Successful Antifungal Combination Therapy and Surgical Approach for Aspergillus fumigatus Suppurative Thyroiditis Associated with Thyrotoxicosis and Review of Published Reports.

In immunocompromised patients, Aspergillus infections are important causes of morbidity and mortality. We describe a patient with cryoglobulinemic vasculitis who developed disseminated invasive aspergillosis with thyrotoxicosis caused by Aspergillus fumigatus. The diagnosis was based upon radiological, microbiological and pathological findings. The patient was treated successfully with voriconazole and caspofungin treatment followed by total thyroidectomy. We provide an overview of published reports on Aspergillus thyroiditis with an emphasis on therapeutic approaches.

Unplanned ultrasound-guided puncture of a tracheal balloon in a premature infant with congenital diaphragmatic hernia.

Temporary tracheal balloons have been shown to improve lung growth in fetuses with severe congenital diaphragmatic hernia. Fetoscopic Endoluminal Tracheal Occlusion (FETO) is performed at 26-28 weeks gestation, and then is removed in utero at 34 weeks gestation at highly specialized centers. In case of preterm labor at a hospital without a specialized team, a number of techniques have been used to remove the balloon, sometimes with death of the newborn. We have successfully performed an ultrasound-guided approach to puncture and remove the tracheal balloon in a premature infant in an emergency setting at birth. After that she was treated for congenital diaphragmatic hernia at our Newborn Intensive Care Unit.

Conservative management of accessory spleen torsion in children.

Accessory spleen torsion is very rare condition especially in children. The aim of this study is to report the conservative treatment option. In April 2009 we observed a 10-year-old child affected by hereditary spherocytosis who reported acute abdominal pain without fever or vomiting. At hospitalization all blood tests were within normal value. Abdominal ultrasounds showed an increase in spleen volume and a solid round-shaped hypoechogenic formation with hyperechogenic areas in the lower pole without vascolarisation on color-Doppler scan. These findings suggested torsion of the accessory spleen. We opted for a conservative approach: analgesics on demand and antibiotics. After a week symptoms resolved spontaneously and patient was discharged in good health conditions. Follow-up ultrasound scans were performed at one week, three-six months and one year after hospitalization and showed a progressive reduction of the dimensions of the solid round-shaped formation. Accessory spleen torsion needs to be added to the differential diagnosis of cases of acute abdomen in children. Ultrasounds with eco-color-Doppler scans seem to be the best option for the diagnosis of such condition in the pediatric age since other diagnostic methods are more invasive and require sedation of patients. Once accessory spleen torsion is correctly diagnosed it is possible to opt for its conservative treatment.

Virtual autopsy using multislice computed tomography in forensic medical diagnosis of drowning.

PURPOSE: This study evaluated the usefulness of multidetector computed tomography (MDCT) in the postmortem diagnosis of death by drowning in fresh water by measuring the difference of blood density within the cardiac chambers. MATERIALS AND METHODS: Twenty-two corpses including six cases of fresh-water drowning (group A) and 16 deaths by other causes (group B), among which were also different forms of mechanical asphyxia other than drowning, underwent MDCT and conventional autopsy. Blood density within the right and left heart chambers, the aorta and the pulmonary trunk was measured and values compared between groups and within each group between heart chambers. RESULTS: Blood density in all cardiac chambers was lower in group A than in group B. The difference was statistically significant within the left atrium and ventricle and was significantly lower in the left than in the right heart chambers in group A only. CONCLUSIONS: MDCT, together with conventional autopsy, may contribute to the diagnosis of drowning, by measuring blood density in the heart chambers.

Correlation between high-resolution ultrasound and surgical/pathological findings in patients with suspected appendicitis.

AIM: Clinical diagnosis of appendicitis in children is often difficult. The aim of this study was to evaluate the usefulness of ultrasound with graded compressed technique in cases with suspected appendicitis. METHODS: A radiological classification of appendicitis was formulated associated with the surgical/histological degree. Afterwards, 92 patients with suspected appendicitis enrolled in this study were prospectively evaluated and managed to follow a new protocol based on the clinical and radiological experiences. In this study, the ultrasonography was considered positive when the diameter of the wall of the appendix was larger than 7 mm and vascularization was increased or absent. RESULTS: Of these 92 patients, 54 patients underwent surgery while 38 were treated conservatively. Of the treated group, 12 patients had a perforated appendicitis, 3 had a gangrenous appendicitis, 36 patients demonstrated a phlegmonous appendix while 3 patients had a catarrhal appendix. Blood cell counts and CRP levels were significantly higher in patients with appendicitis (P<0.05) and WBC and CRP levels were higher for patients with perforated appendicitis compared with patients with simple appendicitis (P<0.05). A CRP value higher than 17 mg/dL was a strong predictor for the presence of infection. Three patients of the conservative group underwent surgery later for recurrent abdominal pain (within 2 weeks); two had a catarrhal appendix while one patient had a normal appendix (confirmed by histology) CONCLUSIONS: Patients with suspected appendicitis could be managed with ultrasound, suggesting an early approach. The selection of patients for surgery prevent complication and unnecessary surgery.

Lower limb enthesopathy in patients with psoriasis without clinical signs of arthropathy: a hospital-based case-control study.

BACKGROUND: Psoriasis is associated with a form of spondyloarthropathy in 10-30% of cases. A major feature of psoriatic arthritis is enthesitis. In some patients with psoriasis the presence of enthesitis could be underdiagnosed. OBJECTIVE: To investigate the presence of lower limbs entheseal abnormalities in patients with chronic plaque psoriasis without signs and symptoms of psoriatic arthritis. METHODS: Thirty patients with psoriasis and 30 controls underwent ultrasonographic evaluation of Achilles, quadriceps, patellar entheses and plantar aponeurosis. Ultrasonographic findings were scored according to the Glasgow Ultrasound Enthesitis Scoring System (GUESS). RESULTS: Mean GUESS score was significantly higher in patients with psoriasis as compared with controls: 7.9 (0.6) vs 2.9 (0.3); p<0.0001. In particular, the thickness of all tendons examined was significant higher in cases than in controls (p<0.0001), as well as the number of enthesophytes in all sites examined. In both cases and controls, the GUESS score was directly correlated with age (r = 0.22; p = 0.008), body mass index (r = 0.23, p = 0.0067) and waist circumference (r = 0.17; p = 0.02). In contrast, the GUESS score was not correlated with the duration and severity of psoriasis according to the Psoriasis Area and Severity Index (r = 0.03; p = 0.8) and body surface area involvement (r = 0.07; p = 0.6). CONCLUSIONS: Entheseal abnormalities can be documented by ultrasonography in clinically asymptomatic patients with psoriasis. These findings could be related to a subclinical entheseal psoriatic inflammation. We suggest close follow-up of patients with psoriasis with entheseal abnormalities for early diagnosis of psoriatic arthritis.

Does the tuberous sclerosis complex include intracranial aneurysms? A case report with a review of the literature.

BACKGROUND: Tuberous sclerosis is a protean, genetically determined disease that may involve any organ or tissue and lead to a great number of symptoms and clinical features. OBJECTIVE: Diagnosis can be very difficult in cases with incomplete manifestations (formes fruste) lacking the classic signs of the disease. MATERIALS AND METHODS: We report a case fulfilling the diagnostic criteria for tuberous sclerosis (shagreen patches, hypomelanotic macules, renal cysts and angiomyolipomas, and "migration tracts" in the cerebral white matter) in association with a giant intracranial aneurysm, but lacking mental retardation, epilepsy and facial angiofibroma. RESULTS: Fourteen other cases of tuberous sclerosis and intracranial aneurysms, all but one without any clear sign of polycystic kidney disease, were found in the literature. CONCLUSION: We suggest that vascular dysplasias in general and aneurysms (mainly intracranial) in particular can be added to the other non-primary diagnostic features for the clinical diagnosis of tuberous sclerosis.

Fossa navicularis magna.

A notchlike bone defect in the basiocciput due to a prominent fossa navicularis was incidentally discovered in a patient referred for radiologic evaluation of sinusitis. MR images showed that the osseous defect was filled with lymphoid tissue of the pharyngeal tonsil. The occurrence of this anatomic variant is discussed, with reference to ancient anatomic works.

Motor representation of the hand in the human cortex: an f-MRI study with a conventional 1.5 T clinical unit.

The purpose of this study was to show a gradient of possible bilateral activation for movements of the non-dominant vs. dominant hand, as well as for areas involved in complex vs. simple hand movements. A standard 1.5 T magnetic resonance imaging (MRI) system has been utilized to localize the cortical motor hand areas, using the blood oxygen level dependent contrast (BOLDc) technique and single-section fast low-angle shot (FLASH) imaging. Ten normal right-handed subjects volunteered for the study. The motor tasks consisted of simple (flexion-extension) finger movements of either hand, and complex movements (finger-to-thumb opposition in a repeating, pre-planned sequence) of the non-dominant hand. Simple movements caused contralateral activation of the primary motor area (MA); ipsilateral activation was observed for the non-dominant hand only. Supplementary motor area (SMA) was also activated, with a clear contralateral prevalence. The ratio of bilateral activation of MA did not change with complex movements of the non-dominant hand, while SMA as well as lateral premotor area were largely bilaterally activated in this task. In conclusion, the ipsilateral MA is activated for movements--even simple--performed with the non-dominant hand. There is widespread functional activity, involving both contralateral and ipsilateral SMA, for complex movements.