The Greatest Show on CT

Although this may sound like the start to a riddle or a joke, it’s in fact what piqued one radiologist’s curiosity about the work-related conditions affecting circus performers. 

But what does the circus have to do with radiology?

According to Douglas C. Khalil, MD, a radiologist at the University of São Paulo in Brazil, a range of diseases and injuries to circus performers can mean a loss of productive work time. 

“The efficient use of diagnostic imaging can lead to proper diagnosis, quicker recovery rates and, as a result, reduced lost work time for the troupe,” he explained.   

Whether you’re a naturally born ringmaster or are just circus curious, in a Tuesday presentation, Dr. Khalil helped radiologists familiarize themselves with common conditions afflicting the fire breathers, sword swallowers, lion tamers and trapeze artists of the world. 

“While these cases aren’t necessarily new in radiology, our presentation approaches them with a creative, circus-themed perspective that makes learning both informative and fun,” Dr. Khalil added. 

Can’t Believe Your Eyes? Then Try Imaging

Take for example the performer who presented with acute exogenous lipoid pneumonia—a rare condition for mere mortals, but a common hazard for those who make a living breathing fire. The condition generally presents with such symptoms as a cough, shortness of breath and mild fever, which often improve with supportive care. 

“We confirmed our fire breather’s condition via chest CT images, which showed low attenuation bilateral consolidation areas in both lung bases,” Dr. Khalil explained. 

Then there’s the time-honored circus act of sword swallowing. 

It should come as no surprise that swallowing swords is rife with risks, including the potential for severe injuries like esophageal perforation, as well as complications affecting the mediastinum, lungs and stomach.

Common imaging findings for foreign body ingestion and esophageal perforation include fat stranding in the mediastinum, identification of the foreign body and the presence of pleural or mediastinal fluid. Pneumomediastinum or pneumothorax are also highly suggestive of perforation.

Cat Scratch Fever

The fact that many big top performers work in close proximity to animals opens the door to a number of circus specific conditions. Take cat-scratch disease, which is triggered by the bacterium Bartonella henselae and typically transmitted through scratches from felines

While the disease does not respond well to antibiotics, most individuals experience spontaneous recovery within months or a couple of years. 

“Proper diagnosis can be the key to a speedy recovery,” Dr. Khalil said.

Furthermore, because imaging findings can mimic malignant diseases, Dr. Khalil says early diagnosis is crucial to avoiding unnecessary treatments.

Send in the Radiologists 

Dr. Khalil’s presentation, which is organized by subspecialities, covers nearly 20 different conditions affecting circus performers. 

“Our goal is to provide insights into a range of health risks specific to circus performers and to help radiologists imagine the various conditions they will likely encounter when joining the traveling carnival,” Dr. Khalil concluded.

Access the education exhibit, “Ladies and Gentlemen! Welcome to the Greatest Show on Earth - A Guide to Ensuring the Continued Health of Circus Performers,” (MSEE-10) in the Learning Center or through the Digital Presentations at RSNA.org/MeetingCentral