Solving the Mystery of Triads: The Beautiful Threesomes of Radiology

Co-authors

• S Koening, MD

• C Restrepo, MD

• V Ojili, MD

• A Sunnapwar, MD

• K Chintapalli, MD

• D Rajderkar, MD

Presenting author

Ameya Jagdish Baxi, MD

Disclaimer: We do not have any conflict of interest or financial gain to disclose

Solving the Mystery of Triads: The

Beautiful Threesomes of Radiology

Acknowledgements: P Nepal, MD

G Gunabushanam, MD

Purpose

• Several disease processes can present as constellations of

clinical, laboratory, & radiological findings - known as

triads

• The clinical significance of each triad varies

• Many times, initial imaging findings may incite further

investigation, such as advising CT abdomen contrast

study in a patient with pulmonary chondroma to look for

gastrointestinal stromal tumors and extra-adrenal

paraganglioma

Our goal is to present cases in quiz format of several classic triads to assist in review of

conditions & to sharpen the acuity of the radiologist’s eye to suggest further imaging

when needed to aid in diagnosis

• 26 year-old male who presents with shortness of breath and chest pain

• History of sickle cell disease

Case

Bilateral lower lobe infiltrates, pleural effusions, cardiomegaly, and auto-splenectomy

What is the name of triad?

Lonergan GJ, Cline DB, Abbondanzo SL. Sickle cell anemia. Radiographics. 21 (4): 971-94.

Acute Chest Syndrome

Case: What is the name of triad?

• 44 year old man with right upper quadrant pain with acute onset after

eating a fatty meal, vomiting, and fever

• Also seen with possible leukocytosis, fever, elevated transaminases

Sonographic and CT Findings

(Triad):

• Pericholecystic fluid

• Gallbladder wall thickening

• Positive USG murphy’s sign

Answer: Acute Cholecystitis Triad

Ralls PW , Colletti PM, Lapin SA, Chadrasoma P, Boswell WD, at al. “Real-time sonography in suspected acute cholecystitis.

Prospective evaluation of primary and secondary signs.” June 1985: 155(3).


Cardiomegaly with pericardial tamponade. Patients also had distended neck veins

Patient 1 Patient 2

Answer: Beck’s Triad (1935)

• It's components are:

– Distended neck veins

– Distant heart sounds

– Hypotension

• Seen with rising venous pressure, falling arterial pressure, and decreased heart

sounds

Fowler NO. “Cardiac tamponade. A clinical or an echocardiographic diagnosis?” Circulation 1993; 87(5): 1738-41.

Case What is the name of triad?

61 year old male with shortness of breath & altered mental status

Bergman’s Triad (1873)

Rodriguez—Gutierrez R et al. “Bergman’s Triad: Fat Embolism Syndrome.” American J of the Medical Sciences 2015; 349(2): 186.

Left-sided Hampton’s hump and pulmonary

arterial filling defects.Left proximal femoral fracture.

Bergman’s triad is seen with fat emboli syndrome and consists of

• Mental status changes

• Petichiae

• Dyspnea

Capp Triad

Capp triad refers to the constellation of clinical and imaging findings in patients with

retropharyngeal haematomas, and consists of:

1.Tracheal and esophageal compression

2.Anterior displacement of the trachea

3.Subcutaneous bruising over the neck and anterior chest

Case

Muñoz A, Fischbein NJ, de Vergas J et-al. Spontaneous retropharyngeal hematoma: diagnosis by mr imaging. AJNR Am J Neuroradiol. 22 (6): 1209-11.

• 48-year-old man presenting with acute

onset of retropharyngeal pain,

dysphonia, dyspnea , and dysphagia

• Status post MVC

• Clinical examination: Neck bruise

Large retropharyngeal hematoma (red

arrows) compressing and pushing

oropharyngeal airway (yellow arrows)



• 31-year-old male who presented with diarrhea, lower extremity edema, and “hot flashes”

Small bowel mass in the right lower quadrant and multiple

hypodense hepatic lesions

Answer: Carcinoid Triad

Gedam BS et al . “Gastrointestinal carcinoids: International J of Biomed and Advanced Research.” 2015 6(11): 801-806

• Classic "carcinoid triad" includes flushing, diarrhea, and cardiac involvement

• The hormone largely responsible for most of these symptoms is serotonin

Case: What is the name of triad ?34 year old female presented with abdominal pain

Further imaging was done which showed multiple gastric masses (GISTs) (blue

arrows), pulmonary chondroma (green arrow), and left adrenal tumor (yellow arrow)

Answer: Carney’s Triad (1977)

Triad: Multifocal gastrointestinal stromal tumors (GISTs) (97%), Pulmonary chondromas (83%), & Extra-adrenal paragangliomas (53%)• 33% have all three findings• 10x more common in females• Paraganglioma usually nonfunctional• Screening of family members not recommended

Mayo Clin. Proc. 1999;74 (6): 543-52

Case

56-year-old male presented with

triad of with RUQ pain, fever

and jaundice

Imaging findings

• Biliary Obstruction

• Enhancing Duct Walls

• Cholangitic abscesses

• Managed with PTBD


Answer: Charcot’s Cholangitis Triad

Frossard, J.L. & Bonvin, F. Int J Emerg Med (2011) 4: 18. doi:10.1186/1865-1380-4-18

28-year-old female with weakness and tremor

Also had staccato speech, nystagmus, & Intention tremor (triad)

• Multiple T2 hyperintense demyelinating plaques

within the callosal, pericallosal, & subcortical

white matter, & in the cervicothoracic spinal cord.


Answer: Charcot’s Neurologic Triad

• Associated with multiple sclerosis

• Named after Jean-Martin Charcot

Frossard, J.L. & Bonvin, F. Int J Emerg Med (2011) 4: 18. doi:10.1186/1865-1380-4-18

Case: What is the name of triad ?• 65-year-old male presented to the emergency center with severe mid

thoracic pain, hematemesis, and hemodynamic instability

Non-contrast, arterial, and venous axial CT images of the chest demonstrate a large

aorto-enteric fistula and thoracic aortic aneurysm

Answer: Chiari’s Triad (1914)

Aortoesophageal fistula and hematoma

Aortic diseases associated with esophageal fistula and consequent hematoma includes

• Thoracic aortic aneurysm

• Penetrating aortic ulcer and aortic dissection

• Prosthetic graft

Heckstall RL et al. “Aortoesophageal fistula: recognition & diagnosis in emergency department.” Ann Emerg Med. 1998 Oct; 32(4): 502-5

Case: Child with deformity

Currarino triad


• Anorectal malformation (yellow arrow)

• Sacrococcygeal osseous defect (red arrow)

• Presacral mass (blue arrow)

Currarino G, Coln D, Votteler T. Triad of anorectal, sacral, and presacral anomalies. AJR Am J Roentgenol. 1981;137 (2): 395-8

Currarino syndrome is an autosomal dominant disorder, characterized by triad of partial

agenesis of the sacrum with additional pelvic malformation – anal atresia and presacral

teratoma. Presentation may be delayed to childhood, and even young adulthood. There is also a

risk for malignant degeneration of the presacral teratoma.

.


Red arrows- Hemorrhagic contusions

Yellow arrows- Vasogenic edema

Green arrow- Tonsillar herniation

• Triad: altered mental status, bradycardia, irregular breathing (impaired brainstem

function), and systolic hypertension (widening pulse pressure)

• Clinical triad with variable physiological nervous system response to increased

intracranial pressure

Hint: This triad suggests a cerebral hemorrhage in the setting of trauma or an space occupying

lesion (e.g. brain tumor) that is growing and a possible impending fatal herniation of the brain

Answer: Cushing’s Triad

Patient 1Patient 2

Fodstad H, Kelly PJ, Buchfelder M. “History of the Cushing Reflex.” Neurosurgery 2006; 59(5): 1132-37.

Case: What is the name of triad ?

• A 3 week old infant with vomiting, jaundice, pale stools, & dark urine

• A right upper quadrant USG & nuclear HIDA scan was performed

Non visualized gallbladder with

no tracer in duodenumUSG findings (Triad)

• Atretic gallbladder, length less than 19 mm

• Lack of smooth/complete echogenic mucosal

lining with an indistinct GB wall

• Irregular or lobular liver contour

Answer: Gall Bladder Ghost Triad

Biliary Atresia

Tan Kendrick AP et al . “Biliary atresia: making diagnosis by gallbladder ghost triad.” Pedatr Radiol 2003 May;33(5):311-5.

Case• 35 year old female presented with fatigue, cough, intermittent

shortness of breath, and swollen lymph nodes

CXR and axial CT images of the chest demonstrate the

“1-2-3 sign” also known as “Pawnbreaker’s sign,”

characterized by bulky right hilar lymphadenopathy (blue

arrow), left hilar lymphadnopathy (green arrow), and

right para-tracheal lymphadenopathy (yellow arrow)

What is the name of triad ?

Answer: Garland Triad

Akbar JJ et al. “Cardiopulmonary Imaging in Sarcoidosis.” Clinics in Chest Medicine. 2009 Sept; 29(3): 429-43.


Answer: Kartanager syndrome

47-year-old male presented with concern for pneumonia

Initially described in 1904 by Siewert. Also known as immotile cilia syndrome.

Triad: situs-inversus, chronic sinusitis, and bronchiectasis

Other findings: Male infertility and lack of smell

Patients present with repeated chest infections and can be clinically confused with

immunodeficient conditions

Bronchiectasis Situs inversusSinusitis

Case Reports176 Journal of Natural Science, Biology and Medicine | January 2014 | Vol 5 | Issue 1

• 58-year-old female presents with sepsis and a right-sided neck mass and pain

• Extensive soft tissue infection of the neck (yellow arrow)

• Thrombosis of the right internal jugular vein (blue arrows)

• Septic pulmonary emboli and parenchymal infection (red

arrows)

Answer: Lemierre’s Syndrome

Diagnosis rests on a high index of suspicion and is confirmed by

culture of Fusobacterium spp. from blood or infected sites

O'brien WT, Lattin GE, Thompson AK. Lemierre syndrome: an all-but-forgotten disease. AJR Am J Roentgenol. 2006;187 (3): W324.

Case: What is the name of triad ?

Reconstructed MDCT

coronal, sagittal, and

SSD images showing

aortic occlusion (blue

arrows) and multiple

collaterals (yellow

arrows)

Case : What is the diagnosis?• 69-year-old man presenting with triad of intermittent claudication,

impotence & diminished peripheral pulses

Diagnosis: Leriche Syndrome

• Aortoiliac occlusive disease: Atheromatous occlusion of the infrarenal aorta, common iliac

arteries, or both

• First described by French Surgeon Rene Leriche as a thrombotic occlusion of the end of

the aorta with a unique triad of claudication, impotence, and decreased peripheral pulses

Wooten et al. Clin. Anat. 27:1264–1274, 2014

Case: What is the name of triad?• 47 year old male who presents with severe chest pain after

vomiting secondary to excessive alcohol use

Pneumomediastinum, pneumothorax, (yellow arrows) left pleural effusion with mild

esophageal wall thickening and irregularity with contrast extravasation into the left

hemi-thorax (blue arrows)

Answer: Mackler’s Triad (1724)

• Mackler's triad: Vomiting, chest pain, & subcutaneous emphysema

• Indicates Boerhaave’s syndrome, also known as esophageal rupture

secondary to forceful vomiting and retching

Yagnik VD. “Boerhaave's syndrome: Spontaneous full thickness esophageal perforation.” Lung India 2012 Apr-Jun; 29(2): 197.


• A 35 year old female, G2P2, presented with weight loss,

increasing abdominal circumference, and palpable pelvic mass

Right hydrothorax Ascites Large right adnexal mass

Answer: Meigs’ Syndrome (1937)

Meigs syndrome is defined as the presence of ascites and pleural effusion/hydrothorax in

association with a benign, usually solid, ovarian tumor usually an ovarian fibroma (80-90%)

Sarria HP et al. “Meigs’ Syndrome: a case presentation and revision of the literature.

” Laparoscopy and Hysterectomy, Pregnancy and Birth, and Weight Management: June 2011.


• Results from valgus stress with rotation of the

knee

– ACL, MCL, MEDIAL MENISCUS TEAR

Shelbourne KD, Nitz PA. The O'Donoghue triad revisited. Am J Sports Med. 1992;19 (5): 474-7.

O'Donoghue's unhappy triad


• Newborn baby boy with

abdominal distention and

undescended testes

• Prune belly syndrome, also known as Eagle Barrett syndrome or triad

syndrome, is a rare anomaly comprising a specific constellation of features

• Three major findings:

– gross ureteric dilatation

– anterior abdominal wall maldevelopment (giving "prune belly" appearance)

– bilateral undescended testes

• Other associations include respiratory, gastrointestinal, musculoskeletal, and

cardiovascular anomalies

Prune Belly Syndrome Triad

Das narla L et-al. Pediatric case of the day. Prune-belly syndrome (Eagle-Barrett syndrome, triad syndrome). Radiographics. 18 (5): 1318-22.

Overdistended urinary bladder Undescended right testis-green

Bilateral hydroureteronephrosis

and thinned out anterior abdominal wall

Dilated posterior urethra and

right hydroureter

Case

• 38-years-old female presenting with the sustained

hypertension, hematuria and postmicturition syncope

Bladder pheochromocytoma presenting as hypertensive emergency

What is the diagnosis?

• Arise in the paraganglia of the visceral (autonomic) nervous system

• Location: submucosal either dome or posterior wall, close to the trigone

• Imaging is useful in localization and for determining multiple sites or metastases

Sweetser PM, Ohl DA, Thompson NW. Pheochromocytoma of the urinary bladder. Surgery. 1991;109:677–681.

triad of

Case


Saint’s Triad

Saint's triad is a medical condition of concurrence of the following:

- Cholelithiasis

- Hiatal Hernia

- Colonic Diverticulosis Diverticular disease

Hauer-Jensen M, Bursac Z, Read RC. “Is herniosis the single etiology of Saint’s triad?” Hernia (2009) 13: 29.


• 10 year old male with elbow injury

Radiographic findings:

Posterior elbow dislocation

Coronoid process fracture

Radial head fracture

Terrible Triad of the Elbow

• The terrible triad of the elbow is a severe elbow fracture-

dislocation pattern and is so-called because it has poor

medium-to-long term outcome

Matthew PK, Athwal GS, Graham JW. “Terrible triad injury of the elbow.” J of the Am Academy of Ortho Surg 2009; 17(3): 137-151.

Case: Identify findings and triad

• 3-year-old female with history of congenital heart disease

• Pulmonary valve stenosis

• Right ventricular hypertrophy

• Atrial Septal Defect

Trilogy of Fallot

Bowie EA. “Longevity in tetralogy and triology of Fallot: Am Heart J 1961; 62(1): 125-132.

45-year-old woman with pain in abdomen


Arrows

• Pneumobilia (yellow)

• Small bowel obstruction (red)

• Gallstone (blue)

Rigler’s triad in gallstone ileus

Lassandro Francesco et al. “Role of Helical CT in Diagnosis of Gallstone Ileus and Related Conditions.” Am. J. Roentgenol. 185, no. 5 (November 1, 2005): 1159-1165


• 38 year old female on oral contraceptive pills presents with left

lower extremity pain and edema after an overseas flight

Answer: Virchow Triad

• Virchow's triad describes 3 broad categories of factors that contribute

thrombosis:

– Hypercoagulability

– Hemodynamic changes to flow (stasis, turbulence)

– Endothelial injury/dysfunction

Makin A, Silverman SH, Lip GY. “Peripheral vascular disease and Virchow’s triad for thrombogenesis.” QJ Med 2002; 95: 199-210.

Case

15 yo male, MV vs. pedestrian

What is the name of the triad?

Waddell’s Triad

Atabaki SM. “Updates in the general approach to pediatric head trauma and concussion.” Ped Clin of N Amer. 2013; 60(5): 1107-1122.

• Femur fracture

• Intra-abdominal or intra-thoracic injury

• Head injury

Case33-year-old obese female with right upper quadrant pain


“WES” – Wall Echo Shadow Triad

Rybicki FJ. The WES sign. Radiology. 2000;214 (3): 881-2.

Single thin curvilinear hyperechoic line representing gallbladder wall & near

surface of gallstone with posterior acoustic shadowing distal to the gallstone

The "WES" triad is the demonstration of the gallbladder Wall, Echo of the stone, and the

acoustic shadow. It permits the specific diagnosis of stones in a contracted gallbladder & helps

to differentiate the contracted gallbladder with stones from a gas filled bowel loop

Two different patients with severe hypoglycemia & immediate response

to IV glucose

Case : What is the name of triad?

Patient 1

Patient 2Whipple’s Triad

Whipple triad is the clinical presentation of pancreatic insulinoma

– Fasting hypoglycemia (<50 mg/dl)

– Symptoms of hypoglycemia

– Immediate relief of symptoms after the administration of IV glucose

AJR Am J Roentgenol. 2003;181 (4): 987-92.

41 year old female with left flank pain

Case 25: What is the name of triad?

Answer: Xanthogranulomatous Pyeleonephritis

• Classic radiology triad of

– Unilateral large kidney

– Renal pelvis stone

– Nonfunctioning or poorly functioning kidney

Craig WD, Wagner BJ, Travis MD. Pyelonephritis: radiologic-pathologic review. Radiographics. 28 (1): 255-77.

Case: What is the name of triad ?37-year-old male presented with perineal pain, recurrent prostatitis,

painful ejaculation, and infertility

Right renal agenesis Seminal vesicle cyst and dilated tubular fluid filled structure in the right pelvis

Answer: Zinner Triad (1914)Maldevelopment of the distal part of the mesonephric duct results in atresia of the

ejaculatory duct (leading to obstruction and dilatation of the seminal vesicle) while abnormal

ureteral budding (leads to renal agenesis/dysplasia)

Ghonge Npet al; Indian J Urol. 2010;26 (3): 444-7.

Thank you

Solving the Mystery of Triads: The Beautiful Threesomes of Radiology

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