High-frequency oscillation and paralysis stabilize surfactant protein-B--deficient infants.

OBJECTIVE: To determine if high-frequency oscillatory ventilation and neuromuscular blockade improve oxygenation and chest radiographic appearance more effectively than high-frequency oscillation alone for surfactant protein-B (SP-B)--deficient infants. STUDY DESIGN: We reviewed medical records and chest radiographs of five SP-B--deficient infants awaiting lung transplantation. Changes in FiO2 and radiographic scores were analyzed with respect to neuromuscular blockade status. RESULTS: FiO2 consistently increased 0.20 (SD 0.11) during high-frequency ventilation without neuromuscular blockade (p = 0.02) and decreased 0.14 (SD 0.11) during high-frequency ventilation with neuromuscular blockade (p = 0.05). Chest radiographic appearance, quantified by an expansion/aeration index, consistently deteriorated without neuromuscular blockade (p = 0.01) and consistently improved with neuromuscular blockade (p = 0.03). Changes in FiO2 correlated with changes in radiograph scores (r = 0.7, p < 0.001). CONCLUSIONS: High-frequency ventilation with neuromuscular blockade optimizes oxygenation for SP-B--deficient infants. This ventilatory strategy should be considered while awaiting the diagnosis of SP-B deficiency or lung transplantation.

Computed radiography versus screen-film radiography: detection of pulmonary edema in a rabbit model that simulates neonatal pulmonary infiltrates.

PURPOSE: To determine if computed radiography is equivalent to screen-film radiography in depicting pulmonary edema and to determine if radiation exposure can be reduced with computed radiography while maintaining equivalent diagnostic accuracy for pulmonary edema. MATERIALS AND METHODS: Oleic acid was intravenously injected into three rabbits at each of four doses: 0, 0.02, 0.04, and 0.06 mL/kg. Two hours later, chest computed radiographs and screen-film radiographs were obtained at 60 kVp and 1.1 mAs. Additional computed radiographs were obtained after reducing milliampere seconds or by reducing milliampere seconds and increasing the kilovolt peak, which reduced bone marrow exposure by up to 20%. The presence of pulmonary opacities, "truth," was established by the wet-dry weight ratio and by chest computed tomography (CT). The radiographs were masked and randomized. Four observers rated the images for the presence of parenchymal opacities with a dichotomous score and judged the quality of the radiographs on a scale from 1 (worst) to 6 (best). Cochran Q tests and McNemar tests were used to analyze the differences in paired comparisons. Image quality was evaluated with logistic regression analysis. RESULTS: There was no significant difference between truth and observer ability to detect opacity for either modality or for any exposure (P > .05). There was no significant difference between computed radiography and screen-film radiography for image quality (P > .05). CONCLUSION: Computed radiography is equivalent to screen-film radiography in the detection of pulmonary edema. Radiation exposure reduction of 20% can be achieved without affecting pulmonary edema detection or image quality.

Primary gastric plasmacytoma: a rare cause of hypertrophic gastritis in an adolescent.

BACKGROUND: This report describes a 16-year-old patient with gastric rugal hypertrophy caused by a primary gastric plasmacytoma. She had a 3-month history of nausea and burning abdominal pain. Radiographic studies showed giant rugal hypertrophy. Superficial endoscopic gastric biopsies showed mild inflammation with plasma cells of polyclonal origin in the mucosa. When symptoms persisted, she underwent laparoscopic full-thickness gastric biopsy. There was monoclonal plasma cell infiltration histologically diagnostic of plasmacytoma and inconsistent with Helicobacter pylori-associated mucosa-associated lymphoid tissue (MALT) lymphoma. There was no evidence for involvement of the bone marrow or regional lymph nodes. The tumor did not respond to radiotherapy, necessitating total gastrectomy. METHODS: Blood samples were analyzed for interleukin (IL)-6 by enzyme-linked immunosorbent assay. Gastric biopsy and gastrectomy specimens were subjected to immunophenotyping for kappa and lambda light chains, CD45, CD20, and LN1 and to polymerase chain reaction analysis for herpes virus HHV8. RESULTS: There was no elevation in circulating IL-6 levels, militating against a pathogenesis akin to that of Castleman's disease. There was no evidence for infection with the Kaposi's sarcoma-associated herpes virus HHV8, which has recently been found in patients with multiple myeloma. CONCLUSIONS: This diagnosis and the characteristics of the tumor are very unusual, if not unique, for a patient of this age. The diagnostic evaluation of this patient also demonstrates the importance of deep endoscopic or full-thickness biopsies in some children with hypertrophic gastritis.

Skeletal surveys for child abuse: comparison of interpretation using digitized images and screen-film radiographs.

OBJECTIVE: The objective of our study was to compare child abuse detection using screen-film radiographs and their digitized images displayed on a computer workstation. MATERIALS AND METHODS: Skeletal surveys of 20 consecutive child abuse patients whose abuse was clinically proven by a combination of history, physical and radiographic findings, and social work history, and 20 consecutive control subjects were evaluated. Three radiologists rated both the screen-film radiographs (400-speed, double-emulsion film) and their digitized images displayed on a workstation (2K x 2K resolution) using a six-point ordinal scale for suspicion of child abuse, fracture detection, and image quality. The rating response was analyzed using multiobserver-multicase receiver operating characteristic analysis of variance. The McNemar test was used to evaluate differences between imaging techniques and between diagnoses made using each imaging technique and clinically proven child abuse. RESULTS: The area under the receiver operating characteristic curve for screen-film radiographs was 0.934+/-0.025 and for digitized images was 0.922+/-0.013. This difference was not significant (p = .658); however, two observers significantly underestimated the child abuse diagnosis with digitized images (p = .02). In a review of the false-negative child abuse diagnoses, observers failed to recognize characteristic metaphyseal fractures (10 observations) and rib fractures (five observations) on digitized images that had been recognized on screen-film radiographs. Mean image quality was rated significantly lower (p < .0001) and interpretation time was significantly longer (75 sec; p < .001) for the digitized images than for screen-film radiographs. CONCLUSION: The characteristic types of fractures that were not identified on the digitized images, lower image quality, and longer interpretation time raise concern that digitized images may not be adequate for interpretation of suspected child abuse.

Hyperechoic caudate nuclei: a potential mimic of germinal matrix hemorrhage.

BACKGROUND: We have encountered bilateral hyperechoic foci in the region of the germinal matrix on cranial sonograms in neonates that have an appearance similar to germinal matrix hemorrhage (GMH), but are unusual either due to the age of the patient at presentation or to the evolution of the foci on follow-up. We believe that these findings represent hyperechoic caudate nuclei (HCN) rather than GMH. OBJECTIVE: To demonstrate that bilateral HCN can be seen on cranial sonography in neonates and can mimic bilateral GMH. MATERIALS AND METHODS: The cranial sonograms were reviewed in nine neonates (three term and six premature) who had HCN identified on at least one sonographic examination. CT (two patients) and MR (one patient) studies were also reviewed, as well as the neuropathological examination in one patient who died and had an autopsy. The patients' medical records were reviewed to identify any clinical markers for significant risk of perinatal ischemia. RESULTS: There was clinical evidence for risk of ischemia in five of the nine neonates. All nine patients had bilateral HCN on the initial or follow-up studies. Small cysts were seen sonographically in two patients. CT was normal in one patient and revealed a small unilateral focus of increased attenuation in one infant (very small compared to the bilateral HCN). MR was normal in one patient. Histopathological examination of the brain was normal in the one patient who died and had an autopsy. CONCLUSION: Hyperechoic caudate nuclei can occur in neonates either as a normal finding, or possibly related to ischemia, and should not always be attributed to GMH.

Pseudotumoral sarcoid granulomatous nephritis in a child: case presentation with sonographic and CT findings.

Granulomatous nephritis with renal masses is a very uncommon complication of sarcoidosis. Renal sonography in a patient with pathologically proven granulomatous nephritis demonstrated echogenic masses. CT demonstrated low-density lesions with mottled contrast enhancement.

Soft-copy versus hard-copy cranial sonography: intraobserver agreement and workstation efficiency.

OBJECTIVE: The objective of the study was to determine the intraobserver agreement, confidence level, and efficiency in interpretation of soft-copy (workstation) versus hard-copy (laser-printed film) sonograms of the cranium. MATERIALS AND METHODS: Cranial sonograms of 100 premature infants were randomly reviewed twice on both soft-copy and hard-copy images by three observers and were graded for hemorrhage using a five-level scale. The kappa statistic was calculated to measure intraobserver agreement. Differences in agreement were tested for statistical significance with a test for marginal homogeneity. Observers rated their confidence in interpretation using a six-point ordinal scale. Total viewing time was recorded, and videotaped sessions were analyzed for image handling time (opening each case, closing each case, and selecting the next case) and interpretation time. RESULTS: For soft copy versus hard copy, the mean kappa value was .73; for hard-copy 1 versus hard-copy 2, .71; and for soft-copy 1 versus soft-copy 2, .65. None of these differences was statistically significant (p > .05). The mean confidence score was the same for soft copy (5.3) and hard copy (5.3). On average, the observers needed 24 min longer to review 100 studies on soft copy than on hard copy. Opening and closing times for soft copy were significantly faster than for hard copy (p = .0001); however, case selection for soft copy, which was not needed for hard copy, took 4.69-9.09 sec per case. Extrapolated to 100 cases, case selection accounted for 8-15 min of viewing time. CONCLUSION: Radiologist agreement and confidence in the interpretation of cranial sonograms for hemorrhage was the same for soft copy and hard copy. However, viewing times were longer for soft copy. Elimination of inefficiency in case selection could improve image-handling time.

Large torsed neonatal ovarian cysts associated with massive vesicoureteral and intrarenal reflux.

The cases of two infants with large neonatal ovarian cysts complicated by salpingotorsion are reported. Both had persistent hydronephrosis after resolution of the ovarian cyst. Voiding cystourethrography in each child demonstrated massive vesicoureteral reflux with intrarenal reflux. The potential significance of this association and its possible cause are discussed.

Pyourachus: CT manifestations.

OBJECTIVE: To assess CT findings of pyourachus. MATERIALS AND METHODS: Computed tomography of two patients with surgically proven pyourachus was reviewed. RESULTS: The CT characteristics of pyourachus include (a) midline location deep to the rectus abdominis muscle; (b) conical shape extending from a tip at the umbilicus to a base over the bladder dome; (c) peripheral inflammatory changes in subcutaneous tissues, rectus abdominis muscle, and mesenteric fat; and (d) intraperitoneal fluid or abscess (if perforation has occurred). CONCLUSION: Abdominal CT demonstrates characteristic findings in pyourachus that should allow differentiation from other abdominal-pelvic masses.

Ureteropelvic junction obstruction in infants mimicking ureterovesical junction obstruction on sonography.

We present two infants with ureteropelvic junction obstruction with very large renal pelves, which extended to the level of the urinary bladder. In both cases, the distal aspect of the renal pelvis simulated a dilated distal ureter, leading to the incorrect sonographic diagnosis of ureterovesical junction obstruction. Awareness of this potential pitfall on sonography is important when imaging infants with prenatal diagnosis of hydronephrosis.

Unrecognized retention of intraorbital graphite pencil fragments: the role of computerized tomography.

Children with unrecognized intraorbital pencil fragments may come to attention because of surrounding abscess and granuloma formation, after a long delay, and may be suspected to have an intraorbital neoplasm. Two such patients are reported, with emphasis on CT findings. Recognition of the CT manifestations of intraorbital pencil fragments may allow a more conservative surgical intervention than that for presumed intraorbital neoplasm.

Craniosynostosis: diagnostic imaging with three-dimensional CT presentation.

PURPOSE: To measure diagnostic performance and preference of two three-dimensional CT reconstruction modalities (voxel-gradient and surface-projection) displayed two ways (conventional and unwrapped) in craniosynostosis confirmed by surgical inspection and histologic analysis of resected sutures. METHODS: High-resolution 2-mm contiguous CT sections were obtained and three-dimensional reconstruction images generated for 25 infants and children with skull deformities before surgical treatment of craniosynostosis. Two pediatric radiologists and two neuroradiologists first ranked images by their own preferences for diagnostic use. Then they diagnosed craniosynostosis from images presented in random order and blinded. The standard of reference was inspection during surgery and histologic evaluation of excised sutures. Finally, reviewers repeated their subjective preference tests. RESULTS: The least experienced radiologist had 100% sensitivity for all imaging modalities and specificities ranging from 43% to 83%. The two most experienced radiologists performed nearly identically, with sensitivities of 96% and specificities of 100%. After performing diagnostic tasks using all image types, all radiologists preferred conventional surface projections. CONCLUSION: Experienced readers can achieve nearly perfect diagnostic performance using the latest three-dimensional CT reconstruction images, making it a contribution to the diagnostic process. Although performance is nearly identical for all modalities, readers strongly prefer conventionally presented surface-projection images.

Binary nature and radiographic identifiability of craniosynostosis.

RATIONALE AND OBJECTIVES: Two independent gold standards and diagnoses from three-dimensional computed tomography (CT) images were used to examine the possibility that craniosynostosis is a binary abnormality that potentially may be diagnosed without error. METHODS: Surgical reports, histology of excised sutures, and three-dimensional CT images were compared for 25 children undergoing surgical management of craniosynostosis. Surgical reports identified sutures as normal or abnormal. Histology reported suture closure on a 5-point scale. Four radiologists used three-dimensional CT images to diagnose sutures on a 6-point rated response scale. RESULTS: Sutures with histology 0, 1, or 2 were normal on surgical reports, and those with histology 3 or 4 were abnormal. Most readers achieved nearly perfect sensitivity and specificity. Reader confidence was unrelated to degree of pathology. CONCLUSION: Craniosynostosis appears to be binary in our sample. Surgical reports, pathology results, and three-dimensional CT images read by experienced viewers achieved nearly perfect agreement.

Inflammatory myofibroblastic tumor of the spleen: report of a case in an adolescent.

Inflammatory myofibroblastic tumor (IMT) is an uncommon quasineoplastic process occurring in young patients. Splenic involvement is uncommon and occurs predominantly in older, adult patients. We present the youngest patient reported to date with splenic inflammatory myofibroblastic tumor and discuss the clinical, pathological and imaging features of this lesion.

Unusual manifestations of Langerhans cell histiocytosis of the head and neck. Case report with pseudoaneurysm of external carotid artery, tracheal, mandibular, and sphenoid involvement.

Langerhans cell histiocytosis of the head and neck is an uncommon histiocytic proliferative disorder that often clinically resembles an inflammatory process. A pseudoaneurysm of the external carotid artery was found by contrast-enhanced CT and confirmed by Doppler ultrasonography and angiography in a 9 year old girl with a lytic lesion of the mandible, a prior severe tracheal inflammatory process, and sclerotic lesions of the sphenoid wings. Biopsies of the mandibular lesion, pseudoaneurysm, and trachea demonstrated Langerhans cell histiocytosis. In cases of LCH with head and neck involvement, contrast-enhanced CT allows adequately detailed initial evaluation of the protean manifestations of this disorder.

Early occurrence of end-stage renal disease in a patient with infantile nephropathic cystinosis.

We report the case of a patient with infantile nephropathic cystinosis who required renal transplantation at age 30 months. Exhaustive evaluation did not identify a cause of progressive renal failure other than cystinosis. The patient's genetic lesion was allelic with those of other patients with cystinosis; fusion of this patient's fibroblasts with fibroblasts from another patient with infantile nephropathic cystinosis did not demonstrate complementation of the biochemical defect.

Imaging the urinary tract.

Since the advent of US, nearly every malformation of the urinary tract has been diagnosed in utero. Physiologic dilatation of the renal pelvis occurs and can be misdiagnosed as hydronephrosis, so the normal gestational development of the urinary tract, and its visualization by ultrasound, should be understood. Gestational diagnosis is important for family counseling, collaboration of the perinatal team, and for determining both the future evaluation needs and the possibility of intervention. Those infants at high risk, as well as others who have specific signs and symptoms of possible urinary tract disease, deserve prompt and careful postnatal imaging studies. Ultrasonograms may be combined with other imaging modalities in specific circumstances to provide accurate diagnoses and some functional information.

Magnesium tocolysis and neonatal bone abnormalities: a controlled study.

This study was conducted to investigate the relationship between maternal administration of intravenous (IV) magnesium sulfate and radiographic abnormality of neonatal long bones. Eleven neonates in the exposed group were born to mothers who had received IV magnesium tocolysis for more than 7 days. Two gestational age-matched unexposed neonates were selected for each member of the exposed group. Initial chest radiographs of exposed and unexposed neonates were reviewed in random sequence by a pediatric radiologist who was blinded to exposure status. On evaluation of the proximal humeri, six neonates had radiographic abnormalities consisting of transverse radiolucent and/or sclerotic bands; all six were in the exposed group. The difference in radiographic findings between the exposed and unexposed groups was statistically significant (P less than .001). These results support the existence of a causal relationship between prolonged IV magnesium tocolysis and abnormal fetal bone mineralization. Further study is needed to elucidate the mechanism and clinical significance of these bone changes.