Diagnostic Accuracy of Multidetector Computed Tomography in Detection of Esophageal Varices.

Objective To determine the diagnostic accuracy of multidetector computed tomography (MDCT) in the detection of esophageal varices by taking endoscopy as the reference standard. Materials and methods This was a cross-sectional prospective study conducted at the Department of Radiology, Aga Khan University Hospital, (AKUH) Karachi, for the duration of 12 months from August 1, 2014 to July 31, 2015. One hundred ninety-six patients with a suspicion of chronic liver disease/cirrhosis undergoing 64 slice MDCT were enrolled in our study and underwent computed tomography (CT) scanning in the Department of Radiology at AKUH. Biphasic CT was performed with images obtained during the hepatic arterial phase (30-second delay) and the portal venous phase (65-second delay) after the intravenous (IV) injection of 120 mL of nonionic contrast material at a rate of 3.5 mL/s. The presence of esophageal varices was evaluated on MDCT with endoscopy as gold standard. The sensitivity, specificity, negative predictive value and positive predictive value, and accuracy of MDCT were assessed against the gold standard. Results Our results yielded an MDCT sensitivity of 98.96%, specificity of 100%, positive predictive value (PPV) of 100%, negative predictive value (NPV) of 66.67%, and diagnostic accuracy of 98.97% for esophageal varices in chronic liver disease (CLD) patients. Conclusion The rate of detection of esophageal varices in patients with chronic liver disease on MDCT in our country is comparable to the international data and we advocate that MDCT should be used as a screening tool in patients with chronic liver disease to exclude esophageal varices.

ACINAR CELL CARCINOMA OF PANCREAS IN A CHILD: A RADIOLOGICAL PERSPECTIVE.

Acinar cell carcinoma is a rare tumour arising from pancreatic acinar cells. Typical radiological patterns associated with it may suggest the unusual diagnosis even before final confirmation by histopathology. We present a case of an 8 year old boy who presented to clinic with symptoms of abdominal pain without associated jaundice or vomiting. Imaging revealed an atypical mass arising from head of the pancreas. Histopathology confirmed the diagnosis of acinar cell carcinoma. An idea about atypical and rare pancreatic masses is necessary to help direct the diagnosis and guide the pathologist for suspecting atypical pathology.

Bipartite lunate incidentally noted on radiographs obtained for skeletal age estimation: A report of two cases.

Bipartite lunate is a rare congenital anomaly of carpal bones. We present a report of two cases where children referred for determination of skeletal age were incidentally found to have bipartite lunate. In both cases, radiographic appearance of lunate could have been mistaken for secondary centres of ossification in other carpal bones. It is imperative for all radiologists to be aware of this rare congenital anomaly in order to avoid pitfalls in clinical diagnosis.

Comparison between Greulich-Pyle and Girdany-Golden methods for estimating skeletal age of children in Pakistan.

OBJECTIVE: To compare Greulich-Pyle (GP) and Girdany-Golden (GG) methods for estimation of Skeletal Age (SA) in children referred to a tertiary care hospital in Karachi, Pakistan. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Department of Radiology, The Aga Khan University Hospital, Karachi, Pakistan, from July 2010 to June 2012. METHODOLOGY: Children up to the age of 18 years, who had undergone X-ray for the evaluation of trauma were included. Each X-ray was interpreted using both methods by two consultant paediatric radiologists having at least 10 years experience, who were blinded to the actual Chronologic Age (CA) of children. RESULTS: A total of 283 children were included. No significant difference was noted in mean SA estimated by GP method and mean CA for female children (p=0.695). However, a significant difference was noted between mean CA and mean SA by GG method for females (p=0.011). For males, there was a significant difference between mean CA and mean SA estimated by both GP and GG methods. A stronger correlation was found between CA and SA estimated by GP method (r=0.943 for girls, r=0.915 for boys) as compared to GG method (r=0.909 for girls, r=0.865 for boys) respectively. Bland- Altman analysis also revealed that the two methods cannot be used interchangeably. Excellent correlation was seen between the two readers for both GP and GG methods. CONCLUSION: There was no additional benefit of using GP and GG methods simultaneously over using GP method alone. Moreover, although GP was reliable in estimating SA in girls, it was unable to accurately assess SA in boys. Therefore, it would be ideal to develop indigenous standards of bone age estimation based on a representative sample of healthy native children.

Effectiveness of Haemophilus influenzae type b conjugate vaccine on radiologically-confirmed pneumonia in young children in Pakistan.

OBJECTIVE: The effectiveness of Haemophilus influenzae type b (Hib) vaccine in preventing severe pneumonia in Asian children has been questioned, and many large Asian countries yet to introduce Hib conjugate vaccine in immunization programs. The primary objective of this study was to assess Hib conjugate vaccine effectiveness (VE) on radiologically-confirmed pneumonia in children born after introduction of Hib conjugate vaccine in Pakistan. STUDY DESIGN: A matched case-control study enrolled cases of radiologically-confirmed pneumonia in several hospitals serving low-income populations during 2009-2011. Cases were matched by age and season with 3 hospital and 5 neighborhood controls. Pneumonia was diagnosed using standardized World Health Organization criteria for chest radiograph interpretation. Matched OR were estimated for VE. RESULTS: A total of 1027 children with radiologically-confirmed pneumonia were enrolled; 975 cases, 2925 hospital controls, and 4875 neighborhood controls were analyzed. The coverage for 3 doses of diphtheria-tetanus-pertussis-hepatitis B-Hib conjugate vaccine was 13.7%, 18%, and 22.7% in cases, hospital controls and neighborhood controls, respectively. Estimated Hib VE for radiologically-confirmed pneumonia was 62% with 3 doses of vaccine using hospital controls and 70% using neighborhood controls. CONCLUSIONS: Hib conjugate vaccine prevented a significant fraction of radiologically-confirmed pneumonia in children in Pakistan. Maximizing impact on child survival needs improved immunization coverage.

Accuracy of computed tomography in diagnosing malignancy in solitary pulmonary lesions.

OBJECTIVE: To evaluate accuracy of Computed Tomography (CT) for diagnosing malignancy in solitary pulmonary lesions (SPLs). METHODS: A prospective cross-sectional study was conducted from 20-01-2007 to 30-06-2008 at the Radiology department, Aga Khan University Hospital (AKUH) Karachi. Fifty-three patients with solitary pulmonary lesions (SPLs) seen in prior chest x-rays or chest CT scans were referred to radiology department for CT guided biopsy. CT scan was performed for each patient prior to biopsy and CT evaluation of the SPLs was performed followed by CT guided Biopsy. Histopathological diagnosis of the lesion was taken as the gold standard. RESULTS: CT was found to be 100% sensitive, 30% specific and 87% accurate for diagnosing malignancy in solitary pulmonary lesions while PPV and NPV were 86% and 100% respectively. CONCLUSION: CT scan is highly sensitive yet non-specific and cannot be used as the definitive diagnostic modality for diagnosing malignancy in solitary pulmonary lesions.

An appraisal of Greulich-Pyle Atlas for skeletal age assessment in Pakistan.

OBJECTIVE: To assess accurate skeletal age (SA) in clinical and medico-legal decisions using the Greulich-Pyle (GP) atlas and to see its applicability across diverse populations in Karachi. METHODS: Hand-Wrist radiographs obtained at our institution from January 2005 to March 2008, for an indication of trauma, in subjects with chronological age (CA) up to 216 months, were reviewed by two radiologists blinded to CA. Subjects ever investigated for metabolic, growth or nutritional disorders were excluded. SA was assessed according to GP atlas. To establish inter-observer reliability, 100 random radiographs were dually evaluated. Both sexes were divided into four subgroups. For each subgroup, difference between skeletal and chronological age was calculated. (paired t-test, alpha < 0.05). RESULTS: Total 889 radiographs were analyzed. Inter-observer correlation coefficient was 0.992 (p < 0.001). Mean differences of up to 13 months between SA and CA were documented. The differences were statistically significant in all groups except adolescent males. CONCLUSION: Our findings suggest against the applicability of GP atlas for accurate SA assessment in Pakistani children.

Squamous cell carcinoma of tongue in an 11-year-old girl.

We report the case of an 11-year-old girl with squamous cell carcinoma of the tongue. This is a very rare disease in children with only a few cases reported in the literature. There is a great need to create awareness of the harmful and potentially lethal effects of chewing paan and betel nut not only in adults but also in children. Pediatricians and family physicians should also be aware of the possibility of this disease entity occurring at an earlier age so as to decrease delay in diagnosis and initiation of treatment.

Impact of bacille Calmette-Guérin vaccination on neuroradiological manifestations of pediatric tuberculous meningitis.

The authors conducted this study to identify whether bacille Calmette-Guérin (BCG) vaccination leads to an altered spectrum of neuroimaging findings outcome in pediatric patients with tuberculous meningitis. This retrospective study was conducted through chart review and review of computed tomography (CT) scans and magnetic resonance imaging (MRI) of patients with confirmed central nervous system tuberculosis from the year 1992 to 2005, at a large tertiary care hospital in Karachi, Pakistan. A total of 108 pediatric patients with tuberculous meningitis were included in the analysis. Of the 108 patients, 63 (58.3%) were male and 45 (41.7%) had received bacille Calmette-Guérin vaccination. There was no difference in terms of severity of clinical presentation and outcome between vaccinated and unvaccinated group. There were no significant differences in CT or MRI findings between the 2 groups except for tuberculomas on MRI, which were significantly higher in the non-bacille Calmette-Guérin vaccinated group (52.2% vs 22.7%, P = .042). Bacille Calmette-Guérin vaccination appears to translate into less tuberculoma formation on MRI.

Calcifying fibrous pseudotumor in association with hyaline vascular type Castleman's disease.

Calcifying fibrous pseudotumor is a recently described rare entity. It is considered as sclerosing end stage of inflammatory myofibroblastic tumor. An association with hyaline vascular type Castleman's disease has also been described. We report a case of a 13-year-old boy who presented with pain in epigastrium. Computed tomography scan of abdomen revealed a circumscribed mass arising from the gastric wall along the greater curvature. Histology revealed a tumor composed of spindle cells present within the dense hyalinized collagenous tissue. Lymphoplasmacytic infiltrate was seen along with lymphoid follicles, dystrophic and ossifying calcification. Tumor cells were focally positive for alpha smooth muscle actin and negative for anaplastic lymphoma kinase protein.

The 'molar tooth sign' in Joubert syndrome.

The molar tooth sign is seen in very few conditions and is a very rare paediatric central nervous system congenital anomaly. Molar tooth sign is the result of cerebellar vermis hypoplasia, thick and maloriented superior cerebellar peduncles, and an abnormally deep interpeduncular fossa. In Joubert syndrome this is seen in about 85% of patients. We present a case of 13 months old baby boy with recurrent episodes of fits and hyperpnoea, regression of milestones and developmental delay. MRI examination showed the characteristic molar tooth sign with apposition of cerebellar hemispheres, batwing-shaped fourth ventricle communicating through a thin fissure with foramen of Magendie, cerebellar vermis agenesis and deep interpeduncular fossa consistent with diagnosis of Joubert syndrome.

Tuberculosis of the scapula.

Tuberculosis (TB) of the scapula is an extremely rare presentation of osteoarticular tuberculosis. In a tuberculosis endemic setting with a rising burden of acquired immunodeficiency syndrome, this rare presentation may become more frequent. The common presentation is with longstanding Complaints of pain and swelling in the shoulder region, typically in young adults. Classic radiographic features include a well defined radiolucent lesion with minimal sequesteration. The erythrocyte sedimentation rate is usually elevated and initially these patients are frequently mis-diagnosed and thus a high index of clinical suspicion is required. Medical therapy with antituberculous drugs is the standard modality of treatment. This case serves to higlight the salient features of scapular TB.

Primary splenic hydatid cyst: a case report with characteristic imaging appearance.

A middle-aged lady presented with pain, tenderness and swelling in the left hypochondrium since one month. She had a history of contact with dogs and grazing animals. Sonography and computed tomography showed the pathognomonic signs of hydatid disease. The patient refused surgical treatment. She was discharged on Albendazole therapy and did not return for a follow up.