Ultrasound-guided aspiration in addition to antibiotics for treatment of liver abscess in children: A randomized controlled trial.

BACKGROUND AND AIM: The criteria for aspiration for pediatric liver abscess are unclear. In this randomized controlled trial, we evaluated the efficacy of ultrasound-guided needle aspiration in addition to antibiotics in children with uncomplicated liver abscess. METHODS: We enrolled 110 children aged 1-18 years (mean [SD] = 7.7 [3.7] years) with uncomplicated liver abscess. The primary outcome was clinical cure at 6 weeks (absence of fever and abdominal pain in the preceding 14 days with reduction in abscess size on ultrasonography). The secondary outcomes were clinical response at 4 weeks, fever resolution time, time to abdominal pain reduction and abdominal tenderness, duration of hospitalization, and treatment failure. RESULTS: Clinical cure at 6 weeks was not significantly different (48/50 [96%] vs 39/46 [85%]; P = 0.082) between aspiration plus antibiotics group and antibiotics only group. The clinical response at 4 weeks was also comparable (49/50 [98%] vs 43/46 [93.5%]; P = 0.347). The mean (SD) of fever resolution time was significantly less in the aspiration plus antibiotics group (198 [90.8] h vs 248.2 [104.6] h; P = 0.014). Time to achieve reduction in abdominal pain (8.32 [3.1] vs 9.46 [3.1] days; P = 0.077) and abdominal tenderness (5.7 [2.4] vs 6.3 [2.3] days; P = 0.242), duration of hospitalization (16.6 [3.9] vs 18.2 [4.4] days; P = 0.07), and adverse event profile (9/50 [18%] vs 14/46 [30%]; P = 0.217) were comparable between the two groups. CONCLUSION: Majority of children with uncomplicated liver abscess achieved clinical cure at 6 weeks with intravenous antibiotics, irrespective of aspiration. However, needle aspiration may slightly reduce the duration of fever and abdominal pain/abdominal tenderness.

Twice Weekly Vs. Thrice Weekly Low-Dose Prophylactic Factor VIII Therapy in Children with Hemophilia A: An Open Label Randomized Trial.

INTRODUCTION: Low dose factor VIII prophylactic therapy in hemophilia has not been well established till date. This randomized controlled trial compared the efficacy of twice vs. thrice weekly schedule of low dose prophylactic factor VIII in children with hemophilia A as evaluated by the bleeding rate and clinico-radiological evaluation. METHODS: Thirty-three children with severe hemophilia A (≤18 years) were randomized into two groups. Baseline evaluation included detailed history, clinical (HJHS 2.1 score and FISH score) and radiological examination (Pettersson score and ultrasound score). Group 1 received twice weekly factor VIII prophylaxis while group 2 received thrice weekly factor VIII prophylaxis, the dose being 10 U/kg in both groups. All participants were followed up over next 6 months to one year. Data regarding acute bleeding episodes and repeat clinico-radiological assessment at the end of follow up were recorded. RESULTS: We analyzed 14 children in twice weekly prophylaxis group and 16 children in thrice weekly prophylaxis group. Statistically insignificant difference was found between the bleeding rates in both the groups after prophylaxis with the median values of monthly bleeding rate being 0.17 and p-value of 0.79. The differences between the initial and final clinical and radiological scores within each group were found to be statistically significant. There was no significant difference in the clinical and radiological scores in between the groups. CONCLUSION: Twice weekly FVIII therapy is effective, easily administered prophylactic schedule to prevent long-term complications of hemophilia A. Lay summaryHemophilia A is one of the most common congenital coagulation factor deficiencies. Low dose factor VIII prophylaxis is recommended for hemophilia in resource-poor settings to reduce the bleeding episodes and improve the quality of life, although the optimal schedule for the same has not been well established. A randomized controlled trial on 33 children with hemophilia A (≤18 years) was done to compare the efficacy of twice versus thrice weekly schedule of prophylactic factor VIII. Group 1 received twice weekly factor VIII prophylaxis while group 2 received thrice weekly factor VIII prophylaxis, the dose in both groups being 10 U/kg. They were evaluated by the bleeding rate and clinical (HJHS 2.1 score and FISH score) and radiological scores (Pettersson score and ultrasound score). All participants were followed up over next 6 months to one year. Data regarding acute bleeding episodes and repeat clinico-radiological assessment at end of follow up were recorded. When analyzed, statistically insignificant difference was found between the bleeding rates after the two prophylaxis regimes. There was a significant improvement between initial and final clinical and radiological scores in both the groups and no difference was recorded in between the groups. To conclude, twice weekly FVIII therapy is effective, easily administered prophylactic schedule to prevent long-term complications of hemophilia A.

Evaluation of frozen section biopsy for fast track diagnosis of endometrial pathology in high-risk women with abnormal uterine bleeding.

OBJECTIVE: To study the accuracy of frozen section biopsy for endometrial pathology in high-risk women with abnormal uterine bleeding (AUB). STUDY DESIGN: A case-control study was conducted between November 2017 to April 2019, a total of 150 women with postmenopausal bleeding, perimenopausal AUB, and high-risk women of age < 40 years with AUB were recruited. All women underwent transvaginal sonography and Doppler, based on age-appropriate endometrial thickness cut-offs 80 women then underwent hysteroscopy. Based on hysteroscopy, women suspicious of malignancy were taken as cases (n = 40) and those with benign findings as controls (n = 40). All cases and controls underwent dilatation and curettage (D & C) with frozen section (FS) and routine histopathology. RESULTS: The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR), negative LR, and overall test accuracy of FS were 90.9%, 93.19%, 83.33%, 96.19%, 13.8, 0.1 and 86.25% respectively for diagnosing endometrial hyperplasia and cancer taking histopathology as the gold standard. Correlation between frozen section biopsy and histopathology was highly significant (p < 0.001) on D & C specimens and the level of agreement was good (K = 0.778). CONCLUSION: In women suspicious of malignancy on hysteroscopy, frozen section has high accuracy on D&C specimen and can be used to diagnose endometrial hyperplasia and cancer in an effort to fast-track investigations and work-up for definitive treatment while awaiting final histopathology.

Can lung ultrasound differentiate between bacterial and viral pneumonia in children?

PURPOSE: This study evaluates whether LUS can differentiate between bacterial and viral pneumonia in children and thus affect their management. METHODS: The prospective, cross-sectional, analytical study included 200 children under 12 years of age (excluding neonates) with clinical suspicion of pneumonia who had undergone a chest radiograph (CR). The CR and LUS findings were classified as bacterial or viral pneumonia. The final diagnosis was made on the basis of a combination of clinical profile, available routine laboratory investigations and CR diagnosis which was taken as the gold standard for the study and LUS was compared with the gold standard. RESULTS: LUS has a high sensitivity (91%; 95% CI [84-96]) and specificity (91.3%; 95% CI [84-96]) in diagnosing bacterial pneumonia with a high positive predictive value (91.9%; 95% CI [85-96]) and negative predictive value (90.3%; 95% CI [82-95]). For diagnosing viral pneumonia, the sensitivity of LUS was 78.4%; (95% CI [68-86]), specificity was high (90.4%; 95% CI [83-95]) and so was the positive predictive value (87.3%; 95% CI [78-94]) and negative predictive value (91.3%; 95% CI [84-96]). CONCLUSION: LUS has a high accuracy in differentiating between bacterial and viral pneumonia in children and can help in their management by avoiding an ill-advised use of antibiotic therapy.

Evaluation of Healed Status in Tuberculosis of Spine by Fluorodeoxyglucose-positron Emission Tomography/Computed Tomography and Contrast Magnetic Resonance Imaging.

BACKGROUND: The healed status (end-point of treatment) in tuberculosis (TB) spine is not defined; hence optimum antitubercular therapy (ATT) duration is unresolved. We, for the first time, prospectively evaluated the healed status in TB spine by fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) and contrast magnetic resonance imaging (MRI) with the objective to define end-point of treatment in TB spine. MATERIALS AND METHODS: Thirty seven patients of TB spine diagnosed on clinicoradio imaging/cytology/histologically/molecular methods were enrolled, treated and were evaluated radiologically, by contrast MRI and FDG-PET/CT at 9 months. ATT was stopped on contrast MRI-based healing or absence of FDG uptake on PET-CT. ATT was continued in active/resolving lesion. Repeat evaluation was done at 12, 18, 24, and 30 months till healing is demonstrated. In this research work, we got contrast MRI and FDG-PET/CT done for the patients from government institution free of cost, so patients did not have to bear the burden of cost of these investigations. RESULTS: Twenty-eight patients achieved healed status out of which 11 demonstrated healed status on contrast MRI and FDG-PET/CT both, 6 were MRI active (contrast enhancement) but FDG-PET/CT healed, 2 were MRI healed but FDG-PET/CT active (soft-tissue standardized uptake value <2.0), 9 patients were MRI incompatible due to stainless steel implants (n = 6), and in 3 patients MRI could not be done due to financial constraints and were declared healed on FDG-PET/CT. FDG-PET/CT showed healed bone lesion in 28/28 (100%) and on MRI 13/19 (68.42%), respectively. We had 6 patients whose spine was stabilized with stainless steel implants where MRI could not be performed, MRI was useful in 13/25 cases (52%) to demonstrate healed lesion. 7, 6, 6, 5, 1, 2, and 1 cases achieved healed status at 9, 12, 18, 24, 30, 36, and 48 months of ATT intake, respectively. CONCLUSIONS: FDG-PET/CT is more useful to demonstrate the healed status than MRI and is the only imaging to demonstrate healed status when MRI could not be performed due to metallic implants. All patients achieved healed status at variable length of ATT intake; hence TB spine should be treated by ATT till healed status (end-point of treatment) is demonstrated by FDG-PET/CT (absence of FDG uptake) or contrast MRI.

Optimal Utilization of Pediatric Computed Tomography to Minimize Radiation Exposure: What the Clinician Must Know s.

The number of computed tomography (CT) scans being done for children all over the world is on the rise ever since the advent of Multi-Detector CT (MDCT). However, CT is a potential source of harmful ionizing radiation, and children are more susceptible to its adverse effects. It is essential for the pediatrician as well as the radiologist to be aware of some important principles and guidelines, by following which, radiation exposure to the child can be minimized to the bare essential. It is important to have knowledge of the valid and justifiable indications of CT for the child, the correct technique of performing the scan, and the new technological innovations now available on modern scanners that help to minimize radiation dose.

Spectrum of Radiological Manifestations in Lymphoproliferative Malignancies with Unusual Extra Nodal Soft Tissue Involvement.

Lymphoproliferative malignancies constitute a wide spectrum of haematological malignancies and their prevalence is widely increasing. Non-Hodgkin lymphomas and Hodgkin disease, frequently involve extranodal soft tissue structures in the head and neck, thorax and abdomen. These malignancies may involve virtually any type of soft tissues to any extent; hence many different imaging manifestations are possible which may mimic other disorders. The imaging characteristics of extranodal lymphomatous soft tissue involvement are described and classified here according to the site of involvement in 6 cases (primary diseases with orbital, muscle, extra testicular, scalp, sinonasal and pachymeningeal/dural involvement). In majority of these cases at presentation we found a predominantly homogeneous soft tissue mass with mildly high attenuation on CT and a T2 intermediate signal on MRI at these sites without any manifestation of disease elsewhere but on follow-up two out of these six cases developed systemic disease elsewhere. Few consistent patterns were noticed on CT and MRI which might help to include lymphomas as an important differential diagnosis of soft tissue masses. Though a definitive diagnosis requires a biopsy (bone marrow, lymph node, or mass), and other laboratory tests, imaging primarily aims at staging of the disease and identification of new or recurrent disease.

Extensive osteolytic skull base amyloidoma simulating malignancy: A rare pseudotumor producing a diagnostic dilemma.

Although amyloidomas are quite well-known, intracranial, and especially skull base lesions have been rarely reported. Extensive lesions in the skull base frequently simulate malignancy clinicoradiologically. Diagnosis of these lesions is important as they offer a favorable prognosis. We describe a large infiltrating osteolytic skull base tumor-like lesion in a 45-year-old male without evidence of associated plasma cell dyscrasia. Squash smears and histopathology revealed a plasma cell-rich lesion with abundant amyloid, confirming amyloidoma. To conclude, amyloidoma of the skull base is a rare tumor-like lesion, with timely diagnosis and management offering a good prognosis.

Choledochal cyst of the cystic duct: Report of imaging findings in three cases and review of literature.

The choledochal cysts, which refer to the cystic dilatation of the biliary duct, are rare lesions generally seen in children. Choledochal cyst of the cystic duct is an uncommon entity. Often, it is associated with the choledochal cyst of the rest of the biliary tree. Isolated cystic duct choledochal cyst is quite rare. Most of these lesions have been recognized only on surgery. Modern cross-sectional imaging methods have facilitated preoperative recognition and characterization of cystic duct cyst enabling formulation of appropriate management strategy. We report the imaging findings in three cases of choledochal cyst involving the cystic duct. All these cases were correctly diagnosed preoperatively. A review of cases reported in the literature and the role of imaging in guiding the management are also presented.

High resolution computed tomography in stapedial otosclerosis.

The value of high-resolution CT scanning in diagnosing stapedial otosclerosis and in influencing surgical planning was studied. 40 cases, consisting of patients of both genders, above the age of 14 years, with a clinical diagnosis of otosclerosis underwent HRCT of the temporal bones. Images were acquired in axial plane, with a bone algorithm, keeping slice thickness at 0.5 mm and intervals of 0.5 mm. Reconstruction of the volume data set was done to obtain overlapping slices in various planes, so as to obtain the best possible images of the footplate of stapes. The thickness of the footplate was measured and the site of lesion was noted in these images. On exploratory tympanotomy, the footplate was assessed and graded according to a visual scale. HRCT was able to diagnose stapedial otosclerosis in 85% ears. It was able to identify the presence of a thickened footplate correctly with a sensitivity of 85.3% (P value 0.16). It was able to correctly localize the site of otosclerotic focus in 85% cases (P value <0.01). Thus, an estimate of the thickness of the footplate likely to be encountered and thus the amount of drilling likely to be required to create a fenestra; and the likely site of maximum thickness could be made pre-operatively. This study also established the value of multislice CT on the acquisition of such data. This method obviates the requirement of difficult patient positioning, reduces scanning time; while greatly improving the sensitivity of the scanning.

Gastrointestinal stromal tumors (GISTs): an imaging perspective.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Computed tomography is the imaging modality of choice for diagnosing GIST. The aim of this retrospective study was to review the imaging features of 22 GIST cases. We also describe the clinical and pathological findings of this well-recognized entity.

Imaging of pancreatic serous cystadenocarcinoma.

Serous cystadenocarcinoma of the pancreas is a rare but well-established entity. The origin of this disorder is speculative, and its evolution remains unclear. On imaging, the malignant behavior of the tumor is best supported by local invasion and/or distant metastasis. The histological characteristics of serous cystadenocarcinoma are indistinguishable from those of its benign counterpart, making the presence of invasion the sole criterion distinguishing the two. The prognosis is excellent even in the face of metastatic disease. We report a case of serous cystadenocarcinoma complicated by recurrent acute and chronic pancreatitis. Initially, no sign of malignancy was seen on imaging. Follow-up study revealed its malignant nature in the form of increased size, presence of duodenal invasion, and multiple liver metastases. The patient underwent Whipple resection with a jejunal Roux-en-Y conduit and microwave coagulonecrotic therapy for metastatic liver lesions. Histopathological examination of the resected specimen revealed a locally invasive cystadenocarcinoma with metastatic disease. One year afterward, the patient is alive with no evidence of progression.

Case report: Filariasis presenting as an intra-abdominal cyst.

Filariasis is an endemic infection seen in the tropical and subtropical regions of the world, presenting with lymphatic dysfunction in the form of lymphocele, hydrocele, chyluria, or groin lymphadenovarix. We report a rare presentation of filariasis as an intra-abdominal cystic mass.

Intramuscular vascular malformation of the masseter muscle presenting with turkey wattle sign.

Intramuscular vascular malformations are unusual tumors in the head and neck region. Less than 1% of vasoformative tumors throughout the body occur in skeletal muscle; 15% of them arise in head and neck musculature. Masseter muscle is the most frequent site for such vascular malformations; it accounts for approximately 5% of all intramuscular vascular malformations in the head and neck region. A case of unusual intramuscular vascular malformation of masseter muscle is described and the diagnosis and management of these tumors is discussed.

Umbilicobiliary fistula in a neonate.

We describe a unique case of congenital umbilicobiliary fistula. A full-term neonate presented with passage of bile through the umbilicus. A contrast study demonstrated communication with the intrahepatic biliary system.

Tuberculous gastric perforation: report of a case.

A 21-year-old woman presented with a 2-day history of acute abdominal pain. Contrast-enhanced computed tomography (CT) showed a perforation in the lesser curve of the stomach. The patient suffered a bout of hematemesis, following which an endoscopy showed a bleeding blood vessel at the edge of the perforation. We performed an emergency distal gastrectomy, including the ulcer site. Histopathological examination revealed tuberculous granulation tissue and acid-fast bacilli in the ulcer. The patient was given antituberculosis therapy (ATT) postoperatively, and was well when last seen 1 year 5 months after surgery. We analyzed the clinical data of five cases of tuberculous gastric perforation (TGP), reported between 1948 and 2003, including our patient. The patients ranged in age from 21 to 45 years, with a mean age of 36.8 years (SD +/- 10.21), and a male to female ratio of 3 : 2. The diagnosis was confirmed by surgery or autopsy. Abdominal lymphadenopathy was present in all patients. Gastrectomy was performed in four patients, and two were given ATT. All four patients in the previous reports died of their disease.