Radiology Quiz: The real Macaroni sign?

Volume 3 Issue 1 (Jul-Dec) 2025 Radiology Quiz (1) Articles in The ESRF Research Journal for Undergraduate Medical Students are Open Access articles published under a Creative Commons Attribution-Non Commercial 4.0 International License (CC BY-NC). This license permits use, distribution, and reproduction in any medium, provided the original work is properly cited, but it cannot be used for commercial purposes and it cannot be changed in any way. Published by: Eureka Scientech Research Foundation, Kolkata. Online access: https://esrfrjums.co.in Radiology Quiz: The real Macaroni sign? DOI: 10.5281/ zenodo.17361202 Available from: https:// esrfrjums.co.in/index.php/main/ article/view/69 Francesco Natale 1,2, Francesco S. Loffredo1,3, Giovanni Cimmino3,4 1Vanvitelli Cardiology and Intesive Care Unit, Monaldi Hospital, 80131 Naples, Italy 2Department of Life Science, Health, and Health Professions, Link Campus University, Rome, Italy 3Department of Translational Medical Sciences, Section of Cardiology, University of Campania Luigi Vanvitelli, 80131 Naples, Italy 4Cardiology Unit, Azienda Ospedaliera Universitaria Luigi Vanvitelli, 80138 Napoli, Italy QUESTION 1 A 77-year-old woman was admitted to Cardiology Unit because of worsening dyspnea. Vital parameters and EKG were normal. No signs of congestion at physical examination. Arterial blood gas analysis, troponin and NTproBNP levels were normal. Echocardiography showed a preserved ejection fraction. In the suspicion of lung disease a CT scan was performed, showing a body shaped like narrow tubes in the digestive tract starting from the esophagus (Panel A and B, white arrow) until the stomach where several undefined tubular structures were visible (Panel C, white arrow). What is the most probably diagnosis 1. Parasites 2. Drug fillers 3. Macaroni Sign 4. Gastric cancer Corresponding Author Giovanni Cimmino Department of Translational Medical Sciences, Section of Cardiology, University of Campania Luigi Vanvitelli, 80131 Naples, Italy E-mail: [email protected] Volume 3, Issue 1 (Jul-Dec), 2025 (2) Articles in The ESRF Research Journal for Undergraduate Medical Students are Open Access articles published under a Creative Commons Attribution-Non Commercial 4.0 International License (CC BY-NC). This license permits use, distribution, and reproduction in any medium, provided the original work is properly cited, but it cannot be used for commercial purposes and it cannot be changed in any way. The Macaroni Sign A primary hypothesis of parasites infection was made but not supported by medical history and lab tests. Drug fillers remnants were supposed but excluded since no medications were taken in the previous 12-hours. Foreign bodies, body packers, bezoars or an atypical manifestation of gastric cancer were thought. Thus, an urgent esophagogastroduodenoscopy was proposed. Scared of this procedure, patient said: “might they be the macaroni pasta eaten just before the exam?”. This was the diagnosis: a macaroni sign! Macaroni sign is known to be a marker of active arterial vessel inflammation1,2 characterized by smooth, homogeneous and moderately echogenic circumferential thickening of the arterial wall (typically of Takayasu arteritis)3,4,5. Our radiological image describes an artifact generated by the macaroni pasta mimicking the scientific Macaroni sign for two reasons: the circumferential mural thickening and the etiology (the macaroni pasta ate by the patient). Despite no correlation between these two macaroni signs existing, we may conclude that one is the scientific macaroni sign, the other is the “real Macaroni sign!”. Because the CT scan was not detecting any abnormality explaining the dyspnea, taking into account the personal history of panic disorder, the final diagnosis of psychogenic cause was then made. Fasting before CT scan is a common rule recommended to all patients once the exam is scheduled6. This recommendation was not followed by the patient without any advisement. Hence, a finding like this should suggest physicians to verify first if fasting was respected, maybe by a pre-imaging checklist, to avoid time consuming and money wasting. REFERENCES 1. Apaydin, M., et al., The macaroni sign. JBR-BTR, 2011. 94(5): p. 297. 2. Natale, F., et al., When a common sore throat unmasks a rare disease. The International Journal of Cardiovascular Imaging, 2025. 41 (4): p. 811-812. 3. Suzuki, M. and T. Watari, Macaroni sign: a clue to Takayasu arteritis diagnosis. BMJ Case Rep, 2022. 15(8). 4. Chattopadhyay, A. and S. Jain, The Macaroni sign: The pathognomonic ultrasonography sign of Takayasu arteritis. Reumatol Clin (Engl Ed), 2020. 16(5 Pt 2): p. 426-427. 5. Meini, S., et al., Images in cardiovascular medicine. Takayasu's arteritis: the "macaroni sign". Circulation, 2006. 114(16): p. e544. 6. Abbara, S., et al., SCCT guidelines for the performance and acquisition of coronary computed tomographic angiography: A report of the Society of Cardiovascular Computed Tomography Guidelines Committee. Journal of Cardiovascular Computed Tomography, 2016. 10(6): p. 435-449. Radiology Quiz