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Background
Atypical presentations, even with common diseases, whether in an unusual age group or due to a rarely encountered radiological entity, can cause confusion and misdiagnoses.

Educational Goals / Teaching Points
To demonstrate a collection of atypically presenting conditions where an uncommon age group was affected, and to raise awareness of these disorders and their potential imaging appearances in young patients.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Pyometrium: A 9-year-old with a recent Covid-19 infection (3 weeks prior) with new fever, urinary retention and suprapubic pain. Lab results demonstrated leukocytosis. Ultrasound showed echogenic fluid within the endometrial cavity with air foci, likely pyometrium, a rare entity in the pediatric population. Surgically, 200 milliliters of pus were evacuated. There was no history of imperforate hymen or sexual abuse, and a vaginitis panel for sexually transmitted diseases was negative. Spontaneous Cerebral Venous Sinus Thrombosis (CVST): A 4-year-old with a history of iron deficiency anemia presents with seizures and altered mental status. Head CT showed extensive hyperdensitites within the superior sagittal, transverse and sigmoid sinuses suggestive of cerebral venous sinus thrombosis (CVST). Magnetic resonance venography (MRV) confirmed the CT findings, with involvement of the bilateral internal jugular veins. The patient was treated with Lovenox. An extensive lab workup did not establish a cause. Vesicovaginal Reflux: A 12-year-old with history of Neuromyelitis Optica (NO) presents with abdominal pain and distended abdomen. CT scan showed large hydrocolpos. She has been menstruating regularly for one year and thus an imperforate hymen was excluded. A clinical diagnosis of vesicovaginal reflux was made by the gynecologist. This was treated behaviorally and with prophylactic antibiotics for urinary tract infections. Previous cases have been seen on ultrasound, but no cases were documented to be seen on CT in the literature. Advanced Rectal Cancer: A 31-year-old with obesity, diabetes, and hypertension presents with 6-weeks of hematuria and urinary frequency that are not responsive to antibiotics. Lab results showed anemia and confirmed hematuria. CT followed by an MRI demonstrated an advanced rectosigmoid mass invading the urinary bladder and prostate without evidence of metastatic disease. This highlights the recently recognized increasing incidence of colorectal cancer in a younger age group. Splenic Sarcoidosis: A 30-year-old with a 2-month history of dull abdominal pain. CT scan showed 2 large splenic lesions containing mixed densities, with one of them demonstrating circumferential calcifications. Ultrasound did not provide additional information. The patient stated a remote diagnosis of ocular sarcoidosis.

Conclusion
Keeping in mind uncommon presentations for common diseases, especially in the younger age groups, can help guide the clinician to reach a challenging diagnosis.