Continuous-type splenogonadal fusion: report of a rare case

Splenogonadal fusion is a rare congenital anomaly. It has two subtypes, discontinuous and continuous. Up to one-third of continuous-type fusion is associated with other congenital anomalies. We present a continuous-type splenogonadal fusion case that was found incidentally during indirect hernia repair; the testicle was preserved during excision. Laparoscopic exploration was helpful in identifying the isolated polysplenia as the origin of continuous-type splenogonadal fusion, and in excising the cord-like attachment proximally. The patient had no other associated anomaly.

Perinatal outcome in fetuses with heterotaxy syndrome and atrioventricular block or bradycardia

Congenital atrioventricular (AV) block is commonly associated with heterotaxy syndrome; together they have reportedly low survival rates (10-25%). However, information about perinatal outcome and predictors of non-survival after prenatal diagnosis of this association is scarce. Therefore, we studied fetuses with heterotaxy syndrome and bradycardia or AV-block diagnosed between 1995 and 2011, and analyzed pre and post-natal variables. The primary outcome was death and the secondary outcome was pacemaker placement. Of the 154 fetuses with heterotaxy syndrome, 91 had polysplenia syndrome, 22/91(24%) with bradycardia or AV-block. Thirteen (59%) patients had sinus bradycardia at diagnosis, 8 (36%) complete AV block, and 1 (5%) second-degree AV-block. Three patients elected for termination of pregnancy (3/22, 14%), 4 had spontaneous fetal demise (4/22, 18%), and 15 (15/22, 68%) were live-born. Of the fetuses with bradycardia/AV-block, 30% presented with hydrops, 20% had ventricular rates <55 beats/min, and 10% had cardiac dysfunction. Excluding termination of pregnancy, 15/19 fetuses (79%) survived to birth. Among the 15 live-born patients, 4 had bradycardia and 11 had AV-block. A further 3 patients died in infancy, all with AV-block who required pacemakers in the neonatal period. Thus, the 1-year survival rate, excluding termination of pregnancy, was 63% (12/19). Of the remaining 12 patients, 9 required pacemaker. Predictors of perinatal death included hydrops (p < 0.0001), ventricular dysfunction (p = 0.002), prematurity (p = 0.04), and low ventricular rates (p = 0.04). In conclusion, we found a higher survival rate (63%) than previously published in patients with heterotaxy syndrome and AV block or bradycardia diagnosed prenatally. Hydrops, cardiac dysfunction, prematurity and low ventricular rates were predictors of death.

Left-sided liver and right sided Polysplenia: a 77-year-old patient with hetrotaxy syndrome

Hetrotaxy syndrome is defined as an abnormality where the internal thoraco-abdominal organs demonstrate abnormal arrangement across the left-right axis of the body. Although it is a known condition among physicians taking care of pediatric patients, it is rarely seen in adult day-to-day medicine and most physicians involved in care of adult patients are unaware of it. It is important to recognize this anomaly based on clinical findings,due to its reported association with various medical conditions. We report a case of a 77-year-old patient diagnosed with Hetrotaxy syndrome.

Accessory spleen

An accessory spleen (AS), or splenunculus, is a small nodule of splenic tissue found outside of the spleen. Post-mortem examinations, also known as autopsies, are carried out to identify a cause of death, and to assess the state of the organs of the deceased. We present two incidental cases of splenunculi, one localized in greater omentum and a second one localized in the hilum of the spleen, diagnosed during a histopathological examination. An immunohistochemical profile of the normal and accessory spleen was followed where the expression of the CD20, CD3, CD23, α-SMA were analyzed.

[Connecting isolated congenital asplenia to the ribosome]

Isolated congenital asplenia is characterized by the absence of a spleen at birth without any other developmental defect. Isolated congenital asplenia is a rare and life-threatening disease that predisposes patients to severe bacterial infections. The first and main genetic etiology of isolated congenital asplenia was discovered in 2013. Mutations in the gene RPSA, which encodes ribosomal protein SA, cause more than half of the cases of isolated congenital asplenia. These disease-causing mutations lead to haploinsufficiency of RPSA. Haploinsufficiency of genes encoding other ribosomal proteins have been reported to cause other developmental defects in humans, and in model organisms like the fly or the mouse. About half of the patients with Diamond-Blackfan anemia, which is a well-characterized ribosomopathy, present developmental defects such as craniofacial defects, cardiac defects or thumb abnormalities. The mechanism of pathogenesis linking mutations in ribosomal proteins, which are highly and ubiquitously expressed, to specific developmental defects remains to be elucidated. One hypothesis is that the ribosome, and ribosomal proteins in particular, regulate the expression of specific genes during development.

Intravenous gammaglobulin as rescue therapy in a patient with sickle cell and septic shock

INTRODUCTION

We present a case involving a patient with sickle cell and hyposplenism, in which refractory septic shock quickly responded after the infusion of intravenous gammaglobulin (IV-GG) given as an adjuvant-rescue therapy

CASE DESCRIPTION

A 30-year-old African-American female with history of Sickle Cell disease was admitted for acute chest syndrome, septic shock and respiratory failure. Despite aggressive therapy the patient remained on two vasopressors and with persistent bacteremia. Within one day of starting IV-GG, both vasopressors (norepinephrine and vasopressin) were able to be discontinued.

DISCUSSION

Patients with hyposplenism have functional opsonization failure. Infusion of IV-GG has been shown to improve such function in patients with hyposplenism. We were able to document a temporal association between IV-GG rescue therapy and septic shock improvement.

CONCLUSION

The utilization of intravenous gammaglobulin should be considered in patients with sickle cell disease and hyposplenism as an adjuvant therapy for refractory septic shock.

Hand-assisted laparoscopic technique in the setting of complicated splenectomy: a 9-year experience

BACKGROUND

Laparoscopic splenectomy (LS) is significantly more challenging in patients with supramassive splenomegaly and those with portal hypertension. We hypothesized that hand-assisted laparoscopic splenectomy (HALS) could facilitate the procedure in these patients.

METHODS

Before October 2009, patients with supramassive splenomegaly and those with portal hypertension underwent LS. After October 2009, we routinely applied HALS in patients with these disorders.

RESULTS

We compared the HALS group (n = 41) with the LS group (n = 45). There were no conversions to open surgery in the HALS group, whereas there was an 4.5 % conversion rate in the LS group. The operating times were shorter, and there was less estimated blood loss, and fewer major complications in the HALS group. Analgesia requirement, time to full diet, and postoperative stay were comparable in the two groups.

CONCLUSIONS

We concluded that HALS was superior to LS in patients with supramassive splenomegaly and in those with portal hypertension.

Acute visceral obstruction

Gastric volvulus is a rare cause for acute visceral obstruction, with a high mortality rate that rises with delay in definitive treatment. A 33-year-old woman with a rare chromosomal mutation (46,XX,del(6)(q25.1q25.3)) presented with evidence of acute visceral obstruction. Diagnostic difficulties delayed treatment and she clinically deteriorated. Urgent CT imaging revealed acute mesentero-axial gastric volvulus. At laparotomy, global failure of colonic and splenic fixation was found. The viscera were de-rotated, the stomach salvaged and gastropexy and colopexy were performed. This is the first report of gastric volvulus secondary to congenital absence of colonic and splenic ligamentous attachments occurring in a patient over 30 years of age. This case is interesting not only due to unique pathology, but also highlights that general surgeons must be aware of the possibility of unusual causes for intestinal obstruction in patients with recognised genetic abnormalities, even in adult cases, to avoid harmful diagnostic delay.

Ribosomal protein SA haploinsufficiency in humans with isolated congenital asplenia

Isolated congenital asplenia (ICA) is characterized by the absence of a spleen at birth in individuals with no other developmental defects. The patients are prone to life-threatening bacterial infections. The unbiased analysis of exomes revealed heterozygous mutations in RPSA in 18 patients from eight kindreds, corresponding to more than half the patients and over one-third of the kindreds studied. The clinical penetrance in these kindreds is complete. Expression studies indicated that the mutations carried by the patients-a nonsense mutation, a frameshift duplication, and five different missense mutations-cause autosomal dominant ICA by haploinsufficiency. RPSA encodes ribosomal protein SA, a component of the small subunit of the ribosome. This discovery establishes an essential role for RPSA in human spleen development.

[Splenic torsion as cause of acute abdomen in children]

A six-year-old boy was admitted with symptoms consistent with acute appendicitis. Immediately before placement of the first trocar, a large abdominal mass was observed which on imaging was identified as a torsioned spleen. Due to suboptimal reperfusion and risk of reperfusion-mediated morbidity a splenectomy was performed. The recovery was uneventful. The child had a twin brother who on a routine ultrasound examination was found to have a normally positioned spleen. Challenges in diagnosis and treatment of children with splenic torsion is discussed.

Splenic duplication: a rare cause of acute upper gastrointestinal bleeding

Acute gastrointestinal bleeding represents a common medical emergency. We report the rare case of acute upper gastrointestinal bleeding caused by varices in the gastric fundus secondary to splenic duplication. Splenic duplication has been only rarely reported in the literature, and no case so far has described the associated complication of gastrointestinal bleeding, caused by venous drainage of the upper spleen via varices in the gastric fundus. We describe the imaging findings from endoscopy, endosonography, computed tomography (CT), flat-panel CT, and angiography in this rare condition and illustrate the effective role of intra-arterial embolization.

Centers for Disease Control and Prevention (CDC). Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine for adults with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP)

On June 20, 2012, the Advisory Committee on Immunization Practices (ACIP) recommended routine use of 13-valent pneumococcal conjugate vaccine (PCV13; Prevnar 13, Wyeth Pharmaceuticals, Inc., a subsidiary of Pfizer, Inc.) for adults aged ≥19 years with immunocompromising conditions, functional or anatomic asplenia, cerebrospinal fluid (CSF) leaks, or cochlear implants. PCV13 should be administered to eligible adults in addition to the 23-valent pneumococcal polysaccharide vaccine (PPSV23; Pneumovax 23, Merck & Co. Inc.), the vaccine currently recommended for these groups of adults. The evidence for the benefits and risk of PCV13 vaccination of adults with immunocompromising conditions was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework and designated as a Category A recommendation. This report outlines the new ACIP recommendations for PCV13 use; explains the recommendations for the use of PCV13 and PPSV23 among adults with immunocompromising conditions, functional or anatomic asplenia, CSF leaks, or cochlear implants; and summarizes the evidence considered by ACIP to make its recommendations.

Discontinuous intrabdominal splenogonadal fusion with germ cell tumor. Excision with robotic assistence. Adult case report

OBJECTIVE

Present the case of a patient with a discontinuous intrabdominal splenogonadal fusion with an associated germ cell tumor.

METHODS

A case of a man of 29 years with bilateral cryptorchidism and left intra-abdominal discontinuous splenogonadal fusion associated with seminoma as an accidental finding in the context of a robotic pyeloplasty due to ipsilateral ureteropelvic junction stenosis.

RESULTS

The total operative time was 80 minutes (atrophic gonad removal and pyeloplasty by the Anderson-Hynes technique) with an estimated blood loss less than 100 cc. The hospitalization time was less than 36 hrs. The pathology and immunohistochemical report was compatible with intratubular germ cell neoplasia (seminoma).

CONCLUSION

The splenogonadal fusion is an uncommon pathology. While a high clinical suspicion may avoid unnecessary orchiectomy in young patients, its association with disorders such as cryptorchidism should make us suspect the possible presence of a concomitant germ cell neoplasia.

Interrupted inferior vena cava syndrome

We report a case of interrupted inferior vena cava (IVC) as a rare developmental defect. Inferior vena cava interruption is usually accompanied with azygos and hemiazygos continuation, and is asymptomatic. Consequently, venous blood from the caudal part of the body reaches the heart via the azygous vein and superior vena cava. A 50 year old female who came for routine health check-up was found to have pulmonary hypertension on two dimensional echocardiography. On further investigations she also had restriction on pulmonary function test. When computed tomography pulmonary angiography was done, showed dilated azygous vein without pulmonary embolism. Computed tomography of the abdomen demonstrated interrupted inferior vena cava. Such patients are at increased risk of deep vein thrombosis and pulmonary embolism.

Hypericum perforatum extract therapy for chickens experimentally infected with infectious bursal disease virus and its influence on immunity

Hypericum perforatum extract (HPE) has been proved a drug effective to many viral diseases. The purpose of this paper was to investigate the therapeutic efficacy and immuno-enhancement of HPE for chickens which were already challenged with infectious bursal disease virus (IBDV BC-6/85). Chickens infected with IBDV were treated with HPE for 5 consecutive days, the observation of immune organ indexes and pathological changes index, determination of IFN-α and detection of IBDV with RT-PCR were employed to assess in vivo whether or not HPE had the certain therapeutic efficacy on infectious bursal disease (IBD), and if HPE was able to improve the immunologic function. The results showed that 1330 and 667.9 mg/kg body weight (BW) per day of HPE had significant therapeutic efficacy and improvement immunologic functions for chickens infected experimentally with IBDV.

Identification of accessory spleens during laparoscopic splenectomy is superior to preoperative computed tomography for detection of accessory spleens

BACKGROUND

Missed accessory spleen (AcS) can cause recurrence of hematologic disease after splenectomy. The objective of the study was to determine whether detection of AcS is more accurate with preoperative computed tomography (CT) scan or with exploration during laparoscopic splenectomy.

METHODS

A retrospective chart review was performed for 75 adult patients who underwent laparoscopic splenectomy for various hematologic disorders from 1999 to 2009. Preoperative CT scans were performed in all patients. Patients were followed for recurrence of disease, and a scintigraphy scan was performed in those with suspected missed AcS.

RESULTS

The most common diagnosis was idiopathic thrombocytopenic purpura in 29 patients (39%), followed by non-Hodgkin's lymphoma in 22 patients (29%). Sixteen AcSs were found during surgery in 15 patients (20%), and preoperative CT scan identified 2 of these. Twelve AcSs were located at the splenic hilum (75%). Nine patients experienced recurrence of their disease, and none had a missed AcS on subsequent scintigraphy. Sensitivity of exploratory laparoscopy for detection of AcS was 100%, and for preoperative CT scan was 12.5% (P = .005).

CONCLUSION

Exploratory laparoscopy during splenectomy is more accurate than preoperative imaging with CT scan for detection of AcS. Preoperative CT scan misses AcS frequently and should not be obtained for the purpose of its identification.

Overwhelming post-splenectomy infection (OPSI): a case report and review of the literature

BACKGROUND

Overwhelming post-splenectomy infection (OPSI) is a serious disease that can progress from a mild flu-like illness to fulminant sepsis in a short time period. Although relatively rare, it has a high mortality rate with delayed or inadequate treatment, and therefore, it is important for Emergency Physicians to be familiar with it. Patients who are asplenic or hyposplenic are at an increased risk for infection and death from encapsulated organisms and other dangerous pathogens.

OBJECTIVES

There is an abundance of literature discussing OPSI from the perspective of hematologists and infectious disease specialists, but an Emergency Medicine perspective is necessary to truly understand the acute nature of the disease. The objective of this article is to present a careful examination of the literature with a focus on early diagnosis and management to provide Emergency Physicians with the ability to positively affect outcomes of this deadly disease.

CASE REPORT

We present the case of a well-appearing 5-month-old girl with congenital asplenia who presented to the Emergency Department with fever, and rapidly progressed to septic shock as a result of OPSI. Aggressive resuscitation was initiated, including empiric antibiotics, and after a prolonged hospital course in the pediatric intensive care unit, the child recovered.

CONCLUSION

Rapid identification of patients at risk for OPSI, followed by administration of intravenous antibiotics, usually vancomycin and ceftriaxone, combined with early goal-directed therapy, are the keys to successful treatment. If initiated early in the patient's course, the 70% mortality rate can be reduced to the 10-40% range.

[Large accessory spleen torsion with a distorted fascicular structure; a case report]

A 37-year-old woman was admitted with left upper quadrant pain. Imaging examinations revealed a cystic mass with a diameter of 70 mm near the tail of the pancreas. The mass had a distorted fascicular structure adjacent to the hilum of the spleen. On operation the distorted fascicular structure was revealed to be connective tissue including vessels. On histopathological examination, the mass was strongly suspected to be an accessory spleen because spleen-like stroma was recognized, in spite of degeneration due to infarction.

Congenital asplenia in mice and humans with mutations in a Pbx/Nkx2-5/p15 module

The molecular determinants of spleen organogenesis and the etiology of isolated congenital asplenia (ICA), a life-threatening human condition, are unknown. We previously reported that Pbx1 deficiency causes organ growth defects including asplenia. Here, we show that mice with splenic mesenchyme-specific Pbx1 inactivation exhibit hyposplenia. Moreover, the loss of Pbx causes downregulation of Nkx2-5 and derepression of p15Ink4b in spleen mesenchymal progenitors, perturbing the cell cycle. Removal of p15Ink4b in Pbx1 spleen-specific mutants partially rescues spleen growth. By whole-exome sequencing of a multiplex kindred with ICA, we identify a heterozygous missense mutation (P236H) in NKX2-5 showing reduced transactivation in vitro. This study establishes that a Pbx/Nkx2-5/p15 regulatory module is essential for spleen development.

The accessory spleen: prevalence and imaging findings in 1,735 consecutive patients examined by multidetector computed tomography

OBJECTIVE

To analyze the prevalence and CT findings of accessory spleens in the normal population.

MATERIAL AND METHODS

CT-examinations of 1735 consecutive patients, all examined by triple phase 16-row multidetector computed tomography (MDCT) of the abdomen, were retrospectively analyzed with special emphasis on the presence, location and imaging aspects of accessory spleens.

RESULTS

199 patients showed an accessory spleen (11%). Size of accessory spleens ranged from 3 to 20 mm (mean 10 mm). In 60% the accessory spleen was located at the level of the splenic hilum and in 33% at the level of the lower pole. In 46% the accessory spleen was located medially and in 43% ventrally. 19 patients presented with two (1.1%) and seven patients with three accessory spleens (0.4%), respectively. One patient showed splenosis and one patient showed an enlarged accessory spleen (5 cm) secondary to a splenic apoplexy (i.e. hemorrhagic infarction) of the accessory spleen, caused by torsion.

CONCLUSION

Accessory spleens may be identified by MDCT in about 11% of patients. Familiarity with normal imaging findings and knowledge on differential diagnoses, possible pathologies and potential pitfalls helps to differentiate from other findings in the upper abdomen.

Intrapancreatic accessory spleen

A case of accessory spleen located in the tail of the pancreas in a stillbirth male foetus is reported. The congenital anomaly was revealed at autopsy. The intrapancreatic spleen was well demarcated and was composed of red and white pulp; however, same pancreatic ducts were intermingled with the splenic parenchyma. As well as the intrapancreatic lesion another minute accessory spleen was also found at the hilum of the proper organ. Since a lack of morphological features of trisomy 13 syndrome were found in the foetus, the ectopic spleens were regarded as incidental findings.

[Prevention of severe infections in patients with hyposplenism or asplenia]

Each year, up to a 1000 splenectomies are performed in the Netherlands. Aside from patients without a spleen, there is also a large group of patients with hyposplenism or functional asplenia due to other primary diseases. All these patients are at risk of developing severe infections, such as post-splenectomy sepsis (PSS), which is associated with very high mortality. However PSS can partly be prevented by taking simple measures such as immunizations and prophylactic or early use of antibiotics. Healthcare professionals in first and secondary care in the Netherlands are generally not well informed about which preventive measures should be taken to prevent these infections, resulting in often suboptimal management of patients. In this article, recommendations are given on vaccination and administration of antibiotics to prevent severe infections such as PSS in this group of patients.

Splenogonadal fusion and sex reversal

Splenogonadal fusion is a rare congenital malformation where an abnormal union occurs between the spleen and gonad or mesonephric derivatives. Although it occurs in females it is much less prevalent than in males (male:female ratio, 16:1), but this may partly be because of the inaccessibility of the female gonads leading to under-diagnosis. To our knowledge this is the first case of splenogonadal fusion associated with sex reversal reported in the literature.

Intrapancreatic accessory spleen: investigative dilemmas and role of EUS-guided FNA for diagnostic confirmation

CONTEXT

We submit a case of intrapancreatic accessory spleen.

CASE REPORT

A 33-year-old patient with history of dyspepsia underwent imaging studies suggestive of a neuroendocrine tumor. After referral to our institute, endoscopic ultrasound guided fine needle aspiration (EUS-FNA) confirmed diagnosis as intrapancreatic accessory spleen.

DISCUSSION

An accessory spleen may develop from estranged mesenchymal cells due to fusion failure of the splenic anlage. The prevalence of an accessory spleen is 10-30% with 80% of them present at the splenic hilum and 17% in the pancreatic tail. Intrapancreatic accessory spleen is commonly misdiagnosed as a pancreatic tumor. Since, the differential diagnosis includes pancreatic neuroendocrine tumors, additional investigation with EUS-FNA should be considered when radiological diagnosis is not definitive.

CONCLUSION

For diagnosis of intrapancreatic accessory spleen, radiographic imaging is useful, but lacks specificity without tissue diagnosis. Diagnosis can be safely and reliably established with EUS-FNA, leading to a benign prognosis and avoidance of unnecessary surgical intervention.

Biliary atresia with associated structural malformations in Canadian infants

BACKGROUND

Biliary atresia (BA) is associated with extrahepatic congenital malformations in a minority of affected infants. The term commonly applied to this subgroup is 'BASM' for biliary atresia splenic malformation syndrome, as spleen abnormalities are prominent.

AIMS AND METHODS

To examine clinical outcome in Canadian BA patients with extrahepatic congenital malformations in the Canada-wide BA database of patients born between 1985 and 2002, and additionally, to recharacterized the syndrome. Patients had ≥1 of the following: a/polysplenia, abnormal abdominal situs, intestinal malrotation, abdominal vascular anomaly or congenital heart disease.

RESULTS

Among 328 BA patients, 44 (13%) had associated congenital abnormalities. Intra-abdominal anomalies included polysplenia (n=25), abnormal abdominal situs (n=9), intestinal malrotation (n=19), portal vein anomaly (n=12), hepatic artery anomaly (n=3) and inferior vena cava interruption (n=20). Twenty-six patients had cardiac malformations including pulmonary stenosis (n=11), ventricular septal defect (n=10), atrial septal defect (n=7), total anomalous pulmonary venous return (n=3), double outlet right ventricle (n=3), tetralogy of Fallot (n=2), atrioventricular canal (n=2), dextrocardia (n=2), bicuspid aortic valve (n=2), hypoplastic left heart (n=1) and partial anomalous pulmonary venous return (n=1). Age at Kasai operation, performance of liver transplant, overall survival, post-Kasai native liver survival and transplant survival were comparable to isolated BA. Presence of polysplenia or complex cardiac disease did not reduce post-Kasai native liver survival. Three patients had ≥2 typical abnormalities without polysplenia: thus, splenic malformations are not essential to this BA subgroup. Hierarchical cluster analysis demonstrated characteristic abnormalities grouped in a multiplicity of combinations, consistent with a spectrum of defective lateralization.

CONCLUSION

We suggest that the acronym 'BASM' be redefined as 'biliary atresia structural malformation'.

Role of four-dimensional ultrasound (spatiotemporal image correlation and sonography-based automated volume count) in prenatal assessment of atrial morphology in cardiosplenic syndromes

OBJECTIVE

To assess the diagnostic role of four-dimensional ultrasound using spatiotemporal image correlation and Sonography-based Automated Volume Count (STIC-SonoAVC) in the identification of the morphology of the atrial appendages in cases with cardiosplenic syndrome.

METHODS

This was a retrospective investigation of 22 fetuses with cardiosplenic syndromes seen at our institution over a 5-year period from January 2004. As control groups, 10 normal fetuses, five cases with a non-isomeric atrioventricular septal defect and five cases with other congenital heart diseases were also analyzed. For all fetuses, one or more cardiac volume datasets were available for offline analysis. Two-dimensional and four-dimensional echocardiography was carried out in all cases at the time of diagnosis using high quality three-dimensional equipment. Dedicated software was used to assess chamber morphology using the SonoAVC technique, which allows the creation of casts of hollow structures. Two different operators used the software. The first performed all steps up to positioning of the region of interest box. The second operator, who was blinded to clinical information, then rendered the cardiac chambers using the SonoAVC technique. This operator then used the rendered image to subjectively assess atrial morphology.

RESULTS

Suitable rendered images of the cardiac chambers could be produced in 40/42 fetuses. In two cases of left atrial isomerism, advanced (34 weeks) and early (13 weeks) gestational age made it impossible to obtain adequate rendered images. In the remaining 40 cases (13 cases of left atrial isomerism, seven cases of right atrial isomerism, five cases of non-isomeric atrioventricular septal defect, five cases of other congenital heart diseases and 10 normal fetuses), atrial morphology was correctly identified by evaluation of the rendered images.

CONCLUSION

Four-dimensional ultrasound with SonoAVC rendering allows correct identification of the morphology of atrial appendages in all cases of cardiosplenic syndromes in which an adequate cardiac volume dataset can be obtained for analysis.

Post-splenectomy and hyposplenic states

The spleen is crucial in regulating immune homoeostasis through its ability to link innate and adaptive immunity and in protecting against infections. The impairment of splenic function is defined as hyposplenism, an acquired disorder caused by several haematological and immunological diseases. The term asplenia refers to the absence of the spleen, a condition that is rarely congenital and mostly post-surgical. Although hyposplenism and asplenia might predispose individuals to thromboembolic events, in this Review we focus on infectious complications, which are the most widely recognised consequences of these states. Because of the high mortality, the fulminant course, and the refractoriness to common treatment of overwhelming infections caused by encapsulated bacteria, prevention through vaccination and antibiotic prophylaxis is the basis of the management of patients who have had splenectomy or have hyposplenism. In this Review, we critically assess clinical and diagnostic aspects of splenic dysfunction and highlight new perspectives in the prevention of overwhelming post-splenectomy infections.

Developmental and posthatch effects of in ovo exposure to 2,3,7,8-TCDD, 2,3,4,7,8-PECDF, and 2,3,7,8-TCDF in Japanese quail (Coturnix japonica), common pheasant (Phasianus colchicus), and white leghorn chicken (Gallus gallus domesticus) embryos

An egg injection study was conducted to confirm a proposed model of relative sensitivity of three avian species to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD)-like chemicals. It was previously reported that the order of species sensitivity to in ovo exposure to TCDD, 2,3,4,7,8-pentachlorodibenzofuran (PeCDF), or 2,3,7,8-tetrachlorodibenzofuran (TCDF) at doses ranging from 0.044 to 37 picomoles (pmol)/g egg was the chicken (Gallus gallus domesticus), common pheasant (Phasianus colchicus), and Japanese quail (Coturnix japonica) based on embryo mortality and hepatic enzyme induction. In the present study, the incidence of developmental deformities, changes in body and relative organ masses, and organ pathology of hatchlings as additional indicators of species sensitivity were assessed; in addition, embryo mortality in the three species was categorized by stage of development. Embryo mortality varied temporally with significant increases generally occurring after organogenesis and just prior to hatching. A significant increase in the percentage of developmental deformities was observed only in Japanese quail exposed to TCDF. Body and relative organ masses of quail, pheasants, and chickens dosed in ovo with TCDD, PeCDF, or TCDF were not consistently affected. Chemical-related pathology occurred only in livers of quail at the greatest doses of each compound. These results indicated that the incidence of developmental deformities, changes in body and relative organ masses and organ pathology could not be used as indicators of species sensitivity or chemical potency.

[Sudden abdominal pain...is it a surprise? Necrosis of an ectopic spleen]

An ectopic/wandering spleen is rare in children. It results from the absence or laxity of the supporting ligaments which may cause torsion of the splenic pedicle with subsequent infarction. We present a case of a six-year-old girl, with history of onphalocele, dextrocardia and ectopic spleen (incidentally discovered three years ago as an abdominal mass on physical examination), with acute abdominal pain and signs of peritoneal irritation. Sonography showed an enlarged ectopic spleen in the pelvis. Computed tomography scan did not enable visualization of the spleen and allowed the identification of a pelvic mass without uptake of intravenous contrast. Splenectomy was performed due to splenic infarction. In the presence of a wandering spleen, even if asymptomatic, splenopexy may be performed to minimize complications, and together with acute abdominal pain, torsion of splenic pedicle may be considered.

Pre-duodenal portal vein in polysplenia syndrome: clinical effects and surgical application

STATING BACKGROUND: Pre-duodenal portal vein (PPV) is a rare congenital anomaly, usually asymptomatic and thus detected only incidentally in adults. It is often associated with other anomalies which can be included into polysplenic syndrome.

METHODS

In this case, a 56-year-old-female was admitted for a degenerative ampullome. The preoperative work-up shows a PPV vein, the absence of inferior vena cava retro-hepatic and the presence of an anastomosis between the inferior vena cava and the azygos system and a complete common mesentery.

DISCUSSION

Such a discovery is often incidental and of little import; however, it takes on major importance for surgeons because the accidental damage of PPV can lead to serious consequences.

CONCLUSION

The aim of this study, based on the embryology of the portal vein focused on a rare anomaly to keep it in mind because this anomaly in case of digestive surgery may need to adjust surgical techniques.

Epithelial cyst arising in an intrapancreatic accessory spleen: a diagnostic dilemma

An epithelial cyst in an intrapancreatic accessory spleen (ECIAS) is a rare disease that is commonly misdiagnosed preoperatively. To identify the clinical and imaging features of ECIAS, we reviewed the relevant medical literature. Twenty-one cases of ECIAS were identified, including our own. The cases were mainly diagnosed as mucinous cystic neoplasm (MCN) preoperatively based on clinical and imaging features, such as, a woman in middle age; elevation of serum CA19-9 levels; location in the tail of the pancreas; and a solid component resembling a mural nodule. ECIAS is another lesion to be considered in the differential diagnosis of MCN.

Cloacal exstrophy: a case report and literature review

Cloacal exstrophy is an extremely rare congenital malformation resulting in an exstrophy of the urinary, intestinal, and genital organs and associated with anomalies of other organ systems. We present a complicated case of cloacal exstrophy and the recent progress in the management of this probably most complicated anomaly in pediatric urology and surgery.

Isolated congenital asplenia: a French nationwide retrospective survey of 20 cases

OBJECTIVE

To better describe the natural history, mode of inheritance, and the epidemiological and clinical features of isolated congenital asplenia, a rare and poorly understood primary immunodeficiency.

STUDY DESIGN

A French national retrospective survey was conducted in hospital pediatric departments. A definitive diagnosis of ICA was based on the presence of Howell-Jolly bodies, a lack of detectable spleen, and no detectable cardiovascular malformation.

RESULTS

The study included 20 patients (12 males and 8 females) from 10 kindreds neither related to each other nor consanguineous. The diagnosis of ICA was certain in 13 cases (65%) and probable in 7 cases (35%). Ten index cases led to diagnosis of 10 additional cases in relatives. Five cases were sporadic and 15 were familial, suggesting autosomal dominant inheritance. Median age was 12 months at first infection (range, 2-516 months), 11 months at diagnosis of asplenia (range, 0-510 months), and 9.9 years at last follow-up (range, 0.7-52 years). Fifteen patients sustained 18 episodes of invasive bacterial infection, caused mainly by Streptococcus pneumoniae (61%). Outcomes were poor, with 9 patients (45%) dying from fulminant infection.

CONCLUSIONS

ICA is more common than was previously thought, with an autosomal dominant inheritance in at least some kindreds. Relatives of cases of ICA should be evaluated for ICA, as should children and young adults with invasive infection.

Liver transplantation in children with biliary atresia and polysplenia syndrome

BACKGROUND

Children with biliary atresia and polysplenia syndrome (BA-PS) have always been considered as high risk liver transplant recipients due to technical problems during transplant surgery. We report single-center experience with liver transplantation in children with this syndrome.

MATERIAL/METHODS

Between 2000 and 2010, 401 liver transplantations were performed in 358 children, including 6 patients with BA-PS, who underwent living (5 patients) or deceased (1 patient) donor liver transplantation. Patients demonstrated various malformations: absence of retrohepatic vena cava (3), intestinal malrotation (3), preduodenal portal vein (1), hepatic artery anomalies (3), cardiac anomalies (2), and situs inversus (1). Transplantations were performed at the patient age of 8 months to 11 years.

RESULTS

There were no serious technical problems during the operations, and we did not have to use vascular conduits for graft revascularization in any case. All patents were alive at follow-up between 14 and 123 months after transplantation (mean 75 months). We observed, however, increased incidence of PV thrombosis and biliary complications in these patients, which did not influence patient and graft survival. In 1 child with graft failure due to chronic rejection after discontinuation of immunosuppression due to PTLD, retransplantation was performed.

CONCLUSIONS

Results of liver transplantation in children with BA-PS are as good as for other indications and non-syndromic BA in an experienced pediatric liver transplant center. Although there were no serious technical problems during deceased or living related donor transplantation in these children, close observation for possible vascular complications should be the routine in the postoperative period.

Unusual presentation of biliary atresia splenic malformation syndrome with autosomal dominant hypospadias

Biliary atresia is associated with polysplenia in 2-10% of cases and is defined as Biliary Atresia Splenic Malformation syndrome (BASM). The main features of BASM syndrome include extrahepatic biliary atresia and polysplenia besides the characteristic findings of laterality anomalies, cardiac anomalies, intraabdominal vascular anomalies, pancreatic anomalies and malrotation. Here we present a 6-month-old male patient with BASM having atrial septal defect, umblical hernia, inguinal hernia, and hypospadias. Clinical history revealed that his father also had hypospadias which showed a rare form of autosomal dominant inheritance. The karyotype was normal and the molecular analysis of CFC1 gene revealed no mutation. We emphasize the importance of a detailed physical examination in cases with BASM.

Splenogonadal fusion: a case report

Splenogonodal fusion is a rare congenital abnormality. We present the case of a continuous splenogonadal fusion diagnosed in the course of a laparoscopy for left non-palpable testis in a 1-year-old boy. This case illustrates that even though testicular salvage is the recommended approach, various anatomical features might preclude conservation.

Infarcted accessory spleen due to segmental portal hypertension

Accessory spleens are frequent entities, but their infarction due to arterial stasis caused by segmental portal hypertension is extremely rare. We present this case of a 38-year-old female patient with a three-week history of abdominal pain and an abdominal CT scan revealing a 7 cm mass near the spleen and tail of pancreas with segmental portal hypertension. The patient had no hematologic disease. This mass was surgically resected, with a pathological diagnosis of an infarcted accessory spleen.

[Isolated congenital asplenia--a rare cause of severe pneumococcal sepsis]

Invasive disease caused by Streptococcus pneumoniae (SPn) is common among young children. Severe sepsis can be seen among those with primary or secondary immunodeficiency states. The absence of a spleen is a well-known risk factor for severe and overwhelming pneumococcal sepsis, as well as other encapsulated bacteria (e.g. Haemophilus influenzae type b (Hib), or Neisseria meningitidis). The most common cause of asplenia is surgical removal of the spleen (after trauma or as a treatment for various hematological conditions). Dysfunction of the spleen can also be seen in sickle cell disease, with high risk of invasive bacterial diseases. Primary congenital asplenia is rare. Congenital asplenia can be a part of Ivemark syndrome which is accompanied by other malformations. Isolated congenital asplenia is exceedingly rare. These patients can present with severe sepsis, meningitis or even sudden death. Overall, 31 cases have been reported, among them 17 were familial and the rest sporadic. The genetic bases for this rare life-threatening malformation are not known. The authors describe a one year old patient, presented with severe pneumococcal sepsis and multisystem organ failure. Isolated congenital asplenia was demonstrated. The child recovered and is being treated according to the recommendations for adults with asplenia.