Parainfluenza and influenza virus infections in pediatric organ transplant recipients.

We retrospectively reviewed parainfluenza and influenza virus infections that occurred in pediatric organ transplant recipients at our hospital from January 1985 through September of 1992. Cultures of respiratory specimens revealed 45 infections in 42 transplant recipients (32 cases of parainfluenza and 13 cases of influenza virus infection). The following organs were transplanted: liver (28 patients), small bowel with and without liver (4), heart (3), lung with and without heart (5), and kidney (2). Clinical presentations of the patients and outcomes were similar regardless of the type of virus isolated or the type of organ transplanted. There were 20 cases in which patients had upper respiratory symptoms but did not require supplemental oxygen, nine cases in which patients required oxygen supplementation only, and eight cases in which the patients survived with mechanical ventilation. Eight patients died (five had parainfluenza, three had influenza virus infection); four children had serious concurrent infections (cytomegaloviral pneumonia in one patient, bacteremia in two, bacteremia and pneumonia in one). Factors associated with poor outcome for the entire group were age (increased morbidity and mortality if < 6 months old), augmentation of immunosuppression, and onset of infection within 1 month of transplantation. In this patient population, parainfluenza and influenza infections were important causes of morbidity and mortality.

Hypertrophic osteoarthropathy in a child with follicular bronchiolitis.

Hypertrophic osteoarthropathy (HOA) is a syndrome affecting the bones, soft tissue, and joints, often occurring in association with chronic pulmonary disorders. Radiography has traditionally been the imaging modality employed to confirm this diagnosis. However, radionuclide bone imaging provides a sensitive method for the detection of HOA and correlates well with the clinical manifestations. The authors's describe the case of a child with HOA in association with follicular bronchiolitis, a rare chronic pulmonary disorder, whose HOA was diagnosed by radionuclide imaging.

Transplantation and the pediatric chest.

The plain chest radiograph is the mainstay in the imaging assessment of the chest in a prospective organ recipient and is invaluable in the initial evaluation of posttransplant complications. Although the presence of focal or diffuse air-space disease on a chest radiograph is often nonspecific, this finding helps direct the choice of other diagnostic methods. Among cross-sectional imaging techniques, computed tomography is used most often to further define anatomy and abnormal findings and to guide needle biopsy or aspiration if necessary. A variety of posttransplant complications are discussed, including common postoperative findings, pulmonary infection, and organ rejection.

Telltale signs of congenital heart disease.

There are several key plain film findings that raise suspicion for and aid in the differentiation of congenital heart defects. These 'telltale' signs and their significance and the additional necessary imaging studies of cardiac lesions are discussed with particular emphasis on the role of magnetic resonance imaging.

Posttransplant lymphoproliferative disorder: intrathoracic manifestations.

Posttransplant lymphoproliferative disorder (PTLD) is a serious complication of organ transplantation and immunosuppression. Early diagnosis and treatment greatly affect prognosis. Chest radiographs (n = 13), chest computed tomographic (CT) scans (n = 2), or both (n = 20) from 35 patients with intrathoracic PTLD were retrospectively studied to define the intrathoracic manifestations of this disorder. Intrathoracic abnormalities consisted of pulmonary nodules (16 patients), patchy air-space consolidation (three patients), mediastinal and hilar adenopathy (17 patients), thymic enlargement (two patients), pericardial thickening and/or effusions (two patients), and pleural effusions (four patients). Multiple, well-circumscribed pulmonary nodules with or without mediastinal adenopathy are highly suggestive of PTLD. However, pathologic examination is usually necessary for a definitive diagnosis.

Respiratory syncytial virus infections in pediatric liver transplant recipients.

Respiratory syncytial virus (RSV) is the most important cause of lower respiratory tract infection in infants and young children. The charts of 17 children found to have RSV among 493 children who underwent liver transplantation between February 1985 and February 1991 were reviewed. The median age at diagnosis was 20 months. Median time of diagnosis was 24 days after transplantation. Thirteen patients developed nosocomial infections while convalescing from their transplant. Common symptoms included tachypnea, cough, fever, and congestion. Acute radiographic changes were seen in 12 patients. Two deaths were associated with progressive pulmonary disease and occurred in children with infection early in the postoperative period who were intubated before the onset of symptoms. RSV in children after liver transplantation has a clinical spectrum similar to that in normal children. Early onset of infection (less than 20 days) after transplantation and preexisting lung disease may predict more severe disease.

Radiographic manifestations of anomalies of the gastrointestinal tract.

Congenital anomalies of the gastrointestinal tract can pose serious threats to the health of newborn infants and children. Perhaps nowhere has pediatric surgery had as dramatic an impact as in the care and treatment of these conditions. The pediatric radiologist works closely with the surgeon in evaluating these anomalies in young children. Plain radiographic films and contrast studies have been and remain the first step in studying these anomalies. Newer imaging modalities, however, also have made contributions to the continuing importance of the role of the radiologist in the diagnosis and care of children with these anomalies.

Radiographic manifestations of anomalies of the limbs.

Limb anomalies and their commonly associated organ malformations are increasingly recognized in fetal life because of the use of high resolution real-time sonography. In most instances plain radiography establishes the diagnosis of limb anomalies shortly after birth. In some neonates the diagnosis is tentative until full skeletal maturity is attained. When evaluation of the soft tissues and unmineralized cartilage or ossification center is a prerequisite to early definitive therapy, computed tomography and magnetic resonance imaging are the procedures of choice.

Otitis media and hearing loss in Turner syndrome.

Twenty-two phenotypic females with Turner syndrome underwent prospective otologic evaluation including a standard history, physical examination, audiogram, and tympanogram. Eight of these patients had computed tomography of the temporal bones. Eighty-two percent of the patients had a history of chronic or recurrent ear infections. Eleven patients (50%) had previous myringotomy and tube placement and 4 (16%) had undergone tympanoplasty or tympanomastoidectomy for sequelae of otitis media. Ten patients (45%) had middle ear effusions evident on examination. Sixteen patients (73%) had hearing loss in at least one ear at the time of examination. Sensorineural losses were evident in 37% of patients. No malformations of the otic capsule were noted on computed tomography. The high prevalence of both hearing loss and otitis media in Turner syndrome warrants otologic and audiologic assessment of patients with this chromosomal anomaly.

Disturbances of bone growth and development.

"What is growth anyway? Can one talk about positive growth in childhood, neutral growth in maturity, and negative growth in old age?" Our goal is to help promote normal positive growth in infants and children. To achieve this, we must be cognizant of the morphologic changes of both normal and abnormal bone formation as they are reflected in the radiographic image of the skeleton. The knowledge of the various causes and the pathophysiologic mechanisms of the disturbances of bone growth and development allows us to recognize the early radiographic manifestations. Endocrine and metabolic disorders affect the whole skeleton, but the early changes are best seen in the distal ends of the femurs, where growth rate is most rapid. In skeletal infections and in some vascular injuries two-or three-phase bone scintigraphy supercedes radiography early in the course of the disease. MRI has proved to be very helpful in the early detection of avascular bone necrosis, osteomyelitis, and tumor. Some benign bone tumors and many bone dysplasias have distinct and diagnostic radiographic findings that may preclude further studies. In constitutional diseases of bone, including chromosomal aberrations, skeletal surveys of the patient and all family members together with biochemical and cytogenetic studies are essential for both diagnosis and genetic counseling. Our role is to perform the least invasive and most informative diagnostic imaging modalities that corroborate the biochemical and histologic findings to establish the definitive diagnosis. Unrecognized, misdiagnosed, or improperly treated disturbance of bone growth can result in permanent deformity usually associated with disability.

Comparative effectiveness of amoxicillin and amoxicillin-clavulanate potassium in acute paranasal sinus infections in children: a double-blind, placebo-controlled trial.

This study compared the relative effectiveness of two antimicrobial preparations, amoxicillin and amoxicillin-clavulanate potassium (Augmentin), in the treatment of acute maxillary sinusitis in children 2 to 16 years of age. Of 171 children with persistent (ten to 30 days' duration) nasal discharge or daytime cough or both, 136 (80%) had abnormal maxillary sinus radiographs. These children were stratified by age and severity of symptoms and randomly assigned to receive either amoxicillin, amoxicillin-clavulanate potassium, or placebo. After the exclusion of 28 children with throat cultures positive for group A Streptococcus and 15 who did not complete their medication, the remaining 93 children were evaluated: 30 received amoxicillin, 28 received amoxicillin-clavulanate potassium, and 35 received placebo. Clinical assessment was performed at three and ten days. On each occasion, children treated with an antibiotic were more likely to be cured than children receiving placebo (P less than .01 at three days, P less than .05 at ten days). The overall cure rate was 67% for amoxicillin, 64% for amoxicillin-clavulanate potassium, and 43% for placebo.

Pediatric liver transplantation. Part I. Standardization of preoperative diagnostic imaging.

The preoperative radiologic imaging workups of 44 pediatric liver transplantation patients were reviewed. Biliary atresia (43%) and metabolic disorders (33%) with end-stage liver disease were the leading indications for pediatric liver transplantation at our institution. The radiologic imaging examinations included chest and skeletal radiography, upper gastrointestinal tract series, abdominal ultrasonography (US), computed tomography, angiography, and contrast echocardiography. Abdominal US (performed in 38 of 44 patients) was the pivotal screening imaging examination; it was invaluable in determining the patency and size of the extrahepatic portal vein and inferior vena cava. Angiography is mandatory if this vascular anatomy is not established with certainty on sonograms or if malrotation is seen on the upper gastrointestinal tract series. Congenital malrotation should be differentiated from small bowel malposition caused by portoenterostomy in patients with biliary atresia. Vascular anomalies, especially absent portal vein and/or inferior vena cava, in patients with biliary atresia and polysplenia syndrome may preclude liver transplantation.

Pediatric liver transplantation. Part II. Diagnostic imaging in postoperative management.

The postoperative diagnostic imaging examinations of 44 children who underwent 59 orthotopic liver transplantations were reviewed. The imaging modalities used for the evaluation of suspected complications include plain roentgenography, ultrasonography (US), computed tomography (CT), nuclear scintigraphy, arteriography, percutaneous and operative cholangiography, and endoscopic retrograde cholangiopancreatography. The main postoperative complications included ischemia, thrombosis (hepatic artery and portal vein), infarction, obstruction or leakage of the biliary anastomosis, hepatic and perihepatic infection, and allograft rejection. US, the most frequently used abdominal imaging modality, was best suited for detection of biliary duct dilatation, fluid collections in or around the transplanted liver, and hepatic arterial, inferior vena caval, and portal vein thrombosis. CT was especially helpful in corroborating findings of infection and in locating abscesses. Technetium 99m sulfur colloid (early- and late-phase imaging) provided a sensitive, although nonspecific, means of assessing allograft vascularization and morphology. Angiography showed vascularity most clearly, and cholangiography was the most useful in the assessment of bile duct patency. A diagnostic imaging algorithm is proposed for evaluation of suspected complications.

Maxillary sinus radiographs in children with nonrespiratory complaints.

An attempt was made to determine the frequency of abnormal maxillary sinus radiographs in a group of unselected children having diagnostic skull radiographs performed for indications unrelated to respiratory infection. An occipitomental, or Water's, view was obtained in every case in order to evaluate the maxillary sinuses. Prior to performance of the radiographs, a history of recent respiratory symptoms was obtained and a physical examination of the ears, nose, and throat was performed. An abnormal maxillary sinus radiograph was defined as one that revealed an air-fluid level, partial or complete opacification, or mucous membrane thickening of 4 mm or greater. Fifty-nine (53%) of 112 presumably "normal" children had evidence of recent respiratory inflammation by history or at physical examination. In 50 subjects less than 1 year of age, abnormal maxillary sinus radiographs were common, irrespective of respiratory symptoms and signs. In contrast, eight of 14 children (57%) aged 1 to 16 years with both symptoms and signs of respiratory inflammation had abnormal maxillary radiographs, compared with only two of 31 children (7%) with neither symptoms nor signs (P less than .005). Crying alone was not associated with abnormal radiographs in the older age group. In children more than 1 year of age, abnormal maxillary sinus radiographs are infrequent and are generally related to inflammation of the upper respiratory tract.

Treatment of acute maxillary sinusitis in childhood: a comparative study of amoxicillin and cefaclor.

Maxillary sinus aspiration and quantitative culture of the aspirate were performed in 50 patients, ranging in age from 1 to 16 years, with clinical and radiographic evidence of acute sinusitis. Of 79 sinuses aspirated, at least one was found to be infected in 35 (70%) children. Streptococcus pneumoniae, Branhamella catarrhalis, and Haemophilus influenzae were the most common organisms recovered. All H. influenzae were nontypeable. Twenty percent of the H. influenzae and 27% of the B. catarrhalis organisms were beta-lactamase positive and amoxicillin resistant. The subjects received either amoxicillin or cefaclor at a dose of 40 mg/kg/day in three doses for 10 days. The clinical cure rate with amoxicillin was 81%, compared to 78% with cefaclor. Radiographic improvement was similar in both treatment groups. Antibiotic therapy failed in four patients; three had been given amoxicillin, and one cefaclor. In three of these, a beta-lactamase-positive antibiotic-resistant bacterial species was recovered from the maxillary sinus aspirate; the fourth aspirate was sterile.

Plain radiographic, nuclear medicine and angiographic observations of hepatogenic pulmonary angiodysplasia.

Clinical and radiological findings of hepatogenic pulmonary angiodysplasia are reported in two cases. Myriad spidery pulmonary blood vessels are seen on plain radiographs and verified with right to left intrapulmonary shunting on pulmonary angiogram and pulmonary isotopic perfusion scan. Pathophysiology and differential diagnosis are discussed. We propose that the term "pulmonary angio-dysplasia" should include: 1) Pulmonary telangiectasia 2) Hereditary hemorrhagic telangiectasia (Osler-Rendu-Weber syndrome) 3) Classical discrete pulmonary arteriovenous fistula 4) Hepatogenic pulmonary angiodysplasia: pulmonary arteriovenous communications with right to left shunting secondary to hepatic cirrhosis.