
D. They are located in the posterior and inferior aspect of testis.

Question #169
Rationales:
A. Incorrect. Tunica Albuginea cyst are extratesticular in location, however when large in size may
mimic an intratesticular cyst.
B. Incorrect. These cysts are palpable and patients present with a palpable lump.
C. Correct. These cysts are of mesothelial origin and range from 2-5mm in size.
D. Incorrect. Their characteristic location is at the upper anterior or lateral aspect of the testicle.

15

Which one of the following commonly causes oligohydramnios?
170.

A. Unilateral renal agenesis
B. Preterm premature rupture of membranes
C. Esophageal atresia without tracheoesophageal fistula
D. Thanatophoric dysplasia

Question #170
Rationales:
Preterm premature rupture of the membranes is the most common cause of oligohydramnios. A is
incorrect since only one kidney is needed for normal urinary output and thus normal amniotic fluid vol-
ume. B is incorrect since esophageal atresia without tracheoesophageal fistula causes polyhydramnios,
not oligohydramnios. D is incorrect since dwarfisms may be associated with polyhydramnios, not
oligohydramnios.


Concerning deep venous thrombosis (DVT), which one is TRUE?
171.

A. Venous compression is performed in longitudinal orientation of the vein.
B. 60% of patients with lower extremity DVT have thrombus in the iliofemoral region.
C. The diameter of the affected vein is decreased in acute deep venous thrombosis.
D. Inability to obliterate the vein lumen completely is the diagnostic criterion.

Question #171
Rationales:
A. Incorrect. The venous compression is performed in the transverse orientation of the vein to mini-
mize the chance of the transducer slipping off the vein.
B. Incorrect. Only 10% of the patients with lower extremity DVT have thrombus in the iliofemoral
region. It is important to recognize this as these patients present with buttock or groin pain.
C. Incorrect. The diameter of the affected vein is increased in acute DVT.
D. Correct. The compression technique is more sensitive and specific in the diagnosis of DVT com-
pared to other criteria such as augmentation, gray scale visualization and color flow Doppler.

17

Which one of the following is associated with the highest incidence of fetal morphologic
172.
anomalies?

A. A poorly-controlled diabetic taking insulin
B. A patient taking a beta blocker for control of hypertension
C. A trauma patient with abdominal pain
D. A patient with prior pregnancy with amniotic band syndrome

Question #172
Rationales:
Glucose is a teratogen. Poorly controlled diabetics have a high incidence of fetal morphologic abnor-
malities such as sacral dysgenesis, neural tube defects, and cardiac abnormalities. B is incorrect since
beta blockers are safe for use in pregnancy. C is incorrect since trauma can cause abruption, and thus
fetal demise, but should not cause a morphologic abnormality. D is incorrect since amniotic band syn-
drome is typically sporadic and therefore does not have a high recurrence risk.


173. A patient is seen in the ultrasound suite for early pregnancy with bleeding. She is certain that her
last menstrual period was 10 weeks ago. An intrauterine sac is visualized with mean sac diame-
ter of 8 mm with a yolk sac but no embryonic pole. Which one is TRUE?

A. This is a miscarriage, and dilatation and curettage should be performed.
B. It is unclear if this is a miscarriage or a normal early pregnancy and follow-up should be
obtained.
C. The findings are consistent with a pregnancy of about 6 weeks. The patient is probably wrong
about her dates. The pregnancy should be re-dated.
D. The findings are consistent with a pregnancy of about 8 weeks. The patient is probably wrong
about her dates. The pregnancy should be re-dated.

Question #173
Rationales:
The findings are consistent with a pregnancy of about 6 weeks, but given that the patient is bleeding
and by dates she should be 10 weeks, follow-up should be obtained. A is incorrect since there is a pos-
sibility that the patient is wrong about her dates, and dilatation and curettage should not be performed if
it is possible that this is a normal early pregnancy. C is incorrect since the pregnancy should not be
redated until an embryonic pole is visualized. D is incorrect since no embryonic pole is seen and there-
fore the pregnancy is not 8 weeks.

19

174. Concerning occupational radiation dose limits, once the technologist declares her pregnancy, what
is the maximum permissible allowed dose in mSv to the embryo/fetus for the entire 9 months?

A. 0.5 mSv
B. 5 mSv
C. 50 mSv
D. 500 mSv

Question #174
Rationales:
A. Incorrect. This limit is for any one month during pregnancy
B. Correct. The nuclear regulatory commission (NRC) limits the dose to an embryo/fetus to be not
more than 5 mSv or 500 mrem for entire 9 months.
C. Incorrect. The limit of 50 mSv applies to occupational exposures and not to fetus exposure.
D. Incorrect. See rationale in B.


Concerning echogenic intracardiac focus on OB ultrasound, which one is CORRECT?
175.

A. Majority are located in the right ventricle
B. Strong association with trisomy 18
C. Represents focal fat of ventricular wall
D. Most commonly seen as normal variant

Question #175
Rationales:
A. Incorrect. 90% of echogenic intracardiac foci are located in the left ventricle.
B. Incorrect. There is an association of trisomy 13 and 21 with echogenic intracardiac focus but not
with trisomy 18.
C. Incorrect. Echogenic intracardiac focus is felt to represent microcalcifications of papillary muscles.
D. Correct. Echogenic intracardiac focus is most commonly seen as a normal variant but should
prompt careful examination for other abnormalities.

21

Concerning ultrasound of the endometrium in premenopausal women, which one is TRUE?
176.

A. The endometrium can normally measure up to 13 mm in thickness.
B. Endometrial fluid should be included in the measurement of endometrial thickness.
C. The thickness of the endometrium will vary during the menstrual cycle but echogenicity will not
change.
D. The hypoechoic halo surrounding the endometrium should be included in the measurement of
endometrial thickness.

Question #176
Rationales:
A. Correct. The endometrium can normally measure up to 15 mm during the secretory phase of men-
strual cycle.
B. Incorrect. Endometrial fluid should not be included in the measurement of endometrial thickness.
The individual walls should be measured separately and added together for final measurement.
C. Incorrect. Thickness and echogenicity of endometrium will change throughout the menstrual cycle.
D. Incorrect. The hypoechoic halo surrounding the endometrium is felt to represent the compact layer
of the myometrium and should not be included in measurements of the endometrium.


Concerning ultrasound of partial molar pregnancies, which one is TRUE?
177.

A. Fetal tissue is not typically present.
B. The majority are diploid.
C. Focal areas of molar degeneration of placenta are present.
D. The beta-hCG is negative.

Question #177
Rationales:
A. Incorrect. Fetal tissue is typically present in the case of molar pregnancies, however, multiple anom-
alies are usually present due to the triploid karyotype present in most cases.
B. Incorrect. 90% of partial moles are triploid with majority inheriting two chromosomal sets of pater-
nal origin and one set of maternal origin.
C. Correct. Focal areas of molar degeneration are present interspersed throughout areas of normal pla-
centa in the case of partial molar pregnancy. This results in a thickened and enlarged placenta with
multiple cystic areas.
D. Incorrect. The Beta hCG is positive.

23

Concerning cavernous transformation of the portal vein, which one is TRUE?
178.

A. Typically occurs with acute portal vein thrombosis
B. Represents recanalized previously thrombosed portal vein
C. Strong association with biliary cystadenoma
D. Represents development of multiple periportal collaterals

Question #178
Rationales:
A. Incorrect. Occurs with longstanding portal vein thrombosis and may take up to 12 months to devel-
op.
B. Incorrect. Cavernous transformation of portal vein represents development of periportal collaterals
in the setting of chronic portal vein thrombosis.
C. Incorrect. No known association between biliary cystadenoma and cavernous transformation of por-
tal vein.
D. Correct. Cavernous transformation of portal vein represents development of periportal collaterals in
the setting of chronic portal vein thrombosis.


Concerning acute ovarian torsion, which one is TRUE?
179.

A. Presents as hyperechoic small ovary without follicles
B. Majority of patients are postmenopausal
C. Typically managed medically rather than surgically
D. Commonly associated with ovarian neoplasm or cyst

Question #179
Rationales:
A. Incorrect. Typically presents as enlarged ovary with multiple peripheral follicles.
B. Incorrect. Most common to present in the first 3 decades of life.
C. Incorrect. Acute ovarian torsion is managed surgically.
D. Correct. 50% to 81% of patients have unilateral ovarian tumor (frequently dermoid or parovarian
cyst).

25

Concerning color flow Doppler artifacts, which one is TRUE?
180.

A. Twinkle artifact can be seen posterior to renal stones.
B. Aliasing occurs when the Doppler shift frequency exceeds twice the pulse repetition frequency.
C. Aliasing artifact can be eliminated by utilizing higher frequency transducer.
D. Color “bleed” can be eliminated by increasing the color gain.

Question #180
Rationales:
A. Correct. Twinkle artifact is generated by a strongly reflecting medium composed of individual
reflectors such as stones. The twinkling artifact is generated by a narrow band of intrinsic machine
noise called phase (or clock) jitter.
B. Incorrect. Aliasing occurs when the Doppler shift frequency exceeds half the pulse repetition fre-
quency.
C. Incorrect. Aliasing artifact can be eliminated by utilizing lower frequency transducer resulting in a
decrease in the frequency shift.
D. Incorrect. Color “bleed” is seen when the color in a vessel extends beyond the vessel lumen,
obscuring the wall or important findings such as plaque. It can be eliminated by decreasing the
color gain.


181. A 50-year-old woman was found to have a 2-cm hyperechoic mass in her right kidney.
What follow-up, if any, should be recommended?

A. No follow-up is recommended as this is most likely a benign angiomyolipoma
B. MRI of the abdomen to further characterize the mass
C. Unenhanced CT scan of the abdomen to assess for the presence of fat
D. Follow-up with renal ultrasound in six months

Question #181
Rationales:
A. Incorrect. Small, < 3cm, renal cell cancers can be hyperechoic and can be confused with an
angiomyolipoma (AML)
B. Incorrect. MRI is not the test of choice to evaluate for the presence of fat.
C. Correct. CT is the test of choice to assess for the presence of fat to characterize this lesion as an
AML.
D. Incorrect. This mass could be a small renal cell cancer. Therefore, an unenhanced CT scan needs to
be performed first. If this mass is found to be an AML, it then can be followed by ultrasound.

27

182. A 30-year-old woman undergoing a thyroid ultrasound is found to have multiple nodules. Which
one of the following nodules should be biopsied?

A. 2.0-cm cystic nodule with echogenic foci demonstrating comet-tail artifact
B. 2.5-cm homogeneous nodule with peripheral eggshell-like calcification
C. 1.0-cm heterogeneous mass with a “honeycomb“cystic appearance
D. 1.5-cm hypoechoic mass with microcalcifications

Question #182
Rationales:
A. Incorrect. This is a colloid nodule and does not require biopsy.
B. Incorrect. Thin peripheral calcification indicates a high probability of benign lesion.
C. Incorrect: “Honeycomb“ cystic features indicate a very high probability of a benign process
D. Correct. Malignancy is likely in a nodule with microcalcifications.


183. Which sonographic characteristic of a complex renal cyst requires follow-up with a CT scan and
not ultrasound?

A. Internal echoes
B. Few thin septations (< 1 mm)
C. Perceptible thickened wall
D. Small amount of peripheral calcification or milk of calcium

Question #183
Rationales:
A. Incorrect. This can be followed up with ultrasound if no other malignant features are present.
B. Incorrect. This can be followed with ultrasound.
C. Correct. This is a malignant finding and CT scan should be performed.
D. Incorrect. This can be followed with ultrasound.

29

Which one is associated with gastroschisis?
184.

A. Chromosomal abnormalities
B. Cardiac abnormalities
C. Gastrointestinal tract atresias
D. Limb reduction defects

Question #184
Rationales:
Gastroschisis is commonly associated with gastrointestinal tract atresias, but not with the other abnor-
malities listed as possibilities.


185. At what hCG level should you expect to visualize an intrauterine gestational sac?

A. 50 IU (IRP)
B. 500 IU (IRP)
C. 2000 IU (IRP)
D. 10,000 IU (IRP)

Question #185
Rationales:
A intrauterine gestational sac should typically be visualized when the hCG is 2000 IU IRP

31

Concerning imaging of a first-trimester intrauterine pregnancy, which one is TRUE?
186.

A. First fetal anatomic structure to be seen is the yolk sac.
B. It is abnormal to have separation of the amnion and chorion.
C. Cardiac activity should be seen by 4 weeks.
D. Gestational sac measurement is the single best measurement for estimating gestational age
between 6 and 12 weeks.

Question #186
Rationales:
A. Correct. Yolk sac is the first fetal structure identified by ultrasound.
B. Incorrect. There is normal separation between the chorion and amnion until 12 to 16 weeks when
these structures fuse.
C. Incorrect. The threshold for detecting cardiac activity is 5 to 6 weeks.
D. Incorrect. CRL (crown rump length) is the single best measurement for estimating gestational age
by ultrasound between 6 to 12 weeks.


Concerning hepatic adenoma, which one is TRUE?
187.

A. Associated with glycogen storage disease
B. More common in men
C. Occur as multifocal lesions
D. Have characteristic sonographic appearance

Question #187
Rationales:
A. Correct. Hepatic adenomas have been reported in association with glycogen storage disease in
addition to oral contraceptive use. Frequency of hepatic adenoma for von Gierke’s disease is 40%.
B. Incorrect. Hepatic adenomas are more common in women.
C. Incorrect. Hepatic adenoma is usually solitary and their size ranges from 8-15cm.
D. Incorrect. The sonographic appearance of hepatic adenomas is non-specific and can be hypo, iso or
hyperechoic or mixed. They also demonstrate intra and perilesional blood flow.

33

Ultrasound Images of HIV Cholangiopathy and Cervical Insufficiency

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