Infection with Ureaplasma urealyticum: is there a specific clinical and radiological course in the preterm infant?

BACKGROUND: Despite having mild early respiratory disease, many preterm babies develop chronic lung disease (CLD). Intrauterine infection with Ureaplasma urealyticum has been associated with preterm labour and CLD. OBJECTIVE: To test the hypothesis that infection with U urealyticum results in a specific clinical and radiological picture in the first 10 days of life. METHODS: Retrospective study of 60 ventilated babies < 30 weeks gestation, who had tracheal secretions tested for U urealyticum. Placental histology was reviewed by a paediatric pathologist for signs of chorioamnionitis. Chest radiographs were independently reviewed by two paediatric radiologists according to previously agreed criteria. All reviewers were blinded to the infection status of the babies. RESULTS: Twenty five babies were U urealyticum positive. These were more likely to experience chorioamnionitis (p = 0.004), premature rupture of membranes (p = 0.01), and spontaneous vaginal delivery (p = 0.09). U urealyticum positive babies had fewer signs of respiratory distress syndrome on early chest radiographs (p = 0.038), and they could be weaned from their ventilation settings (fraction of inspired oxygen (FIO(2)) and mean airway pressure) more quickly in the first few days. Subsequently U urealyticum positive babies deteriorated clinically and radiologically. More often they required ventilation to be restarted (p = 0.051), a higher proportion being ventilated on day 10 (p = 0.027) with higher FIO(2) (p = 0.001) and mean airway pressure (p = 0.002). Their chest radiographs showed more emphysematous changes as early as day 5 (p = 0.045), with a pronounced difference by day 10 (p = 0.009). CONCLUSIONS: Preterm ventilated babies with U urealyticum in their tracheal secretions have a different clinical and radiological course, with less acute lung disease but early onset of CLD, compared with those with negative cultures.

An unusual presentation of neonatal adrenal hemorrhage.

Case report of a neonate presenting within 1 h of birth with right side scrotal swelling and a dusky skin discoloration thought clinically to be a hydrocele or testicular torsion. Ultrasound examination demonstrated bilateral hydroceles, more prominent on the right, scrotal oedema and a perinephric loculated fluid collection secondary to right adrenal hemorrhage. We review the ultrasound appearance of the normal and haemorrhagic neonatal adrenal and discuss the differential diagnosis of both neonatal adrenal lesions and scrotal swellings. The role and benefits of ultrasound in the primary diagnosis and management of neonatal adrenal hemorrhage is emphasized.

Transient synovitis: is there a need to aspirate hip joint effusions?

There is debate as to the optimal management of children with hip joint effusions especially regarding the decision to aspirate. The objective of this study was to determine whether there is a need to aspirate hip joint effusions detected on ultrasound in patients with clinical transient synovitis (TS) and to identify the natural history of these effusions. Twenty-five children with proven hip joint effusions were followed up sequentially by clinical and radiological examination until symptom free. The mean age was 6 years with equal right/left distribution. No child underwent hip aspiration and no cases of sepsis were missed. The median size of hip effusion detected on ultrasound at presentation was 9 mm. At 7 days 60% (15/25) of patients had a normal clinical examination with no detectable effusion on ultrasound. At 14 days 16% (4/25) had an effusion detectable on ultrasound but they were all pain and limp free and their effusions were reducing in size. These results support the known benign nature of TS and that it will settle with conservative treatment.

Magnetic resonance imaging as the primary imaging modality in children presenting with acute non-traumatic hip pain.

The role of magnetic resonance imaging (MRI) in children presenting with acute non-traumatic hip pain was evaluated prospectively. Hip MRI was performed in addition to standard investigations (arthrosonography +/- hip radiographs) in 50 children presenting to the accident and emergency department of a paediatric hospital. MRI was performed on an open 0.23T system and comprised gradient echo T1 weighted coronal, fast spin echo T2 weighted coronal and inversion recovery spin echo (IRSE) axial sequences. Diagnostic quality MRI examinations were obtained in 94% of children. The IRSE sequence was the most reliable at determining underlying disorder (p<0.002). Interobserver agreement on the MRI examinations was very good with unweighted kappa value of 0.89, 95% confidence intervals 0.79, 0.99. Sensitivity of MRI was 0.79 (0.68, 0.90, specificity 1.00 (0.89, 1.00), accuracy 0.81 (0.70, 0.92), PPV 1.00 (0.89, 1), NPV 0.36 (0.25, 0.47). Sensitivity of standard imaging was 0.70 (0.54-0.86), specificity 0.57 (0.41, 0.73), accuracy 0.72 (0.56, 0.88), PPV 0.91 (0.75, 1.00), NPV 0.24 (0.08, 0.40). MRI correctly identified all seven children with serious underlying disorder whereas conventional imaging correctly diagnosed only two. Pelvic musculoskeletal infection was associated with the combination of marked alteration in signal in tissues adjacent to a symptomatic hip and an erythrocyte sedimentation rate of >20 mm 1st h (p<0.0001). In conclusion, MRI is a practical, well accepted and accurate non-invasive imaging technique in children presenting with acute non-traumatic hip pain. Combined with inflammatory markers MRI can be used to determine those children who require aggressive management. Where it is available, MRI is the imaging modality of choice in this condition.

Magnetic resonance imaging of the paediatric chest.

Magnetic resonance (MR) has an important role to play in the imaging of the paediatric chest, not least because of its zero ionizing radiation dose. Computerized tomography (CT) has been the preferred technique for cross-sectional imaging to date because of the ease of access, speed and superior spatial resolution. This article discusses the clinical situations where magnetic resonance may be used as the primary cross sectional imaging modality. The clinical indications and the complimentary roles of magnetic resonance and computerized tomography are discussed. The patient preparation, technical aspects, advantages and disadvantages of MR are documented.

High rates of Chlamydia trachomatis infections in young Papua New Guinean infants.

OBJECTIVE: Determine the importance of Chlamydia trachomatis in the etiology of severe infection in young Papua New Guinean infants. METHODS: Between March, 1991, and April, 1993, children <3 months old were recruited as outpatients at Goroka Base Hospital, Papua New Guinea, as part of a multicenter study in four developing countries. Children with predefined inclusion criteria were enrolled. C. trachomatis was identified by direct fluorescent antibody staining in nasopharyngeal aspirates (NPAs) collected from children with and without signs of severe disease and eye swabs from children with and without conjunctivitis. Two to three radiologists read chest radiographs without knowledge of clinical and laboratory findings. RESULTS: Of 3280 outpatients seen 2168 enrolled, 955 NPAs were tested for C. trachomatis and 549 chest radiographs were read. Of 210 eye swabs from children with conjunctivitis 57% were positive for C. trachomatis compared with 8% from 167 children with no conjunctivitis. The prevalence of C. trachomatis in NPAs was 9% in asymptomatic children and 18 and 33% in children with nonsevere or severe pneumonia, respectively. C. trachomatis in NPAs was strongly associated with clinically severe pneumonia [odds ratio (OR), 2.91], reduced arterial oxygen saturation (OR 2.58) and radiographic evidence of pneumonia (OR 5.84) and was also associated with pneumococcal bacteremia (OR 3.48). CONCLUSIONS: In Papua New Guinea Chlamydia must be considered as a cause when treating pneumonia in infants, and effective treatment and prevention of sexually transmitted diseases are urgently needed for a number of reasons, including the need to curb high rates of chlamydial infection in women and infants.

Congenital hemihypertrophy and epithelioid haemangioendothelioma in a 10-year-old boy: a case report.

Epithelioid haemangioendothelioma has not been previously described in a patient with congenital hemihypertrophy and diabetes mellitus. Hepatic nodules were incidentally discovered on a routine US examination searching for known associated abnormalities. Pulmonary nodules were present on chest X-ray and CT of the lungs. The diagnosis was confirmed by open biopsy of a hepatic nodule. Despite significant disease progression the patient remains symptom free.

With advances in medical imaging can the radiologist reliably diagnose Wilms' tumours?

AIM: To evaluate whether radiologists can accurately differentiate Wilms' tumours from other paediatric abdominal masses with renal involvement using modern imaging methods alone. METHODS: From February 1993 to June 1997, 23 patients presented to the Paediatric Oncology Service at The Royal Hospital for Sick Children, Edinburgh with an intra-abdominal mass which had renal involvement. Nine patients had Wilms' tumours, 12 had neuroblastomas, one patient had xanthogranulomatous pyelonephritis and there was a single case of a mesoblastic nephroma. In each case, two radiologists retrospectively reviewed the initial imaging examinations and independently reached a radiological diagnosis. RESULTS: The radiologists were concordant and reached the correct diagnosis in 20/23 cases (87%), unsure of the diagnosis in one case (4.3 %) and discordant in two cases (8.7 %). Radiologists should be aware that a mesoblastic nephroma can have identical imaging features to a Wilms' tumour. In most cases, ultrasound and a chest X-ray were sufficient to reach the correct diagnosis although computed tomography (CT) and magnetic resonance imaging were superior for demonstrating the relationship of the mass to the great vessels, retroperitoneum and spinal canal. Inferior vena cava invasion was strongly predictive of a Wilms' tumour. Displacement of the great vessels, extension of the mass across the mid-line, renal displacement and tumour calcification on CT were more suggestive of a neuroblastoma although these features were also seen in a significant number of patients with Wilms' tumours. Encasement of vessels by tumour, a paravertebral mass and spinal canal invasion were highly predictive of neuroblastoma. CONCLUSION: In this study, radiologists were accurate at diagnosing Wilms' tumours using modern imaging methods, however, care should be taken in children who are less than 1 year of age as a mesoblastic nephroma may have identical imaging characteristics.

Spontaneous involution of pulmonary sequestration in children: a report of two cases and review of the literature.

BACKGROUND: Two cases of pulmonary sequestration which regressed spontaneously are presented. OBJECTIVE: To demonstrate the value of imaging studies in the diagnosis and follow-up of some forms of congenital masses of the lung in asymptomatic patients. MATERIAL AND METHODS: We reviewed the clinical records and imaging studies of two asymptomatic children, one newborn and the other 3 months old, with thoracic masses which demonstrated variable degrees of spontaneous involution. RESULTS: Abdominal ultrasound performed on the newborn with a palpable mass showed a triangular echogenic mass with a large central feeding vessel arising from the aorta. The mass had disappeared on follow-up US exam performed 6 years later. CT was performed in the 3-month-old patient with a persistent retrocardiac mass. A soft-tissue density mass in the left pulmonary base with a large feeding vessel arising from the aorta was visualised on contrast-enhanced CT. Five years later, a new CT scan showed significant shrinkage of the mass and no vessel. CONCLUSION: Radiological techniques such as real-time US with Doppler imaging and contrast-enhanced CT may establish the diagnosis of pulmonary sequestration by demonstrating the mass and its systemic vessel, thereby eliminating the need for more aggressive imaging procedures. Partial or total disappearance of these masses represents a further example of involutive pathology and suggests that not all cases of pulmonary sequestration should be surgically treated.

Orogastric magnet removal of ingested disc batteries.

Ingestion of disc batteries by infants and small children is an increasing problem. Batteries that remain in the stomach can corrode and damage mucosa and/or produce poisoning. Between 1989 and 1992, 37 children who had swallowed a total of 46 disc batteries presented to the Royal Hospital for Sick Children, Edinburgh, and were referred for battery removal by use of an orogastric magnet under fluoroscopy. Thirty-nine batteries were removed successfully (without anesthesia) from 32 children, using a magnet attached to an orogastric tube. In three cases the battery had passed into the small bowel. In one case, magnet extraction failed, but the two batteries the child had ingested subsequently passed into the small bowel. In two cases the patients refused to swallow the tube. In one of these cases the battery was removed successfully by the magnet, with the patient under general anesthesia; in the other it passed spontaneously into the small bowel. The authors conclude that orogastric magnet removal is a minimally invasive, well-tolerated method of removing ingested disc batteries.

The rare association of right adrenal haemorrhage and renal vein thrombosis diagnosed with duplex ultrasound.

Neonatal adrenal haemorrhage with renal vein thrombosis, an almost exclusively left-sided phenomenon, may occasionally be bilateral in the presence of inferior vena cava thrombus but has only twice been reported as confined to the right side. These cases required a combination of ultrasound (USS), excretion urography, cystoscopy with retrograde pyelography, radioisotopes, and CT to diagnose this rare right-sided combination. We report a case of right adrenal haemorrhage causing right renal vein thrombosis accurately diagnosed using only duplex USS and radioisotopes. The potential complications of renal vein thrombosis and hypertension associated with adrenal haemorrhage requires accurate diagnosis and this paper emphasises the value of duplex USS.

Evaluation of long-term central venous patency in children with chronic venous catheters using image-directed Doppler ultrasonography.

All children in the Oncology Unit in the Royal Hospital for Sick Children, Edinburgh who had had long-term central venous catheters removed between 1987 and 1991 underwent central venous assessment by image-directed Doppler ultrasound scanning techniques. In this study, the implant vein remained patent after decannulation, and we believe should be re-accessed rather than moving to another site.

Colonic complication of acute lymphoblastic leukaemia.

We present four unusual colonic complications of acute lymphoblastic leukaemia which occurred during the early induction period of chemotherapy. These included a transverse colitis, a haemorrhagic proctitis, a caeco-colic intussusception and an ileo-colic intussusception complicating typhlitis. Although complications are rare, they should be considered in the differential diagnosis of abdominal pain in children undergoing chemotherapy.

Pneumatic reduction of intussusception: clinical experience and factors affecting outcome.

Between 1987 and 1992, 54 patients (32 male, 22 female) underwent 62 attempts at pneumatic reduction of intussusception. The mean age at presentation was 12.5 months (range 2.5 to 4 years 4 months). A retrospective review of all cases was performed to identify success rate and factors affecting it. Successful reduction was achieved in 46 cases (74%). One case was complicated by perforation and four cases (7%) by early recurrence. Patients with failed pneumatic reduction were more likely than those with successful reduction to have: (1) long duration of symptoms; (2) bleeding per rectum; (3) small bowel obstruction. Among the 16 cases of failed reduction, surgical findings were: five cases of ileo-ileo-colic intussusception, one with ileo-ileal, one with perforated ischaemic colon during air enema and one whose intussusception was found to be reduced at surgery. Three patients had lead points: Meckel's diverticula in two and a pinworm in one. Resection was required in three cases for non-viable bowel and in another two for the Meckel's diverticula. Pneumatic reduction of intussusception offers a high success rate with few complications. Performing an air enema earlier in the course of the disease may increase the chance of successful reduction.

Case report: primary intrathoracic rhabdomyosarcoma: a rare childhood malignancy.

Primary intrathoracic rhabdomyosarcoma is a rare tumour in childhood. Three cases are presented and the radiological findings and clinical course are reviewed. The radiological manifestations are varied but a rapidly growing soft tissue mass with compression of adjacent structures is the most common. A rare association with an underlying congenital pulmonary cyst is described. The prognosis is worse than for rhabdomyosarcoma at other sites, with a predisposition for cerebral metastases.

Case report: duodenal and jejunal strictures treated with balloon dilatation through a duodenostomy.

An 11-year-old girl with duodenal and jejunal strictures considered to be inaccessible for surgery was successfully treated using balloon dilatation under fluoroscopic control via a duodenostomy. This is the first reported paediatric case of small bowel stricture dilatation using a balloon catheter, and it is also the first report of the small bowel being approached for balloon dilatation through a duodenostomy. This case demonstrates another use for balloon dilatation which appears to be a relatively safe and effective form of treatment for short, subacute strictures involving the gastro-intestinal tract.

Cerebrovascular resistive index assessed by duplex Doppler sonography and its relationship to intracranial pressure in infantile hydrocephalus.

Duplex Doppler sonography and direct intracranial pressure (ICP) measurement were performed on 18 patients with infantile hydrocephalus. ICP was measured through a frontal reservoir or ventricular tap using a nondisplacement pressure transducer. The Pourcelot Resistive Index, RI = (peak systolic-end diastolic)/peak systolic velocity was obtained from pulsed-wave Doppler measurements of blood flow velocity in the anterior (ACA) and/or the middle cerebral (MCA) arteries. There was a statistically significant positive correlation between ICP and RIs in the MCA and ACA. Paired RI measurements in 7 patients with raised ICP decreased significantly from a mean of 0.90 pre-tap to 0.75 post-tap. Our results suggest that the RI provides a reliable measure of cerebrovascular resistance in hydrocephalus. Duplex Doppler ultrasonography thus is a useful noninvasive means of monitoring cerebrohaemodynamic change with simultaneous imaging of ventricular size in infantile hydrocephalus.

Initial investigation of childhood urinary tract infection: does the plain abdominal X ray still have a role?

To reassess the plain abdominal X ray (AXR) in the initial investigation of childhood urinary tract infection, radiologists from four paediatric units prospectively collected data on the yield from the AXR in 683 children. Five children had renal calculi. All were detected on ultrasound, but one was not visible on the initial AXR. Four spinal abnormalities were identified, none of which prompted any action by the clinician involved. While the costs, in both financial and radiation risk terms, may be small, the benefit of the AXR appears equally small. Where expert paediatric ultrasonography is available we would recommend that the AXR be reserved for patients with haematuria, loin pain, family history of calculus disease, or where further urinary tract infection occurs despite a normal ultrasound scan.