MR imaging diagnosis of central precocious puberty: importance of changes in the shape and size of the pituitary gland.

OBJECTIVE: Central precocious puberty occurs as a result of premature pituitary stimulation and increased secretion of gonadotropins. The aims of this study were to analyze MR imaging findings in the pituitary glands of children with central precocious puberty compared with matched control subjects, to define MR imaging-derived variables useful in the diagnosis of central precocious puberty, and to correlate MR imaging-derived variables with the hormonal profile and other imaging and clinical findings. MATERIALS AND METHODS: Twenty-six children with central precocious puberty (two boys and 24 girls) were divided into two subgroups according to MR imaging findings: idiopathic (21 patients) and nonidiopathic (five patients: three hypothalamic hamartomas, one pineal tumor, one empty sella syndrome). The control group consisted of 17 normal age- and sex-matched children (two boys, 15 girls). Analyzed parameters included pituitary height, length, width, midsagittal cross-sectional area, calculated volume, and shape. The shape was assessed by a pituitary grading system and two other shape indexes (length-to-height and length-to-width ratios). Pituitary grade was defined by the concavity of the upper pituitary surface (grade 1 = marked concavity, grade 2 = mild concavity, grade 3 = flat, grade 4 = mild convexity, grade 5 = marked convexity). RESULTS: Pituitary grade showed a highly significant difference among groups (p < .001). Area, height, and length-to-height ratio were significantly different (p < .05), whereas length, width, length-to-width ratio, and volume were not. There was no significant difference in any of the variables compared between idiopathic and nonidiopathic groups. When selected variables (pituitary grade, area, height, length) in the central precocious puberty group were stratified by bone age and findings on pelvic sonograms, patients with advanced bone age had a significantly higher pituitary grade (p < .01) and had a tendency toward a greater pituitary length. Pituitary size and shape correlated with the hormonal profile. CONCLUSION: Change in pituitary grade is the most helpful variable for the diagnosis of central precocious puberty in a prepubertal child. A high pituitary grade (4 or above) is highly predictive of central precocious puberty, with the highest specificity and positive predictive value, but with low sensitivity. The use of combinations of high pituitary grade with two other positive findings (height and area greater than 1 SD from the respective means in the control group) improves the sensitivity, specificity, and predictive value of MR imaging in the diagnosis of central precocious puberty.

Orbital pseudotumor in the differential diagnosis of pediatric uveitis.

Pediatric orbital pseudotumor may be associated with iritis, unlike the adult form of this disorder. However, orbital pseudotumor is seldom considered in the differential diagnosis of childhood uveitis. We report two cases of children with uveitis who were ultimately diagnosed as having orbital pseudotumor. No proptosis was noted in either child. For those pediatric patients with a persistent or recurrent uveitis and a previous negative diagnostic workup, the possibility of an orbital pseudotumor should be considered and ultrasonography, magnetic resonance imaging, and/or computed tomography performed.

A magnetic resonance imaging study of the upshoot-downshoot phenomenon of Duane's retraction syndrome.

Patients with Duane's retraction syndrome may have an associated upshoot or downshoot of the involved eye in adduction. This vertical movement has been attributed to the lateral rectus muscle slipping over or under the globe and acting as an elevator or depressor, respectively ("bridle-effect"). We used magnetic resonance imaging to investigate this phenomenon in two patients, one with an overshoot and the other with an undershoot. Minimal vertical displacement of the lateral rectus muscle in relation to the orbit was noted both on upshoot and downshoot. The bridle-effect theory must be modified to account for this finding.

Long term radiologic outcome of Pseudomonas osteomyelitis of the foot.

The medical records of 27 patients with puncture wound-induced Pseudomonas aeruginosa osteomyelitis/septic arthritis of the foot hospitalized from 1980 through 1988 were reviewed. Twenty patients received anti-Pseudomonas therapy for greater than 21 days and 7 patients received anti-Pseudomonas therapy for less than or equal to 21 days. There was no difference in age, sex, race, duration of wound or symptoms before admission or in admission physical findings including temperature, lymphadenopathy, puncture site appearance or admission laboratory data including white blood cell count or erythrocyte sedimentation rate between the two groups. All children but two in the long term therapy group had surgical as well as parenteral anti-Pseudomonas therapy. Fifteen patients returned for follow-up radiographs 1 to 8 1/2 years after hospitalization, 10 of 20 who had received therapy for greater than 21 days and 5 of 7 who had received therapy for less than or equal to 21 days. Poor radiologic outcome, ranging from bony deformity to joint space abnormality, was noted in 4 patients, of whom 3 had had joint involvement. Clinical abnormality was noted in only one adolescent male, and he had the most severe radiologic sequelae. The longer term functional significance of these radiologic anomalies awaits further delineation.

Neurosonographic changes in newborns treated with extracorporeal membrane oxygenation.

Ten out of 40 near-term neonates on extracorporeal membrane oxygenation (ECMO) therapy developed abnormal neurosonograms. We identified two abnormal patterns. Hyperechoic areas of intracranial hemorrhage were observed in two patients (a significantly lower incidence than previously reported). Diffuse or focal echogenic areas of hypoxia-ischemia resulting from periventricular leukomalacia, cerebral edema or large vessel infarction had not previously been noted in nine of these patients. Three of the ten patients survived with neurological sequelae. Recognition of hemorrhage or a hypoxic-ischemic pattern should serve as a warning to initiate or accelerate the weaning of infants from ECMO.

Arthrography in the diagnosis of fractures of the distal end of the humerus in infants.

Single-contrast arthrography was performed in six infants who had an injury to the elbow because the exact nature of the injury was uncertain from interpretation of the plain radiographs and clinical findings. A correct diagnosis was made in all six patients, and it significantly altered the treatment in five. Four lesions were a Salter-Harris Type-I fracture and two were a Salter-Harris Type-II fracture. Three patients had a closed reduction, two required no reduction, and one had an open reduction. Child abuse of two infants was confirmed, and it was suspected in another two.

Bronchogenic cysts in children.

Radiographic, surgical and pathological features of 33 paediatric patients with bronchogenic cysts are reviewed. These congenital lesions usually presented as spheroid mediastinal masses, near the carina or right paratracheal area, 2-3 cm in diameter with sharply delineated borders. Occasionally, the masses were lobulated or triangular in shape. Some cysts produced considerable airway distortion. All intrapulmonary cysts had connections, sometimes patent, with the trachea or main-stem bronchi. Thin-walled, completely aerated cysts became thick-walled with infection. A few air-filled and solid cysts grew rapidly. Cystic lung disease distal to central bronchogenic cysts was observed.

Congenital peritoneal mesothelioma.

Only three primary peritoneal mesotheliomas in children have been previously reported. We describe a 6-wk-old girl with a papillary peritoneal mesothelioma of low grade malignancy. This is probably a congenital mesothelioma and is the youngest patient reported to date.