Acute interstitial nephritis secondary to infectious mononucleosis.

Renal involvement in infectious mononucleosis (IM) is infrequent. In most cases it is self-limited and is rarely associated with loss of renal function. The purpose of this case report is to document a case of acute interstitial nephritis (AIN) leading to acute renal failure (ARF) in a patient with Epstein-Barr virus (EBV) infection and to review literature of EBV infection and its renal manifestation. The patient was managed with hemodialysis and steroids and made an uneventful recovery. Renal involvement in IM may be more common than generally appreciated and may occasionally lead to ARF. Therapy with corticosteroids may have role in the management of IM-induced ARF and may shorten the duration of renal failure.

Transcatheter intraarterial infusion of rt-PA for acute lower limb ischemia: results and complications.

PURPOSE: To determine the success and complication rates of intraarterial recombinant tissue-type plasminogen activator (rt-PA) infusion for the treatment of acute lower extremity artery and bypass graft occlusions. MATERIALS AND METHODS: The results of 74 limbs in 70 patients (mean age, 66 y) treated with catheter-directed rt-PA infusion for the treatment of acute lower extremity ischemia were retrospectively evaluated. The group included 42 bypass grafts and 32 native arteries. All limbs were viable at presentation. The mean duration of symptoms was 11.9 days. rt-PA was infused for a mean of 27.9 hours for a mean total dose of 38.7 mg. Initial infusion rates of 3-6 mg/h were lowered to a preferred rate of 1.5 mg/h. Thrombolytic success was defined as 95% thrombolysis of an occluded segment with return of antegrade flow. Major bleeding complications were defined as any hemorrhagic event leading to surgery, extended or unexpected hospitalization, transfusion, death, intracranial hemorrhage, or a decrease in hemoglobin of 5 g/dL or in hematocrit of 15%. Thirty-day mortality and amputation rates were calculated. Patient characteristics and infusion parameters were evaluated as to whether they contributed to thrombolytic success or major bleeding events. RESULTS: Thrombolytic success was achieved in 64 limbs (86%). Major bleeding complications occurred in 33 (47%) patients. In 22 of these patients, bleeding occurred at a vascular puncture site, whereas remote bleeding occurred in seven patients. Remote bleeding complications included two retroperitoneal hematomas, two rectus sheath hematomas, one lower gastrointestinal hemorrhage, one episode of hemoptysis, and one dehiscence of a femoral-popliteal bypass graft revision. No parameters were found to be predictive of thrombolytic success, whereas a negative history of smoking, increasing duration of infusion, and a low preprocedural ankle-brachial index (ABI) were found to be associated with major hemorrhagic events. Four patients (6%) underwent amputation and one patient (1%) died, resulting in a 30-day amputation-free survival rate of 93%. CONCLUSION: Catheter-directed rt-PA infusion is effective in achieving thrombolysis. Despite a significant number of bleeding complications, 30-day mortality and amputation rates were favorable. Nonetheless, complication rates related to bleeding were not trivial and further evaluation with use of variable dosing regimens is indicated.

Percutaneous transthoracic needle biopsy of the lung: review of 612 lesions.

PURPOSE: The results and complications of 651 pulmonary fine-needle aspiration biopsies (FNABs) were reviewed. The number of needle passes and needle size were correlated to pneumothorax and chest tube placement rates. MATERIALS AND METHODS: FNAB of the lung was performed on 651 occasions in 612 patients with 18- to 22-gauge Franseen needles. Diagnostic rates were calculated. The number of needle passes performed and needle size used were evaluated for their association with pneumothorax and subsequent chest tube placement. RESULTS: Diagnostic accuracy was 94% with sensitivity for malignancy of 95%. Positive and negative predictive values were 99.5% and 90%, respectively. Pneumothorax occurred in 26.9% of patients with 9.2% requiring chest tube placement. Increasing numbers of needle passes and larger needle sizes did not increase the rates of pneumothorax or chest tube placement. CONCLUSIONS: FNAB of the lung has excellent diagnostic rates and remains the procedure of choice for diagnosing pulmonary lesions. This large study contradicts perceptions that pneumothorax and chest tube placement rates decrease with thinner needles and fewer passes.

Reversal of insulin-dependent diabetes mellitus after percutaneous pancreatic pseudocyst drainage.

A 75-year-old man achieved complete reversal of insulin-dependent diabetes mellitus after percutaneous, computed tomography-guided, pancreatic pseudocyst drainage. This reversal is believed to have resulted from removal of physiologic stress after drainage. This and previously reported cases of new-onset diabetes following this procedure suggest close serum glucose monitoring in all patients undergoing percutaneous pancreatic pseudocyst drainage.

Complications of laparoscopic cholecystectomy and their interventional radiologic management.

Cholelithiasis and cholecystitis are encountered throughout the world and are responsible for the majority of cholecystectomies performed. Treatment has traditionally consisted of open cholecystectomy, but laparoscopic cholecystectomy is currently a popular alternative. Laparoscopic cholecystectomy offers several benefits over the open procedure, but it also has its own set of complications. Complications include those of laparoscopy (abdominal wall bleeding, omental bleeding, abdominal vessel injury, retroperitoneal vessel injury, gastrointestinal perforation, bladder perforation, solid visceral injury, and infection) and those of cholecystectomy (gallbladder fossa bleeding, bile duct injury, bile leakage, and infection). The literature suggests that the total complication rate for the laparoscopic procedure compares favorably with that of the open procedure, but this may apply only to surgeons who have accomplished numerous laparoscopic procedures and not to those who have just completed a training course and are performing their first few procedures. With the growing success of the laparoscopic procedure, it is essential that the radiologist be knowledgeable about the radiographic manifestations and interventional radiologic management of potential complications, since the radiologist can significantly affect patient care.

Renal pseudotumor due to aberrant renal capsular artery supplying normal spleen.

A renal pseudotumor caused by a small portion of normal spleen receiving blood supply from a renal capsular artery is described. CT with nonselective enhancement and liver/spleen scan may fail to delineate this previously unreported finding. CT angiography, however, can establish the diagnosis. The consideration of this situation in the differential diagnosis may help avoid costly additional workup.

Adrenal pseudomasses due to varices: angiographic-CT-MRI-pathologic correlations.

Periadrenal and adrenal portosystemic collaterals are a recently reported cause of adrenal pseudotumor on computed tomography (CT). Nine patients with this left adrenal pseudotumor illustrate its typical position and appearance on CT, angiography, CT-angiography, and magnetic resonance imaging (MRI). The anatomic basis for variceal adrenal pseudotumors is the left inferior phrenic vein, which passes immediately anterior to the left adrenal gland and which serves as a collateral pathway from splenic to left renal vein in portal hypertension. Thus, unlike previously described adrenal pseudotumors, these venous collaterals are not anatomically distinguishable from the adrenal gland on CT. Bolus dynamic CT is usually diagnostic, but in equivocal cases, MRI may prove useful.

Transcatheter embolization with sodium tetradecyl sulfate. Experimental and clinical results.

Sodium tetradecyl sulfate (Sotradecol), which has been employed for sclerotherapy of varicose veins, was evaluated in dogs and humans as an agent for selective arterial embolization. In dogs, intraarterial injection of Sotradecol 3% into the proximally occluded renal, hepatic, splenic, and deep femoral arteries produced arterial occlusion and tissue destruction. Transcatheter embolization with Sotradecol was performed in 11 patients and was successful in 10; in the remaining patient, failure was attributed to rapid dilution by unobstructed blood flow in arteriovenous malformations of the neck. The authors conclude that Sotradecol is a safe and efficient agent for selective arterial embolization.

Venous involvement in islet cell tumors of the pancreas.

Peripancreatic venous abnormalities were demonstrated angiographically in 10 patients with islet cell tumor: six nonfunctioning, two gastrin-producing, one glucagon-producing, and one pancreatic polypeptide-producing. Venous involvement recognized included venous occlusion, venous encasement, and intraportal tumor growth. Seven patients had islet cell carcinoma with hepatic metastases while the other three had benign tumors. Three patients had arteriographic evidence of intraportal tumor growth with the "thread and streaks" sign, similar to that of portal venous extension of hepatocellular carcinoma.

Angiographic patterns of involvement in renal and perirenal lymphoma.

Ten patients with renal lymphoma studied by selective angiography are reported. Seven patients had unilateral and 3 had bilateral involvement. A localized mass was seen in 6 patients and diffuse infiltration in 3. In 1 patient with bilateral nodular involvement, the angiographic findings resembled those of adult-type polycystic kidney disease. In all cases, renal lymphoma was suspected angiographically. The findings included hypovascular mass or masses with fine neovascularity, smooth and diffuse arterial encasement, and faint tumor staining.

Computed tomography of renal infarction: clinical and experimental observations.

Acute renal infarction is rarely diagnosed before death despite fairly characteristic clinical and radiographic features. Definitive radiologic diagnosis of renal infarction often requires invasive procedures such as retrograde pyelography and angiography. The characteristic CT findings in three patients with proven renal infarction are reported. In these patients a CT rim sign was seen: a higher-attenuation subcapsular rim surrounded renal parenchyma of lower attenuation on contrast-enhanced scans. The appearance of renal infarction varies with both the extent and age of infarction. To assess these variables, segmental, major, and total renal infarcts were created in a series of six dogs; CT scans were obtained within 2 hr after infarction, and 1, 2, 4, and 8 weeks later. In all animals the ischemic and subsequently infarcted areas were seen on the initial examination as regions of low attenuation compared to the enhanced kidney. The low-attenuation areas markedly diminished by 2 weeks after infarction. CT should be useful in the prompt and noninvasive diagnosis of renal infarction.

Renal artery occlusion and infarction with Sotradecol.

Sodium tetradecyl sulfate 3% (Sotradecol) was perfused into a proximally obstructed renal artery in ten random-source adult dogs. In all animals, the intra-arterial injections of Sotradecol produced immediate thrombosis of the renal arteries. Angiographic studies, lasting up to ten weeks, on eight dogs demonstrated persistent occlusion. In one dog, unintentional thrombosis occurred in the opposite renal artery due to reflux of Sotradecol. Histopathologic studies showed total obliteration of the renal arteries through organized thrombosis, intimal sclerosis, and luminal collapse. In all dogs, the kidneys were not visible, and diffuse renal infarction was confirmed by histologic studies of five dogs.

Relative accuracy of two diagnostic schemes for detection of pulmonary embolism by ventilation-perfusion scintigraphy.

Two diagnostic schemes for detection of pulmonary embolism by ventilation-perfusion (V-P) scintigraphy were compared for relative accuracy by two groups of observers interpreting 70 V-P scintiscans. Observers in Group B, who used the criteria recently proposed by Biello et al., had a significantly smaller average number of "indeterminate" interpretations (41%) than did the observers in Group A (55%), who used a simpler scheme (p less than 0.05). In addition, Group B showed a slight improvement in positive predictive value without a deterioration in the negative predictive value compared with Group A. Along with this improvement in diagnostic performance, Group B achieved a significant reduction in interobserver variability compared with Group A for patients without pulmonary embolism (p less than 0.05). There was no significant difference in interobserver variability between the two groups for patients with pulmonary embolism. The diagnostic scheme introduced by Biello et al. represents a useful improvement for the diagnosis of pulmonary embolism by V-P imaging.

Angiographic nephrectomy using iodinated contrast agent.

Diatrizoate meglumine and sodium (Renografin-76) was perfused in an obstructed renal artery in 13 dogs. Intense and prolonged accumulation of contrast agent ("contrast staining") was achieved in all animals. Repeat injection was frequently necessary to enhance staining. Renin output from the stained kidneys was lower than that from the opposite kidneys. Angiography at 14-18 weeks demonstrated a marked decrease in renal size in all dogs, with complete occlusion of the renal artery in two dogs. No collateral circulation was discerned. Grossly, all experimental kidneys were uniformly shrunken. Histologically, diffuse renal infarction was evident with coagulative necrosis. Contrast staining is an effective method for uniform destruction of renal tissue.

Localization of the source of hyperinsulinism: percutaneous transhepatic portal and pancreatic vein catheterization with hormone assay.

Insulin concentrations were measured in the portal venous system through the percutaneous transhepatic approach in 12 patients with organic hyperinsulinism. Single insulinomas were found in 10, an adenoma and islet cell hyperplasia in one, and nesidioblastosis in one patient. Angiography localized adenomas in two. Local step-ups of insulin levels in the portal venous system, found in all patients with insulinomas, corresponded to tumor sites at surgery. Multiple step-ups were found in the portal venous system of the patient with nesidioblastosis and the patient with an adenoma with islet cell hyperplasia. Three tumors were localized in the head of the pancreas which would indicate the primary surgical approach rather than blind resection of the body and tail. Three of the 10 adenomas were not identifiable by palpation after pancreatic mobilization during surgery. In all patients, organic hyperinsulinism was cured after surgery. Percutaneous transhepatic portal and pancreatic vein catheterization with measurement of radioimmunoactive insulin concentrations is a safe and reliable method and may play an important role in the localization of adenomas in patients with normal angiographic studies and previous negative surgical explorations.

Further observations on the arthropathy of calcium pyrophosphate crystal deposition disease.

The arthropathy of calcium pyrophosphate dihydrate (CPPD) crystal deposition disease is distinctive and may affect lumbar spinal and sacroiliac joints, as well as appendicular joints. Subchondral pseudocysts that are a hallmark of the disease have a variable appearance, but often occur as a typical cluster of subchondral, coalescent lucencies with smudged, sclerotic margins. Structural joint collapse with fragmentation of cartilage and bone may occur and appear to be related, at least in some cases, to antecedent pseudocysts. Characteristic intra-articular osteochondral bodies are often extensive and may affect multiple joints; their pathogenesis is discussed. Articular synovial calcification is common and may be due to calcium hydroxyapatite, as well as CPPD, particularly if advanced degenerative changes are present. Recognition of the radiologic features may be encountered in CPPD crystal deposition disease is important for differential diagnosis.