Randomized controlled trial of intrapleural streptokinase in empyema thoracis in children.

AIM: To compare intrapleural streptokinase and placebo in paediatric empyema. METHODS: Children with empyema greater than stage 5 received intrapleural streptokinase (n = 19) or normal saline (n = 21) along with intercostal drainage. Clinical and serial sonographic outcomes were compared. RESULTS: Although there was no difference in clinical and sonographic outcome, none of the children with stage 7 empyema (multi-loculated empyema) who received streptokinase developed pleural thickening 30 d later. CONCLUSION: There is no short-term clinical benefit of intrapleural streptokinase in paediatric empyema; this therapy may be reserved for those with stage 7 empyema to prevent pleural thickening in the long term.

An unusual renal malignancy of childhood: unilateral teratoid Wilms's tumor.

Teratoid Wilms's tumor is a rare histologic variant of the classical Wilms's tumor, containing predominantly heterolougus tissues (adipose, glial, muscle, cartilage, or bone). We report an unusual variant of such tumor, which simulated renal teratoma because of abundant fat within the tumor. The child underwent radical excision; postoperatively, he was treated with chemotherapy, and now the child is well at 36 months after surgery. The behavior of this kind of tumor usually is not aggressive, and the outcome is good. Surgery should be the treatment of choice, because the efficacy of chemotherapy and radiotherapy is probably reduced by the high amount of differentiated and mature tissue that characterizes this neoplasm. Radiologic imaging and pathological features of this rare entity are described.

Renal lymphangiomatosis: a rare cause of bilateral nephromegaly.

We report the ultrasound, excretory urography and MR findings in a young child with renal lymphangiomatosis who presented with gradually progressive bilateral flank swelling but who was otherwise asymptomatic. The typical perirenal and parapelvic cysts are visualized as hypoechoic lesions on sonography and hyperintense on T2-weighted HASTE images. T1-weighted image could not delineate the cysts clearly. The renal parenchyma was hyperechoic on sonography, and MRI showed reversal of the normal corticomedullary signal intensity, and confirmed the diagnosis by suggesting the non-parenchymal origin of the cysts.

Hemangioendothelioma of liver and spleen: trauma-induced consumptive coagulopathy.

The case of a 9-year-old boy with hemangioendothelioma of the liver and spleen who presented with consumptive coagulopathy one month after sustaining a blunt trauma to his abdomen is reported. A contrast enhanced computed tomography scan of the abdomen showed a ruptured spleen with multiple lesions in the liver that were enhancing with contrast. On exploration, the child was found to have splenic rupture with multiple vascular lesions of the liver. A splenectomy with liver biopsy was done. The histopathologic examination found that both the liver and spleen had a similar tumor morphology characteristic of an epithelioid and spindle cell hemangioendothelioma. The child ultimately died of relentless consumptive coagulopathy.

Evaluation of the predictors of choledocholithiasis: comparative analysis of clinical, biochemical, radiological, radionuclear, and intraoperative parameters.

This prospective study was performed to assess the predictive ability of the various indicators of common bile duct (CBD) calculi, individually or in combination, by analyzing 88 patients with gallstone disease. The patients were classified into two groups according to the presence of 10 predefined criteria. Of 53 patients with one or more risk factors (group 2), 26 harbored CBD calculi; none of 35 patients with no risk factors (group 1) had CBD stones. Jaundice correlated best, with a sensitivity of 69%; and pancreatitis had the lowest sensitivity (12%). Elevated serum bilirubin and alkaline phosphatase levels correlated better than liver enzymes and serum amylase. The sensitivity and negative predictive value of cholescintigraphy scanning for diagnosing CBD calculi were better than those of ultrasonography, the sensitivity being 84% versus 50% and the negative predictive value 95% versus 82%. Endoscopic retrograde cholangiopancreaticography was successful in 94% of the patients, and CBD calculi were diagnosed in 74%. Moreover, peroperative cholangiography was 100% sensitive with no false-positive results. Ultimately, a palpable stone at surgery was the best predictor. When all the criteria were analyzed, it was found that as the number of criteria increased so did the percentage of patients harboring CBD calculi.

Postasphyxial encephalopathy in preterm neonates.

OBJECTIVE: Perinatal asphyxia is an important determinant of infant neurological outcome. There are very few studies looking exclusively at postasphyxial encephalopathy in preterm neonates. METHODS: We studied the neurologic and sonographic abnormalities in 40 preterm babies with severe birth asphyxia during their hospital stay and till 3 months corrected age. RESULT: 87.5 % of the asphyxiated preterm babies had neonatal neurologic abnormality, compared to only 17% of the control babies (p<0.0001). Generalised hypotonia and reduced activity were the commonest abnormalities (observed in 85% of asphyxiated babies) while depressed sensorium (60%) and seizures (35%) were seen in more severe cases. White matter disease (WMD-including periventricular flare, cerebral edema and periventricular leucomalacia) was significantly more frequent in the study cases (34.5% in study cases vs 7.5% in controls, p<0.0001) as was grade 3/4 intraventricular hemorrhage(IVH) (25% in study cases vs 2.5% in controls, p<0.0001). There was 11 fold higher mortality among the asphyxiated babies (23 deaths in study cases vs 2 in controls, p<0.0001). CONCLUSION: The survivors had a significantly higher incidence of both mild and severe neurological abnormalities at corrected age of 3 months among the asphyxiated babies. There was a good correlation between the severity of the neonatal encephalopathy as well as the sonographic findings and the outcome.

Blunt injury of the abdomen: a plea for CT.

A 3-year-old boy was brought to the emergency unit 1 h following a deceleration injury. On clinical examination there were no signs of injury and US showed only free intraperitoneal fluid. The following morning, contrast-enhanced CT showed the right kidney did not enhance and delayed scans showed contrast medium in the renal vein. This is an indirect sign of post-traumatic renal artery occlusion. Failure to recognise this sign may have disastrous consequences in a patient with solitary kidney or bilateral renal artery occlusion. Contrast-enhanced CT scan remains the most widely available investigation for accurate staging of blunt renal trauma.

The role of ultrasonography in the management of tumors of the neck.

By themselves, clinical examination and palpation do not provide an accurate assessment of metastatic neck nodes. They do not yield sufficient information to ascertain the benign or malignant nature of nodes or to determine the presence of extracapsular spread and vascular invasion. The use of real-time ultrasonography with high-frequency transducers can significantly improve the evaluation of patients with neck masses. We studied the use of ultrasound in evaluating metastatic neck disease in 25 patients. We found that it is useful not only in detecting neck nodes, but in assessing their characteristics and the degree of vascular invasion. We recommend that ultrasonography be routinely performed as part of the evaluation of all patients with head and neck masses. It is also valuable in the postoperative or postirradiation followup of patients whose necks are otherwise difficult to evaluate.

Ultrasound versus physical examination in staging carcinoma of the mobile tongue.

Surgical therapy for early lesions of the tongue should have the potential to be both oncologically sound and easy to rehabilitate. Obviously, the amount of tongue left behind after surgery is proportional to the post-operative function. Hence accurate mapping of the diseased tongue is of paramount importance in order to limit or extend the resection margins. We have evaluated the use of ultrasound in carcinoma of the tongue, and also compared its relative accuracy with physical examination for determining the extent of growth, keeping the histopathological size as a gold standard. We found that ultrasound is more accurate in detecting T2 and T3 tumours than T1 lesions. Intraoral sonographic mapping may be the answer for such small lesions. In addition, ultrasonography is beneficial in showing spread to contiguous areas of the tongue. However, post-radiation fibrosis and frank residual disease were not differentiated accurately by ultrasound. Thus ultrasonography can be an effective investigative tool and together with physical examination it can increase diagnostic accuracy leading to precise surgery for carcinoma of the tongue.

Sonography in pyogenic meningitis.

In this prospective study to evaluate usefulness of ultrasonography for early diagnosis and monitoring of complications of acute pyomeningitis, we performed serial sonographic examinations of skull in 50 infants (with open fontanelle) with proven pyomeningitis. One or more abnormal sonographic findings were detected in 32 infants. These were echogenic sulci (26%), ventriculomegaly with some or other complication (26%), brain abscess (20%), ventriculitis (14%), subdural effusion (6%) and cerebral edema (10%), and were detected mostly after the first week of illness. Ultrasonographic findings were in complete agreement with CT scan diagnosis of ventriculomegaly, ventriculitis, solitary brain abscess and cerebral edema. However, sonography missed cases of subdural effusion (2 out of 5), multiple brain abscesses (1 out of 2), and cerebral infarction (all the four), which were detected on CT Scan. Serial sonographic findings were useful in documenting progressive increase in ventricular size in all the 13 infants with ventriculomegaly and monitoring response to anti-edema therapy in 5 infants with cerebral edema. Sonography is a useful tool for diagnosis of complications of pyomeningitis after the first week of illness, and for monitoring the progress of ventriculomegaly.

Gallbladder varices in portal vein thrombosis.

OBJECTIVE: We performed a prospective study to determine the frequency that gallbladder varices are seen on duplex sonograms of patients with portal vein thrombosis. SUBJECTS AND METHODS: Findings of gallbladder wall varices were sought on duplex Doppler sonograms of 74 patients with portal vein thrombosis. The diagnosis of portal vein obstruction was made on the basis of sonographic or splenoportographic findings. RESULTS: Sonography showed gallbladder varices in 22 (30%) of 74 patients. Varices were defined as anechoic, serpentine areas in the wall of the gallbladder showing venous flow on Doppler imaging. However, no gallbladder varices were detected in six patients who had patent surgical splenorenal shunts. Gallbladder varices did not correlate with the site and extent of portal vein thrombosis, the presence of a spontaneous (natural) splenorenal shunt, or endoscopic obliteration of varices. CONCLUSION: Gallbladder varices are common in patients with portal thrombosis. Awareness of gallbladder varices should increase the surgeon's caution during biliary tract surgery in patients with portal hypertension.

Oesophageal tuberculosis mimicking a tumour during treatment for nodal tuberculosis.

A patient with cervical lymph node tuberculosis developed a tubercular ulcer in the oesophagus eight weeks after starting treatment. This was probably due to a drug related hypersensitivity reaction in an adjacent mediastinal lymph node and subsided with continued treatment.

Clinical & bacteriological profile of neonatal pneumonia.

In a prospective study of 44 neonates (33 outborn and 11 inborn) with pneumonia, the bacteriology of pneumonia was determined by blood culture and serum counterimmunoelectrophoresis (CIEP). Twenty-nine babies also underwent lung aspiration. The lung aspirate was subjected to bacterial culture and CIEP. CIEP was done to detect the bacterial antigens of Streptococcus pneumoniae and Haemophilus influenzae. Absence of tachypnoea, found more commonly in low birth weight babies, was a poor prognostic sign. Low birth weight babies had a significantly higher mortality than babies with normal birth weight. Altogether, a bacterial etiology of neonatal pneumonia could be established in 25 cases (56.7%). In 10 babies, Strep. pneumoniae antigen was detected in serum and/or lung aspirate. Micro-organisms were cultured from blood and/or lung aspirate from 17 babies. Eleven babies (25%) grew Gram negative bacteria. The common bacteria identified in decreasing order of frequency were Strep. pneumoniae, Klebsiella pneumoniae, Staphylococcus epidermidis, Acinatobacter lowfii, Staph. aureus, Pseudoamonas aeruginosa etc. All the Gram negative bacteria as well as staphylococci were sensitive to amikacin while only 23.5 per cent was sensitive to gentamicin. All staphylococci isolated were sensitive to methicillin.

Ultrasound in choledocholithiasis.

Twenty-five patients of obstructive jaundice due to choledocholithiasis, were prospectively evaluated by ultrasonography and cholangiography. Ultrasound could demonstrate choledocholithiasis in 10 patients (40%). Choledocholithiasis in non-dilated ducts could be demonstrated only in one patient. All cases were diagnosed by cholangiography. Ultrasound, though an accepted modality of choice for diagnosing cholelithiasis, has a limited role in the diagnosis of choledocholithiasis. Ultrasonography (USG) is the screening modality of choice to distinguish obstructive from non-obstructive jaundice. It is highly accurate in the diagnosis of cholelithiasis but its role in detection of choledocholithiasis is less clear. Choledocholithiasis complicates 10% of all cases of cholecystitis and occurs in 2-4% of postcholecystectomy patients. The present study deals with the diagnostic value of USG in cases of choledocholithiasis subjected to USG prior to cholangiography and surgery.

Mirizzi syndrome: a rare cause of obstructive jaundice.

Mirizzi syndrome is an uncommon cause of extra-hepatic obstructive jaundice. Gall stones impacted at the neck of gall bladder, causing compression in the common hepatic duct (CHD) was diagnosed on endoscopic retrograde cholangio pancreaticography (ERCP). There was necrosis of the septum between the CHD and gall bladder neck, which was seen at surgery. Cholecystectomy and serosal patch of gall bladder to cover the CHD defect was performed. Patient's management and review of the literature is discussed.