By Fathima Hasan Mohamed

Senior Radiographer Date: 22/08/2016

Food Signs in Radiology

Objectives

• To provide the information and learn the characteristic radiological signs resembling various food items.

• Discuss and illustrate the radiologic signs of a number of diverse conditions whose classic radiologic manifestations resemble various types of food.

• Descriptive “food signs” are highly memorable and easily recognizable and allows a confident diagnosis on the basis of imaging findings alone or can narrow down the differential diagnosis.

Introduction

• Radiologists have unique skills of observation and description

• Pattern recognition is one of the techniques used in the interpretation of radiographs, and this skill improves with experience.

Selections from the Buffet of Food Signs in Radiology

Fruits:• Apple core lesion• Berry aneurysm• Pear-shaped bladder• Lemon sign• Banana sign

Vegetable:• Celery stalk metaphysis• Onion skin periosteal reactionMeat, fish, and egg dishes:• (Hamburger sign, sausage digit, vertebral

scalloping, eggshell calcification)

Selections from the Buffet of Food Signs in Radiology

Pasta, rice, grains, and bread (carbohydrates):• linguine sign, rice grain calcification, miliary

shadowing, cottage loaf signDesserts, cakes, and candy:• Donut sign, omental cake, pancake vertebra,

honeycomb lung, popcorn calcification, licked candy stick appearance

Selections from the Buffet of Food Signs in Radiology

Dishes, cutlery, condiments:• Diffuse idiopathic skeletal hyperostosis [DISH]• Champagne glass pelvis• Dinner fork deformity• Salt and pepper calvaria• Coffee bean sign

Selections from the Buffet of Food Signs in Radiology

Food Signs in Gastrointestinal Diseases

Apple Core Lesion

• The annular carcinoma of colon produces focal circumferential thickening of the bowel wall, narrowing of colonic lumen, associated with shouldering.

• On barium examination, this gives rise an appearance of the affected colon similar to the partially eaten apple.

Apple Core Lesion

partially eaten apple

Double contrast barium enema showingapple core lesion due to carcinoma of colon

Apple core lesion

Apple core lesion

Apple core lesion

FOOD SIGNS IN BRAIN DISORDERS

• Berry Aneurysm• The appearance of the intracranial saccular

aneurysm on CT scan may resemble the size and shape of a berry hence termed berry aneurysm. They are congenital and characteristically occur at points where arteries bifurcate.

• It may occur in isolation or in association with polycystic kidneys or coarctation of aorta.

Berry Aneurysm

Berries.

CT brain showing Berry aneurysm.

Berry aneursym

Banana Sign• The banana sign, is one of the many notable fruit inspired

signs.• The banana-appearance of the cerebellum on the antenatal

ultrasound is due to downward traction of the spinal cord and brainstem in neural tube defects hence giving the name banana sign.

• It is also seen in the majority of fetuses with spina bifida, but disappears after 24 weeks. It is only rarely seen in a normal fetus.

• There is very frequent concurrent hydrocephalus.• The same condition also gives rise to the lemon sign.

Banana Sign

BananaAntenatal US of fetal head showing bananasign in the posterior fossa.

Lemon Sign

• The appearance of the fetal cranial vault on antenatal ultrasound resembling lemon is an excellent indicator for open spina bifida.

• The lemon sign refers to an abnormally shaped fetal head seen at antenatal US performed during the second trimester. The cranial vault appears lemon-shaped in axial cross section because the frontal bones are flattened or concave .

Lemon Sign

Lemon Antenatal US of cranium showing lemon sign

Food Signs in Urogenital Diseases• Pear-shaped Bladder• The bladder assumes the shape of a pear

when it undergoes extrinsic compression due to excess tissue in the pelvis.

• The causes for the pear-shaped bladder include pelvic lipomatosis, pelvic hematoma, pelvic collection, pelvic masses, bilateral pelvic muscle hypertrophy or lymphadenopathy.

Pear-shaped Bladder

Pears

Cystogram showing pear-shaped bladder

Pear shaped bladder

Pear shaped bladder

Pear shaped bladder

Celery stalk Metaphysis

• This is a term referring to vertical striations in the metaphysis of long bones or pelvis produced by the dysplastic bone disease like osteopathia striata

• This is an asymptomatic condition and the radiological picture resembles with the Celery stalk, a vegetable used in salad.

• Similar picture may also be seen in congenital rubella infection.

Celery stalk Metaphysis

Celery stalk X-ray left hip showing vertical Striations infemoral neck in Osteopathia Striata

X-ray right knee in Osteopathia Striata

Onion Skin Periosteal Reaction

• In an aggressive bone lesion like acute osteomyelitis, Ewing’s sarcoma or osteosarcoma, the successive deposition of periosteal layers gives a lamellated or onion skin appearance on plain films.

• Lamellated - Onion-skinning due to successive layers of periosteal development

Onion Skin Periosteal Reaction

Onion skin showing whorls

X-ray tibia revealing lamellated periostealreaction on lateral aspect in Ewing’s sarcoma.

multiple concentric parallel layers of new bone adjacent to the cortex

Hamburger Sign

• Normally, at axial CT, the vertebral facet (apophyseal) joint space looks like a hamburger

• When the facet joint is dislocated, the articular facets become uncovered, or naked, also called "naked facet sign”.

• This CT sign is characteristic of a flexion-distraction injury and indicates severe ligamentous disruption and spinal instability.

• It may be either unilateral or bilateral depending on whether facet dislocation is unilateral or bilateral.

Hamburger Sign

Hamburger

Axial CT Scan of a vertebra revealingpresence of hamburger sign on right side and loss ofhamburger sign on left side indicating flexion distractioninjury.

Sausage Digit• Sausage is a minced and seasoned meat stuffed into

cylindrical case of animal tissue frequently eaten in Europe.

• The term sausage digits refer to the clinical and radiologic appearance of diffuse fusiform swelling of digits due to soft-tissue inflammation from underlying arthritis or dactylitis .

• The most common cause of sausage digit is psoriatic arthropathy.

• Other causes include osteomyelitis, sickle cell anemia, sarcoidosis, and tuberculous dactylitis (spina ventosa).

Sausage Digit

• .Sausages

• Bangers and mash Psoriatic hands, resembling sausages X-rays finger

showing soft tissue swellingresembling sausage digit

Sausage digit

Eggshell Calcification

• Eggshell calcification of nodes consists of shell-like calcification in the periphery of the node.

• Eggshell calcification of lymph nodes occurs in up to 5% of cases of silicosis.

• The hilar nodes are predominantly involved, but mediastinal, cervical, and intraperitoneal nodes may also be affected.

• Eggshell calcification has also been observed following treatment for lymphoma; the calcifications appear 1–9 years following radiation therapy.

• Eggshell calcification is occasionally observed in patients with sarcoidosis and is usually associated with advanced pulmonary disease.

• Coal worker pneumoconiosis, amyloidosis, and scleroderma are other conditions in which eggshell calcifications have been observed.

Eggshell Calcification

Eggs

Chest PA showing eggshell calcification

Magnified lateral view

Eggshell Calcification

Food Signs in the Chest Diseases• Miliary Shadowing• The term miliary comes from "millet seed" popular

birdseed. On the Chest radiograph, a pattern of diffuse, tiny, well-defined nodules of 2–4 mm in size is called “miliary shadowing”. This pattern is often seen with pulmonary tuberculosis .

• The other differential diagnosis of miliary shadowing includes fungal infections, inhalational diseases, sarcoidosis, eosinophilic granuloma, and metastatic disease (particularly from thyroid tumors, melanoma, and choriocarcinoma).

Food Signs in the Chest Diseases

Miliary Shadowing in Tuberculosis Millet seed

Miliary Shadowing

Miliary Shadowing

Honeycomb Lung

• Honeycombing refers to an advanced stage of fibrosis in which normal lung parenchyma is replaced by cystic spaces of 5-10 mm . This is visible on Chest x-ray as well as on C T scan.

• The other common causes of honeycomb lung include pneumoconiosis, sarcoidosis, fibrosing alveolitis, scleroderma and rheumatoid diseases.

Honeycomb Lung

Bee honeycombC T Scan showing Honeycombing

Honeycomb Lung

Honeycomb Lung

Honeycomb Lung

Honeycombing in pneumoconiosis

Pasta

Fettuccine with pesto Not quite linguine but close . Lemon linguine

linguine sign

• After implantation of a silicone or saline breast implant, a fibrous capsule (scar) forms around the implant shell. In an intracapsular rupture the contents of the implant are contained by the fibrous scar while the shell appears as a group of wavy lines.

• This has been termed the “Linguine sign” and has been most commonly described with MR imaging. Here, the same findings are seen on CT imaging in a patient with bilateral ruptured saline implants.

linguine sign

Breast MRI showing the linguine sign indicating intracapsular implant rupture.

Rice Grain Calcification

• Calcified Cystiserci within the muscles produce ovoid flecks of calcification parallel to the long axis of muscles and resembling grains of rice.

Rice grains.

Rice Grain Calcification

X-ray both knees showing bilateral rice grainsoft tissue calcifications around the knees

Doughnut sign

• Doughnut sign refers to the imaging finding that resembles a doughnut. Circumferential thickening of the bowel wall in carcinoma of the colon and inflammatory bowel disease

• resembles an appearance similar to that of the doughnut.

Doughnut

Doughnut sign

CT Scan pelvis showing Doughnut sign (arrow) inInflammatory bowel disease.

Pancake vertebra

• A vertebra plana or pancake vertebra is the term given when a vertebral body has lost almost its entire height anteriorly and posteriorly, representing a very advanced crush fracture.

• It is caused by trauma in normal vertebra or collapse of vertebral body in pathological spine like metastases, multiple myeloma, lymphoma, haemangioma, eosinophilic granuloma or osteogenesis imperfecta.

Pancake vertebra

Pancake

Reconstructed CT showing vertebral compression

MRI showing vertebral plana

Licked Candy Stick Appearance

• The term licked candy stick appearance refers to tapering of the tips of the metacarpal bones, metatarsal bones, phalanges, or clavicles and is usually associated with:

• psoriatic arthropathy• rheumatoid arthritis• leprosy

Licked Candy Stick Appearance

Candy sticks

X-ray both feet showing tapered metatarsalends in psoriasis

, Popcorn calcification• Cartilaginous tumors (such as osteochondromas,

enchondromas, and chondrosarcomas) may produce irregularly shaped calcifications within their matrix that resemble popcorn on imaging studies.

• These "popcorn calcifications" can usually be distinguished from the "mashed potato," or cloudlike, ossific matrix of bone-forming tumors such as osteosarcomas.

• The term "popcorn calcification" has also been used to describe the lucent areas with sclerotic margins seen in the metaphyses and epiphyses of patients with osteogenesis imperfecta.

Popcorn calcification

Popcorns

13 mm lung nodule with "popcorn" calcification.

Cottage Loaf Sign

Cottage loaf bread, a traditional bread in U.K

The MRI appearance of the partiallyherniated liver through the ruptured rightHemidiaphragm.

Coffee-bean sign

• Coffee bean sign is a characteristic sign of sigmoid volvulus and consists of a greatly distended, air-filled loop of sigmoid colon extending from the pelvis at abdominal radiography.

• The apposed medial walls of the dilated bowel form a distinct oblique line that resembles the cleft of a coffee bean.

• The “coffee bean” arises from the pelvis and may be very large, with its apex often extending above the level of T10 to the left or right of midline.

Coffee-bean sign

Case 1: with perforation

Sigmoid Volvulus

coffee bean

Champagne glass pelvis

• The champagne glass pelvis is a helpful sign in achondroplasia which the iliac blades are flattened, giving rise to a pelvic inlet that resembles a champagne glass. The acetabular angles are increased, and the sacrosciatic notch is small.

Champagne glass pelvis

Champagne glassX-ray pelvis in Achondroplasia

Champagne glass pelvis

Dinner fork deformity

• In Colles’ fracture, the distal radius is fractured and angulated dorsally, giving rise clinically and radiologcally to the “dinner fork deformity” at the wrist .

• This has typical resemblance to the dinner fork.

Dinner fork deformity

Picture of dinner fork

Colles’ fracture showing dinner fork deformity

Inspired signs

• Fruit inspired signs• Vegetable and plant inspired signs• Inanimate and object inspired signs• Weapons and ammunition inspired signs• Animal and animal produce inspired signs • May sound a little silly, but the radiology

literature is replete with signs, some more fanciful than others.

Dagger sign in Ankylosing Spondylitis

Single central radiodense line related to ossification of supraspinous and interspinous ligaments which is called dagger sign.

Animal inspired sign- Scotty dog sign

X-ray lumbar spine-Oblique view

Conclusion

• The recognition and application of these food signs on imaging is highly helpful for the diagnosis of various diseases throughout the body.

• However, these radiological signs should be correlated with clinical and other relavant informations to reach the correct diagnosis

Conclusion

• Recognition of these signs, served with an understanding of the relevant differential diagnosis and pathologies, will go a long way toward satisfying the radiologist's ever-present hunger for learning and thirst for knowledge.

• Bon apetit!

References

• http://radiopaedia.org/