Alternative diagnoses at paediatric appendicitis MRI.

As the utilization of MRI in the assessment for paediatric appendicitis increases in clinical practice, it is important to recognize alternative diagnoses as the cause of abdominal pain. The purpose of this review is to share our institution's experience using MRI in the evaluation of 510 paediatric patients presenting with suspected appendicitis over a 30 month interval (July 2011 to December 2013). An alternative diagnosis was documented in 98/510 (19.2%) patients; adnexal pathology (6.3%, n = 32), enteritis-colitis (6.3%, n = 32), and mesenteric adenitis (2.2%, n = 11) comprised the majority of cases. These common entities and other less frequent illustrative cases obtained during our overall institutional experience with MRI for suspected appendicitis are reviewed.

Metaphyseal fractures mimicking abuse during treatment for clubfoot.

BACKGROUND: Metaphyseal injuries resembling the classic metaphyseal lesion (CML) of abuse may occur as the result of serial casting during treatment of clubfoot deformity. Mentioned in the orthopedic literature in 1972, this iatrogenic fracture has not been described in the radiologic literature nor has the similarity to injuries occurring with abuse been previously recognized. OBJECTIVE: To describe the mechanism and radiographic appearance of metaphyseal injury observed during serial casting of clubfoot. Note similarities to the CML of abuse. MATERIALS AND METHODS: Eight children ranging in age from 1 to 4 months underwent casting for clubfoot. Five orthopedic surgeons from three different institutions performed the casting. Two patients had spina bifida and one, arthrogryposis. A complete skeletal survey was performed on one child who was abused; there was no suspicion of abuse in the remaining seven. RESULTS: All children manifest injury with periosteal new bone. One child had clear evidence of abuse with 24 rib fractures. X-rays of lower extremities in short leg casts revealed bilateral tibial metaphyseal fractures. Four other children had metaphyseal fractures resembling the CML of abuse, and three developed an area of sclerosis within the metaphysis. CONCLUSION: In the setting of serial casting for equinovarus deformity, metaphyseal injury even the CML of abuse may be noted. Since inflicted injuries are almost always unobserved and explanations rarely offered, the fact that the CML occurs as a result of orthopedic maniuplation may offer some further insight concerning the pathogenesis of this well-described abuse injury.

Hemoperitoneum and disseminated intravascular coagulation in two neonates with congenital bilateral neuroblastoma.

We report two neonates with anemia, hemoperitoneum, and bilateral palpable abdominal masses. Both developed bleeding: a hemoperitoneum in one and visceral hemorrhages secondary to disseminated intravascular coagulation in the other. Each child was thought to have an unusual complication of adrenal hemorrhage, as the masses were of mixed echogenicity. However, histological evaluation revealed neuroblastoma. These cases point out the diagnostic dilemma of a mixed echogenicity suprarenal mass in the neonatal period and emphasize that local and disseminated bleeding can occur as a major manifestation of neuroblastoma.

Avascular necrosis after treatment of DDH: the protective influence of the ossific nucleus.

We retrospectively reviewed the results of open or closed reduction for developmental dysplasia of the hip (DDH) in 49 children younger than 12 months old, who had 57 hip dislocations. Group A (18 hips) developed partial or complete avascular necrosis (AVN), and group B (39 hips) did not develop AVN. Thirty-eight hips were treated by closed reduction, and 17 had open reduction. One patient with bilateral hip dislocation initially had closed reductions followed by bilateral open reduction 3 months later. With the numbers available for study, there was no significant difference in the occurrence of AVN with respect to variables such as preliminary traction, closed versus open reduction, Pavlik harness use, and age at the time of operative intervention. However, the presence of the ossific nucleus before reduction, detected either by radiographs (p < 0.001) or ultrasonography (p = 0.033) was statistically significant in predicting AVN. Only one (4%) of 25 hips with an ossific nucleus developed AVN, whereas 17 (53%) of 32 hips without an ossific nucleus before reduction developed AVN. Our results suggest that the presence of the ossific nucleus before closed or open reduction for DDH may decrease the risk of AVN.

Optimal cost-effective timing of cranial ultrasound screening in low-birth-weight infants.

Our aim in this study was to determine whether delaying the initial screening cranial ultrasound on infants of low birth weight until the 2nd week of life affects clinical diagnosis and cost of patient care. Data were reviewed on all premature infants of less than 33 weeks gestation or less than 1500 g birth weight admitted to the Neonatal Intensive Care Unit between January 1989 and August 1992. Babies admitted before August 1991 were screened on day 4 or 5 with a second scan frequently performed on day 14; babies admitted after that date were screened once between days 10-14. Populations were compared for (1) proportion of ultrasound findings considered normal on final diagnosis; (2) incidence of major and minor abnormalities; (3) periventricular leukomalacia (PVL); (4) change in diagnosis from 1st to 2nd week; and (5) number of studies performed per patient. The study group was composed of 499 eligible infants. Demographic features of infants screened in the 1st vs. 2nd week of life were similar, with comparable diagnoses of major and minor intracranial hemorrhage and ventricular dilatation; however, more patients screened in the 1st week had questionable PVL diagnosed (p = 0.04). There was a significant decrease in the number of scans per patient in the group screened in the 2nd week (p < 0.004). Routine screening may be delayed until the 2nd week without compromising patient care. Widespread use of a similar screening protocol would result in significantly fewer studies being performed, with an estimated saving, in the USA, of more than $3 million annually.

Tc-99m MAG3 renography in renal vein thrombosis secondary to Finnish-type congenital nephrotic syndrome.

Scintigraphic findings in renal vein thrombosis (RVT) have been well described on studies performed with Tc-99m DPTA, Tc-99m glucoheptonate, and I-131 orthoiodohippurate. The authors could find no reports of RVT findings on Tc-99m mercaptoacetyltriglycine (MAG3) imaging. Tc-99m MAG3 renal scintigraphy in an infant with RVT because of Finnish-type congenital nephrotic syndrome is described. Correlative ultrasound and inferior vena cava venogram findings are presented.

Fetal rhabdomyoma and nevoid basal cell carcinoma syndrome.

A 6-year-old white female presented with a fetal rhabdomyoma of the posterior mediastinum and retroperitoneum. Radiologic evaluation and family history revealed features of the nevoid basal cell carcinoma syndrome (NBS). Literature review disclosed two other children with NBS and fetal rhabdomyoma, which should be regarded as one of the soft tissue tumors associated with NBS.

CT and MR imaging of the pediatric orbit.

Orbital abnormalities encountered in the pediatric population differ substantially from those found in adult patients. Retinoblastoma, the most serious intraocular tumor, is often difficult to diagnose, but use of computed tomography (CT) (which reveals the characteristic focal calcification) and magnetic resonance (MR) imaging allows this tumor to be differentiated from pseudogliomas, such as Coats disease, and retrolental fibroplasia. CT and MR imaging help in the differentiation of orbital cellulitis from preseptal, lacrimal, and eyelid infectious processes and of orbital pseudotumor from Graves disease. In cases of orbital trauma, CT is excellent for detecting orbital fractures and metallic foreign bodies; MR imaging is better for depicting ocular and optic nerve injuries. Both modalities allow the differentiation of rhabdomyosarcoma from dermoid, cavernous hemangioma, and lymphangioma and provide helpful information for the diagnosis of many other tumors. Since CT and MR imaging have widely expanded the capabilities of orbital imaging, it is more important than ever before for radiologists to understand pediatric orbital disease.

Juvenile xanthogranuloma: non-X histiocytosis with systemic involvement.

Two patients with different patterns of soft tissue and bone involvement demonstrate the variability of extracutaneous manifestations of juvenile xanthogranuloma, a non-X histiocytosis, better known to dermatologists than to radiologists.

Focal fatty infiltration of the liver in a healthy child.

Fatty infiltration of the liver may occur in healthy children. The ultrasonographic, CT, and MRI findings are identical to those already described in the adult population.

Rickets--a complication of ifosfamide chemotherapy for Wilms tumor.

Recent reports of metabolic bone disease occurring as a result of drug induced Fanconi syndrome due to ifosfamide have appeared in the pediatric literature. Ifosfamide is a chemotherapeutic agent used for treatment of pediatric solid tumors. We present an additional case of ifosfamide induced rickets, the first in the radiologic literature.

Assessment of congenital hip dislocation with real-time ultrasound: a pictorial essay.

Real-time ultrasound (US) is the imaging method of choice for diagnosis and follow-up of congenital dislocation of the infant hip (CDH). Clinical aspects and the role of imaging are reviewed. Technique and anatomy, both normal and abnormal, are illustrated, as well as, the use of sonography during treatment with Pavlik harness and spica cast. Correlation of ultrasound findings with clinical examination, other available imaging studies and long-term patient follow-up shows 100% sensitivity and 100% specificity for real-time US diagnosis of CDH.

Hepatic granulomata. Presenting with prolonged fever. Resolution with anti-inflammatory treatment.

A patient is described who presented with a 1-month history of daily fever to 38.8 degrees C. There was no sign of joint pain or swelling and no skin rash. The patient had impressive hepatomegaly without splenomegaly. The only abnormal laboratory test was a sedimentation rate of 120 mm/hr. Ultrasound examination showed hypoechoic foci throughout the liver. These foci were confirmed by CT scan, which showed multiple well-marginated lesions of decreased attenuation and variable size throughout the right and left lobes of the liver. A liver biopsy specimen showed large nodules that were yellow and gritty in texture. Microscopic examination of biopsy specimens of these nodules showed extensive areas of necrotizing granulomatous inflammation with palisading histiocytes and occasional giant cells surrounded by necrotic foci. There was an associated fibroinflammatory infiltrate. The patient was treated with a nonsteroidal anti-inflammatory agent with prompt cessation of fever. A repeat CT examination of the liver after 14 months of treatment showed only mild hepatomegaly and a normal liver parenchyma. The focal lesions had disappeared. This is a case of hepatic granulomata in a child showing features of necrotizing inflammation.

Prenatal detection of Roberts-SC phocomelia syndrome: report of 2 sibs with characteristic manifestations.

We describe 2 sibs with Roberts-SC phocomelia syndrome. Although an ultrasound scan performed at 13 weeks of gestation failed to identify specific abnormalities, repeat scan at 17 weeks detected tetraphocomelia. Ultrasonography can reliably detect Roberts-SC phocomelia prenatally; however, serial scans may be needed. Postmortem examination of the proposita confirmed the sonographic findings and also disclosed dysplastic kidneys and ovarian dysgenesis. The degree of phenotypic variation observed between the sibs supports the hypothesis that Roberts syndrome and SC phocomelia represent a single genetic entity.

Sonographic assessment of normal renal size in children with myelodysplasia.

Periodic assessment of upper urinary tract anatomy and renal size is an important component in the urological management of children with myelodysplasia (spina bifida). As a correlation to a previous study of renal growth in children with spina bifida determined by excretory urography, we evaluated 297 renal ultrasonographic examinations in 145 patients with spina bifida and compared the renal size and growth pattern to those of normal children. Patients with known vesicoureteral reflux (grade 2 or greater), congenital renal anomalies, hydronephrosis, renal scarring or urinary tract surgery were excluded. Mean values and standard deviations for sonographically determined renal length were calculated. In general, mean renal length for each age group was below mean values for normal children. A normal renal growth curve for children with spina bifida, based on sonographic renal measurements, is developed for clinical use.

Dandy-Walker malformation in Ellis-van Creveld syndrome.

We report on 2 Old Order Amish patients with Ellis-van Creveld (EvC) syndrome and the Dandy-Walker malformation; a similar case is noted in the literature. Pedigree analysis of our patients documents extensive inbreeding in successive generations. Considering the rarity of EvC syndrome and Dandy-Walker malformation as isolated malformations, the appearance of both in our 2 patients plus the patient in the literature suggests that Dandy-Walker malformation may be a manifestation in the EvC syndrome. However, in this isolate the coincidental occurrence of 2 rare recessive traits cannot be excluded.