[Fractures of the ankylosed spine: MRI features]

The diagnosis of transverse spinal fractures in patients with ankylosing spondylitis and Forestier's disease (DISH) may be difficult. The MRI features of 9 such fractures at the disk, vertebral body, spinal canal and posterior elements are presented. Fractures of the posterior elements (posterior arch fractures and/or rupture of interspinous or supraspinous ligaments and contiguous soft tissue structures) were present in all cases, underscoring the importance of MR signal abnormalities of posterior structures for diagnosis of these fractures. MR is advantageous due to its ability to demonstrate signal abnormalities of the posterior elements, which combined with disk and vertebral body abnormalities, play a major role for accurate diagnosis of this type of fracture.

Successful management of a retroperitoneal kaposiform hemangioendothelioma with Kasabach-Merritt phenomenon using alpha-interferon

It has been shown recently that Kasabach-Merritt phenomenon, the association of a vascular tumour and consumption coagulopathy, does not--as previously thought--complicate "classical" infantile hemangiomas but distinctive entities called kaposiform hemangioendothelioma (KHE) and tufted angioma (TA), both tumours on the same neoplastic spectrum. These tumours have been found in the neck, face, thorax, abdomen, retroperitoneum and limbs and are associated with a mortality rate of as high as 30 %. Several therapeutic modalities, including alpha-interferon, vincristine, radiotherapy and surgery have been reported in the literature. We report a case of retroperitoneal kaposiform hemangioendothelioma regression using alpha-interferon and discuss the current knowledge of this entity and its treatment.

Spontaneous Pneumothorax in Wegener Granulomatosis

Spontaneous pneumothorax in Wegener granulomatosis (WG) is uncommon. Three cases of pneumothorax that occurred early in the course of this vasculitis are reported. In the first patient, the disorder was disclosed by a pyopneumothorax. In the second patient, a rupture of the subpleural cavitary nodule into the pleural space was observed. In the third patient, the pneumothorax was discovered at the same time as a pulmonary hemorrhage. The three patients improved with immunosuppressive therapy. In WG, the pulmonary nodules are predominantly in the subpleural location, which entails the risk of pneumothorax and therefore require particular attention.

Inflammatory pseudotumor of the ureter

Inflammatory myofibroblastic pseudotumors are rare solid tumors found in most soft tissue locations although mainly in the lung. Their etiology is uncertain, and they are generally considered benign although some have a potential for recurrence and dissemination. Recent studies have suggested, however, that some of these tumors are in fact neoplastic processes that harbor chromosomal aberrations similar to those seen in certain lymphomas. The authors report a case of inflammatory pseudotumor of the ureter in a child and discuss recent reports.

Infiltration foraminale L5-S1 radioguidée dans le traitement de la lombosciatique S1

OBJECTIVE

To assess the efficacy of fluoroscopy guided L5-S1 transforaminal steroid injections for the treatment of S1 radiculopathy secondary to intervertebral disk disorder.

METHOD

41 patients were included: prospective study (20 patients) and retrospective study (21 patients). All patients suffered from S1 radiculopathy secondary to nerve root compression by intervertebral disk material, as demonstrated by lumbar spine CT. The patients underwent 2 fluoroscopy guided L5-S1 transforaminal injections of steroid (Hydrocotancyl 125 mg), at 8 days interval.

RESULTS

60% of patients showed significant improvement of their painful radiculopathy at day 8 (n:41), 60-67% at day 30 (n:41) and 67% at day 90 (n:18).

CONCLUSION

Fluoroscopy guided L5-S1 transforaminal injection showed good efficacy in the treatment of S1 radiculopathy.

Peritoneal needle suction for intestinal perforation in the preterm neonate

A few years ago, most intestinal perforations in the premature newborn appeared within the clinical context of necrotising enterocolitis (NEC). Since then, we have observed an increase in the number of isolated perforations appearing outside typical NEC. The fact that the perforations are more often isolated, and the healing capabilities of the premature intestine, led us to propose peritoneal needle suction (PNS) alone as first treatment for intestinal perforations in the premature neonate.

MATERIALS AND METHOD

The charts of 6 consecutive premature infants presenting with intestinal perforations treated initially by PNS alone were reviewed.

RESULTS

The patients' median birth weight was 1030 g, with a median gestational age of 27 weeks. In 5 out of 6 infants (83 %), PNS achieved complete exsufflation without recurrence of the pneumoperitoneum and complete intestinal healing, allowing complete enteral feeding 30 to 71 days after perforation. One infant with recurrent pneumoperitoneum after 3 PNS and peritoneal drainage was operated. All infants survived.

CONCLUSION

We believe that for early perforations of the premature neonate, the poor diffusion of the infection and the frequent capacity of the perforation to close and subsequently heal without scars, favour a minimally invasive management using PNS.

Interest of laparoscopy in polysplenia syndrome

Polysplenia syndrome (PS) is usually discovered in symptomatic patients in association with congenital heart disease or biliary atresia. Asymptomatic patients can present associated anomalies of the digestive tract such as intestinal malrotation and gastric or splenic malfixation. We report a case of PS presenting as a left flank mass shown to be an accessory spleen by denatured red blood cell scintigraphy. Upper gastrointestinal tract studies showed intestinal malrotation. Laparoscopic exploration confirmed intestinal malrotation and showed the absence of fixation of the accessory spleen. We performed a laparoscopic Ladd's procedure followed by fixation of the accessory spleen and resection of Meckel's diverticulum through a short left-flank incision.

[Pulmonary nodules: dosimetric and clinical studies at low dose multidetector CT]

PURPOSE

To measure breast radiation dose from multidetector CT using three different low dose protocols and compare it to a standard two view chest examination. To compare the number of pulmonary nodules detected at low and standard dose.

MATERIALS AND METHODS

Thermoluminescent dosimetry was used to measure the absorbed dose on a phantom (Rando) and 10 patients. Then, we compared the standard dose to the low dose examinations. The Wilcoxon rank test and the kappa test were used to assess differences in the detection of nodules.

RESULTS

The absorbed dose of these low dose protocols correspond to the radiation dose for the acquisition of two to ten chest radiographs (two views). This study suggests that only the 30 mA protocol is sufficient for the detection of all pulmonary nodules; nodules smaller than 5 mm were overlooked at 10 mA.

CONCLUSION

A good image quality can be obtained with low dose protocols at multidetector CT (correspond to 2 to 10 chest radiographs).

Management of asymptomatic neonatal cystic adenomatoid malformations

BACKGROUND/PURPOSE

Although much is known about the prenatal course of cystic adenomatoid malformations (CCAM), the postnatal course of asymptomatic lesion is less well documented. The authors studied the pre- and postnatal course and treatment of asymptomatic CCAM.

METHODS

The authors reviewed the files of all patients referred to Necker-Enfants Malades hospital with an antenatal diagnosis of CCAM and asymptomatic at birth.

RESULTS

Files of 29 patients were studied. The first x-ray film was considered normal in 12 cases (41.3%). Computed tomography was normal in 4 cases and showed cystic lung malformations in the other patients. Postnatally, clinical manifestations occurred in 3 patients (10.3%). CCAM vanished in 6 cases. Surgical resection of CCAM was performed in 17 cases (58.6%). All the patients currently are asymptomatic.

CONCLUSIONS

CCAM can shrink or vanish during pregnancy and antenatal ultrasound findings are not predictive of the postnatal course. Thus, all infants with prenatal diagnosis of CCAM require postnatal evaluation. Normal radiographic findings at birth do not rule out CCAM persistence on CT. The treatment of asymptomatic CCAM is controversial. Surgery may be advocated because of the low morbidity and the prevention of late complications, above all, cancer. The surgical indications of small (<3 cm) and asymptomatic lesions should be discussed on a case-by-case basis with the parents.

[POEMS syndrome: imaging of skeletal manifestations, a study of 8 cases]

PURPOSE

To describe the imaging features of POEMS, and to compare our experience of 8 cases to a review of literature.

MATERIALS AND METHODS

This retrospective study included 8 patients (6 men, 2 women) with POEMS. Plain radiographs (8 patients), CT (6), MR (2) were performed.

RESULTS

Topographic localizations of POEMS were pelvis (7 cases), spine (5), femur (1), humerus (1), rib cage (1). Focal bone lesions, multiple (5 cases) or solitary (3 cases), were sclerotic in 4 cases, mixed lytic-sclerotic (lytic center and sclerotic rim) in 3 cases and one patient had an osteolytic lesion with sclerotic margins associated with many osteosclerotic lesions. Profilerative osseous changes were seen in 4 cases (pelvis, spine, tibia). MR imaging was performed in 2 patients: in one patient MR imaging revealed areas of low signal intensity on spin echo T1- and T2-weighted images in vertebral bodies, the other showed a lesion of low signal intensity on spin echo T1-weighted and high signal intensity on T2-weighted images in the ilium and adjacent soft tissue.

CONCLUSION

The imaging features commonly observed in POEMS syndrome are sclerotic and mixed lytic-sclerotic lesions, particularly in the pelvis and spine. Proliferative new bone formation is detected in 50%. MR imaging correlates with ostesclerotic or mixed lytic-sclerotic appearance.

[Priapism in the course of generalized atopic dermatitis]

BACKGROUND

Priapism is a pathologically prolonged and painful penile erection, not resulting in ejaculation. Causes include certain oral medication, perineal trauma, thrombo-embolic process or primary priapism. We report a case of priapism secondary to diffuse general atopic dermatitis.

CASE REPORT

An 11 year-old child, with atopic dermatitis, presented over the last 36 hours an irreduced painful penile erection. Other than priapism, he presented numerous scratched lesions on the body and the penis having developped over the last 2 months (treated by daily topical corticosteroid application) and consistent with atopic dermatitis exacerbation. Due to the urological emergency, a puncture of the corpora cavernosa was made, followed by an injection of etilephrine in the penis. Complete and definitive detumescence was obtained. Application of betamethasone healed the cutaneous lesions. The child was treated with ciclosporine for his atopic dermatitis with good results at 6 months.

DISCUSSION

In our case, hypothesis of myeloid leukemia, sickle-cell disease and essential thrombocythemia were turned down. The young child did not exhibit any recent perineal trauma but the scratched lesions can be considered as microtraumas. The formation of an inflammatory oedema obstructed venous drainage of the penis and provoked priapism. We can not rule out the responsibility of topical corticosteroids in the formation of the priapism in this patient. Indeed, it was the only drug therapy prescribed, and since introduction of ciclosporine, there has been no relapse.

Indications and results of surgery in patients with Crohn's disease with onset under 10 years of age: a series of 18 patients

In order to examine the presentation and course of Crohn's disease (CD) with an onset of CD before the age of 10 and to assess indications and effects of surgery, a retrospective study was performed in 18 children. One hundred and twenty-two children with CD have been followed over the last 22 years in our institution. Thirty of them had the first onset of disease before 10 years of age. Eighteen out of these 30 underwent intestinal resection (IR). The mean age at the onset of CD was 6.4 years and the average duration of follow-up was 11.1 years. Most common symptoms were abdominal pain (72 %), diarrhoea (72 %), and growth retardation (50 %). Colon and ileum were the most frequently involved areas. Most of the children (94.5 %) received extensive medical and or nutritional treatment before surgery. We performed 26 IRs and 14 other operations in 18 patients. Indications for IR were chronic intestinal obstruction (13 cases) and chronic intestinal disability (13 cases). Improvements in the general clinical state were obtained in 17 cases out of 18. IR is beneficial for chronically ill children with ineffective medical therapy. A disease-free interval after surgery may provide an important time for improved growth and pubertal development and a return to nearly normal life for a long time.

[Treatment of giant congenital nevus with high-energy pulsed CO2 laser]

All authors agree upon the need for early treatment of giant congenital nevi. The surgeon must seek to minimize the risk of malignancy. The objective calls for radical excision of all pigmented areas; this may be impossible because of the risk of leaving the patient with disfiguring scars. The aim of this study was to assess treatment of giant congenital nevi with the high-energy pulsed CO2 laser as an alternative to surgery.

PATIENTS AND METHODS

Between 1998 and 1999, the high-energy pulsed CO2 laser was used in nine newborns and five children.

RESULTS

The treatment with the high-energy pulsed CO2 laser achieved 70-90% clearing of the giant nevi in most of the children. Two children developed hypertrophic scars on a companion nevi and on giant congenital nevi. One child required a skin graft because of tissue necrosis, associated with a disseminated intravascular coagulation and septic shock.

DISCUSSION

Laser is a surface technique proposed when surgical excision cannot be performed because the surface is too large or the localization is incompatible with surgery. Early treatment, in the first 15 days, is not required for the quality of the cosmetic result. The high-energy pulsed CO2 laser provides satisfactory cosmetic results with short cicatrisation time. It allows the treatment of the companion nevi at the same time. The risk of malignant transformation is greatly but not totally reduced. Regular clinical surveillance should help reduce the risk.

[A case of hepatic pseudoaneurysm treated with percutaneous embolization in a child with multiple trauma]

Hepatic artery pseudoaneurysms are rare complications of blunt abdominal trauma in children. Diagnosis is frequently delayed and made by splanchnic angiography. Most of the indications for surgical treatment have disappeared after the development of selective catheterization and embolization. We report a case in an 8-year-old pedestrian who was struck by a car and suffered a multiple trauma with a severe blunt abdominal trauma. A severe collapse upon admission commanded immediate laparotomy that depicted a liver fracture with associated jejunal and pancreatic lesions. Recovery was progressive until the 15th postoperative day where an abrupt haemobilia occurred. A CT-scan exploration was performed and revealed a vascular mass lesion in the left lobe of the liver. The performance of a selective angiography confirmed the diagnosis of left artery pseudoaneurysm, but because of technical difficulties, no embolization could be performed by this way. A direct percutaneous puncture and embolization of the aneurysm allowed a complete exclusion of the lesion. Eventually, recovery was complete. This percutaneous technique could be a valuable alternative to classical embolization and could avoid surgical treatment that still carries a high morbidity.

Resurfacing CO2 laser treatment of linear verrucous epidermal nevus

The term linear epidermal nevus (LVEN) refers to benign hyperplasia of the epidermis. Three types of LVEN can be distinguished: localized, systemic and inflammatory form. All have in common resistance to treatment and risk of recurrence. We report the observations of 5 patients with inflammatory linear verrucous epidermal nevus and 5 patients with linear verrucous epidermal nevus. Management by superpulsed CO2 laser was performed as follows: test treatment, completed by removal of the lesion in one or more sessions. Treatment was effective in all cases but 2. Satisfactory cosmetic results were obtained; slight hyperpigmentation, transitory desquamation and erythematous papules were observed. There was no recurrence in two years follow-up. We suppose that for the two patients with recurrence, our treatment failure is due to the lower laser parameters used in these patients compared to the others, because of their younger age.

Urological complications after renal transplantation using ureteroureteral anastomosis in children

PURPOSE

Ureterovesical reimplantation is most often performed for renal transplantation in children. We reviewed our experience to evaluate the safety and efficacy of ureteroureteral reimplantation in pediatric renal transplantation.

MATERIALS AND METHODS

We retrospectively evaluated the charts of 92 boys and 72 girls who underwent a total of 166 ureteroureteral anastomoses for renal transplantation from January 1990 to December 1999. Spatulated end-to-end anastomosis was performed between recipient and graft ureters without stenting and with a bladder catheter for at least 10 days.

RESULTS

Mean patient age at transplantation was 11.2 years (range 1 to 21.5). There were 22 living related donor and 144 cadaveric grafts. Urological anomalies and nephropathy were the cause of end stage renal disease in 146 and 20 patients, respectively. Urological complications were noted in 14 of the 166 transplantations (8.4%) in 10 boys and 4 girls, including 12 initial and 2 repeat grafts from 2 living related and 12 cadaveric donors. Five of these patients had undergone previous urological surgery. The 2 children (1.2%) with acute ureteral obstruction underwent repeat intervention after stent failure. Anastomotic leakage in 7 cases (4.2%) was treated conservatively in 1 and with a Double-J stent (Medical Engineering Corp., New York, New York) only required in 3. Reoperation was required in 3 cases. One patient (0.6%) with late ureteral stenosis underwent repeat anastomosis, 1 (0.6%) required reimplantation for recurrent pyelonephritis due to vesicoureteral reflux in the graft, 1 (0.6%) with a valve bladder required bladder augmentation and ureteral reimplantation, and 1 (0.6%) with lymphocele and 1 (0.6%) with lithiasis were successfully treated conservatively. Complications were associated with acute rejection in 6 cases. Mean followup without graft loss in patients who presented with versus without complications was 58.3 months (range 1 to 112) versus 75 (range 1 to 118). In the former patients with a mean age of 16 years 9 months versus those without urological complications mean serum creatinine was 116 and 108 mol./l., respectively. Two grafts were lost in patients with urological complications, including 1 who died of pulmonary embolism and 1 with refractory chronic rejection. Seven patients were lost to followup after 54 months (range 12 to 113) of adequate graft function.

CONCLUSIONS

Ureteroureteral anastomosis is a safe and effective technique for pediatric renal transplantation with a low complication rate, which may be due to better vascularization of the shorter ureteral end of the graft. Our results should encourage the use of this technique in pediatric renal transplantation. Efforts to preserve the recipient ureters should be made at nephrectomy.

[An assessment of low-dose high resolution CT in the detection of benign asbestos-related pleural abnormalities]

PURPOSE

To assess the reliability of low-dose high-resolution computed tomography (HRCT) in the detection of benign asbestos-related pleural abnormalities.

METHODS

Fourty-one patients exposed to asbestos were imaged on two occasions; the first time with conventional HRCT parameters: 140kVp, 220mAs; the second time with low-dose HRCT parameters: 120kVp, 60mAs.

RESULTS

The qualitative assessment dit not show any difference in the visibility of benign pleural abnormalities from one technique to the other in 98% cases.

CONCLUSION

The detection of pleural plaques and thickening did not vary with the two scanning protocols and, when compared with conventional HRCT, low-dose HRCT allows reduced radiation exposure by at least 76.5%, with an absorbed dose close to that delivered when using conventional chest radiography. Nevertheless, low-dose HRCT is a complementary study to helical acquisitions.

Spontaneous pneumomediastinum in children

SUMMARY. Spontaneous pneumomediastinum (SPM) is rare in children, mainly affecting male adolescents. It is usually secondary to alveolar rupture in the pulmonary interstitium, followed by dissection of gas towards the hilum and mediastinum. Many pathological and physiological events can lead to alveolar rupture, but the most common cause in children is asthma. The clinical diagnosis is based on the symptom triad of chest pain, dyspnea, and subcutaneous emphysema, and is also based on Hamman's sign. The diagnosis is confirmed by chest radiography. The main differential diagnosis is esophageal perforation, which requires an esophagogram with contrast when there is the slightest doubt in the diagnosis. Spontaneous pneumomediastinum generally resolves spontaneously within a few days, meaning that ambulatory treatment is usually appropriate. Management consists of treating the underlying cause (if identified), rest, analgesics, and simple clinical monitoring. Predisposing factors should be identified and controlled to prevent recurrence. Cases of idiopathic SPM necessitate diagnostic pulmonary function tests after the acute episode, to establish whether the child has asthma.

[Zinc deficiency in mucoviscidosis]

Zinc deficiencies can induce dermatitis in subjects presenting cystic fibrosis.

CASE REPORT

A patient, Clement, presented with a digestive form of cystic fibrosis. At four months of age, he presented a dermatitis similar to acrodermatitis enteropathica. Early clinical diagnosis and treatment led to a rapid response to zinc sulfate therapy.

DISCUSSION

Less intestinal absorption, malnutrition, and diet are just some of the numerous reasons for the zinc deficiency in this case. Biological support is not necessary to begin the treatment.

[Solar urticaria: one case treated by intravenous immunoglobulin]

BACKGROUND

Solar urticaria is a rare photodermatosis which often begins from the third to the fifth decade. Usual treatment consists of photoprotection measures and antihistamines although disease control is sometimes unsatisfactory with both. We report herein a very severe case of solar urticaria we treated with intravenous immunoglobulins.

CASE-REPORT

A 55-year-old woman suffered for 3 years from very severe solar urticaria which resisted treatment. Phototests revealed two action spectra: the first in UVA near 380 nm with a minimal urticarian dose of 0.025 J/cm(2), the second near 500 nm in visible light.

RESULTS

As last resort treatment, we gave our patient intravenous immunoglobulins. After the third course of treatment, the improvement was impressive as the patient could tolerate visible light and 15 minutes of intense solar exposure. The minimal urticarian dose was raised from 0.025 J/cm(2) to 27 J/cm(2) in UVA. One year after treatment, the solar urticaria has disappeared.

CONCLUSIONS

We report herein the first case of solar urticaria treated with success with immunoglobulin. Intravenous immunoglobulin treatment is well for its effectiveness in many autoimmune diseases such as autoimmune thrombocytopenic purpura, and also, as recently proven, in some cases of severe idiopathic chronic urticaria.