Sonographic and color Doppler sonographic diagnosis of acute osteomyelitis: report of one case

Acute osteomyelitis in childhood is uncommon. Early diagnosis is often difficult. We present a 7-year-old boy with clinical manifestation of fever and progressive left thigh swelling for one week. Sonography of the left thigh showed periosteal thickening with subperiosteal abscess around the metaphysis of the left distal femur. Tc-99m bone scintigraphy showed increased uptakes at the left distal femur. Osteomyelitis was suspected from the examination of ultrasound and bone scan examinations. His symptoms were not relieved following systemic antibiotic therapy and a follow-up color Doppler sonography showed vascular flows within and around the periosteum indicating active inflammation. He finally received surgical drainage and the operative findings confirmed the diagnosis of osteomyelitis. In conclusion, ultrasound may be a helpful and convenient tool for establishing the early diagnosis of pediatric osteomyelitis. Ultrasound and color Doppler sonography can be used as clinical parameters to evaluate the disease severity and the progression of osteomyelitis in children.

Ultrasonographic diagnosis and color flow Doppler sonography of internal jugular venous ectasia in children

We investigated the diagnostic utility of ultrasonography in the diagnosis of internal jugular venous ectasia. Eight children (six boys, two girls) were recruited into this prospective study. Sonography of internal jugular venous ectasia in these patients revealed fusiform dilation of the internal jugular vein, and the possibility of thrombus and external compression could be ruled out. Marked variation in size of ectatic jugular veins during respiration was demonstrated under real-time sonography. The mean anteroposterior diameter of these dilated internal jugular veins was 0.79+/-0.18 mm (mean+/-standard deviation), which increased to 1.58+/-0.27 mm with Valsalva maneuver. Our study showed that the anteroposterior diameters of the internal jugular veins in cases of ectasia were greater than those of contralateral jugular veins in same patients as well as those in normal children, and they showed greater increase after Valsalva maneuver. Under color Doppler flow studies, turbulent vascular flows were demonstrated in these patients with jugular venous ectasia. No progression of venous ectasia was found in any of our patients during a 6 month follow-up period. We conclude that internal jugular venous ectasia in children is a benign condition, which usually does not require surgical intervention. Ultrasonography is a good diagnostic modality for the diagnosis of internal jugular venous ectasia. Color Doppler ultrasonography demonstrate the turbulent flow in jugular venous ectasia.

Sonographic diagnosis of mesenteric hematoma

Blunt abdominal trauma is common in children. Handlebar injuries may produce duodenal hematoma and pancreatic injuries, but mesenteric hematoma is relatively uncommon. We report a mesenteric hematoma resulting from a handlebar injury in a 4-year-old boy. Abdominal sonography showed a heterogeneous hypoechoic mass with an echogenic wall in the central portion of the abdomen. Color Doppler study revealed vascularity at the periphery of the lesion, suggesting mesenteric hematoma. CT, upper gastrointestinal endoscopy, and a small bowel x-ray series confirmed the diagnosis.

Genotoxicity of contaminated soil and shallow well water detected by plant bioassays

Three major plant bioassays, i.e., the Allium root anaphase aberration (Allium-AA), the Tradescantia-micronucleus (Trad-MCN) and the Tradescantia stamen hair mutation (Trad-SHM) tests, were utilized in soil solutions or shallow well water samples to determine the degree of their genotoxicity. Shallow well water samples were collected from five different farms, and soil solutions were extracted with distilled water or dimethyl sulfoxide (DMSO) from pesticide-contaminated (metolachlor, atrazine, extrazine, and 2, 4-D) and pesticide-free soil samples. Genotoxicity was expressed in terms of anaphase aberration (AA) frequencies in the Allium-AA test, in terms of micronuclei frequencies in the Trad-MCN test, and in terms of pink mutation events in the Trad-SHM test. On average, results of Allium-AA tests showed a 2.78-3.01 fold increase in anaphase aberration frequencies in contaminated soil solution samples and well water samples as compared with the negative control. Results of Trad-MCN tests showed a 1.66-4.75 fold increase of MCN frequencies in contaminated soil solution samples and shallow well water samples as compared with the frequencies of the controls. Results of Trad-SHM tests showed a 2.7-2.86 fold increase of pink mutation events in the contaminated soil solution samples over that of the controls. Control groups of the Allium-AA tests had an average of 0.75/1000 anaphase figures, and control groups of the Trad-MCN tests had an average of 3.2 MCN/100 tetrads, while control groups of the Trad-SHM tests had an average of 1.4 mutation events/1000 hairs. In general, soil solutions of DMSO extracts showed higher genotoxicity than that of distilled water extracts. Among these three plant bioassays, the Trad-MCN test has the highest efficiency. The highest toxicity, based upon the Trad-MCN test results, was found in the pesticide contaminated soil samples from Monroe's farm. Water samples from the Fountain Green/Bushnell area ranked second in genotoxicity.

Esophageal foreign body presenting with stridor: report of one case

We report a case of a 12-month-old infant who developed acute respiratory distress with stridor from an impacted proximal esophageal foreign body. She was treated inappropriately as upper respiratory infections prior to the validation of the presenting complaint. Difficulties in diagnosis of esophageal foreign bodies arise, when the patient presents with atypical symptoms. Clinical suspicion remains the most important aid to diagnosis and endoscopic examination is essential for the diagnosis and successful management of foreign bodies in the esophagus.

Diagnosis of necrotizing fasciitis in children

Necrotizing fasciitis is a rare but progressive soft tissue infection. This condition is difficult to recognize in the early phase, when it is often confused with cellulitis. We report the cases of four children with necrotizing fasciitis. The initial presentation in these cases was cellulitis. Fever and soft tissue swelling occurred within 24 h and spreading erythema within 4 to 12 h. Radiologic studies of the lesions showed soft tissue thickening. Ultrasonography of the lesions demonstrated distorted, thickened fascia with fluid accumulation. Well-defined, loculated abscesses were demonstrated in two cases. Although typical dusky skin and purplish patches were not found in our cases, necrotizing fasciitis was strongly suspected on the basis of the clinical course and sonographic findings. Ultrasonography also was used as a guide for aspiration of pus. Gram-stained smears and bacterial cultures yielded the pathogens. The choice of antibiotic therapy was made on the results of smears and culture. All patients survived after immediate surgical debridement, intensive antibiotic therapy, and aggressive wound care. In conclusion, ultrasonography provides a rapid and valuable diagnostic modality for necrotizing fasciitis. The pus obtained through sonographically guided aspiration for bacterial culture can allow identification of the pathogenic organisms.

Congenital hepatic arterioportal fistula complicated with gastrointestinal bleeding treated with transcatheter embolization: case report

Congenital hepatic arterioportal fistula (HAVF) is extremely rare in children. We present a patient with congenital hepaticoportal arteriovenous fistula complicated with gastrointestinal bleeding treated using transcatheter arterial embolization. Our patient was the youngest (2 days old) case ever reported with congenital HAVF and the first one to receive arterial embolization for HAVF during childhood. The 3-year-old girl was suggested of having congenital HAVF using Doppler ultrasonography. However, her family refused further investigation, and she was lost to follow-up. Three years later, she was sent to our hospital due to melaena. Repeated ultrasonography revealed dilated intrahepatic portal vein with arterial flow demonstrated using Doppler imaging. No esophageal varices or gastric or duodenal ulcer was seen during endoscopy. Angiography showed a HAVF and transcatheter embolization was done simultaneously. Follow-up at one and two weeks post-embolization revealed no more shunt flow within the portal vein, though cystic like dilatation of the portal vein persisted, and no thrombosis was observed. This case emphasizes that transcatheter arterial embolization can be easily and successfully used for treating childhood congenital HAVF. Abnormal dilatation of the portal vein in children needs doppler evaluation and possibly angiography.

Prompt recognition of necrotizing fasciitis in a newborn

We report a 13-day-old female neonate with necrotizing fasciitis, who presented with fever and erythema on her back. Rapidly progressive extension of the erythema to the abdominal wall occurred within 12 hours. Sonography for the lesion showed extensive fascial thickening with fluid accumulation. An abscess was also demonstrated. Necrotizing fasciitis was highly suspected. Under sonographic guidance, pus was aspirated from the abscess. A smear for the aspirated pus revealed a large number of neutrophils and abundant gram-positive cocci. Immediate surgical debridement was done. Cultures from the pus and blood revealed Staphylococcus aureus. The patient was free of symptoms after surgical debridement and aggressive antibiotic therapy. She had skin grafting to reconstruct the debrided wound on the 20th hospital day and was discharged shortly after the debridement of wound.

Neonatal ileoileocolic intussusception associated with ileal polyp: report of one case

Neonatal intussusception is an uncommon disease. We report a case of neonatal ileoileocolic intussusception led by an ileal polyp in a female neonate. The patient presented with irritable crying, bilious vomiting and frank bloody stool on the 26th day of life. On physical examination, a mobile abdominal mass was palpated. Abdominal sonography demonstrated a long segment intussusception; associated with a low echogenic mass. At laparotomy, ileoileocolic intussusception led by an ileal polyp was found. Pathology confirmed the diagnosis of polyp. Because intestinal obstruction is the primary manifestation, neonatal intussusception is initially indistinguishable from obstructions due to other reasons like intestinal atresia, congenital bands, necrotizing enterocolitis or midgut volvulus. Our experience showed that although uncommon, intussusception should be considered in the differential diagnosis of intestinal obstruction during the newborn period.

Three-dimensional magnetic resonance cholangiopancreatography for evaluation of obstructive jaundice

The purpose of this study was to assess the diagnostic value of magnetic resonance cholangiopancreatography (MRCP) in studying the anatomy, sites, and causes of obstructive jaundice. From September 1994 to May 1996 three-dimensional MRCP was performed on 31 patients with abdominal pain and obstructive jaundice with a fast spin-echo T2-weighted pulse sequence. The images were reconstructed using maximal intensity projection, AVERAGE and SURFACE algorithm processing techniques at a graphics workstation. All the reconstructed images were compared with those obtained using conventional cholangiographic techniques, such as endoscopic retrograde cholangiopancreatography, percutaneous transhepatic cholangiography and drainage, and intraoperative cholangiography. The patients' diagnoses included choledochal cyst (13), cholangiocarcinoma (five), choledocholithiasis (four), pancreatic head carcinoma (three), rhabdomyosarcoma (one), papillary Vater carcinoma (one), recurrent gastric carcinoma (one), ascaris (one), and biliary atresia (two). Extrahepatic biliary dilatation was present in all 13 patients with choledochal cyst; the pancreatic ducts and their entrance level to the common bile duct were observed in eight of these patients. The level of obstruction in patients with cholangiocarcinoma was well documented but the biliary tract of one patient with biliary atresia was not identified by MRCP. In one patient with biliary rhabdomyosarcoma, MRCP clearly delineated the extrabiliary extension of the tumor. In a patient with ascaris in the common bile duct an increase in signal intensity inside the digestive tract of the worm denoted fluid in its gut. Lithiasis was shown in all of the four patients with choledocholithiasis. Thus, MRCP is a useful tool in the assessment of biliary tract obstruction and its causes, and is a valuable addition to ultrasonography.

Hepatitis C and G virus infections in polytransfused children

The prevalence of hepatitis C virus (HCV) and a newly identified hepatitis G virus (HGV) and their clinical significance were studied in 42 polytransfused Taiwanese children. Serological assays for antibodies against HCV (anti-HCV) and polymerase chain reaction for serum HCV ribonucleic acid (RNA) and HGV RNA were performed. The prevalence of anti-HCV and HGV RNA was 17% and 14%, respectively in 42 polytransfused children. Anti-HCV seropositives had a significantly higher mean age, peak serum transaminase level, and longer transfusion duration than seronegatives, while children with HGV infection usually had no or only mild hepatitis activities. The prevalence of anti-HCV dropped sharply after implementation of anti-HCV screening, however the prevalence of HGV viraemia remained unchanged.

CONCLUSIONS

HGV infection is not uncommon in polytransfused Taiwanese children and the virus does not cause significant hepatitis compared to HCV infection. Current blood donor screening for anti-HCV can effectively protect polytransfused children from HCV infection but the impact of additional screening for HGV markers awaits further studies.

Universal hepatitis B vaccination in Taiwan and the incidence of hepatocellular carcinoma in children. Taiwan Childhood Hepatoma Study Group

BACKGROUND

A nationwide hepatitis B vaccination program was implemented in Taiwan in July 1984. To assess the effect of the program on the development of hepatocellular carcinoma, we studied the incidence of this cancer in children in Taiwan from 1981 to 1994.

METHODS

We collected data on liver cancer in children from Taiwan's National Cancer Registry, which receives reports from each of the country's 142 hospitals with more than 50 beds. Data on childhood liver cancer were also obtained from Taiwan's 17 major medical centers. To prevent the inclusion of cases of hepatoblastoma, the primary analysis was confined to liver cancers in children six years of age or older. Data were also obtained on mortality from liver cancer among children.

RESULTS

The average annual incidence of hepatocellular carcinoma in children 6 to 14 years of age declined from 0.70 per 100,000 children between 1981 and 1986 to 0.57 between 1986 and 1990, and to 0.36 between 1990 and 1994 (P<0.01). The corresponding rates of mortality from hepatocellular carcinoma also decreased. The incidence of hepatocellular carcinoma in children 6 to 9 years of age declined from 0.52 for those born between 1974 and 1984 to 0.13 for those born between 1984 and 1986 (P<0.001).

CONCLUSIONS

Since the institution of Taiwan's program of universal hepatitis B vaccination, the incidence of hepatocellular carcinoma in children has declined.

Chronic granulomatous disease: a case report

Chronic granulomatous disease is an uncommon inherited disease with presentations of frequent pyogenic and fungal infections. In this disease, the phagocytes ingest pathogens, but the ingested microorganisms can not be killed because the cells lack the ability to convert oxygen into superoxide using the enzyme known as NADPH oxidase. We report on a patient who had experienced frequent lymphadenopathy and bacterial infections since childhood. In addition to his history of repeated bacterial infections, diagnosis was also based on abnormal findings in immunologic tests including the nitroblue tetrazolium test assay, analysis of chemiluminescence and detection of hydrogen peroxide using flow cytometry. He received prophylactic treatment with antibiotics, and the condition remained stable during a six-month follow-up period.

Factors related to detection of blood flow by color Doppler ultrasonography in intussusception

Color Doppler ultrasonography was performed in 125 patients with 134 intussusceptions. Color flow was present in 121 cases of intussusception (group A) and was absent in 13 cases (group B). Young age and duration of symptoms greater than 48 hr were significantly related to the nonvisualization of blood flow detected by color Doppler sonography (P < 0.05). The successful rate of air reduction was significantly higher in group A than in group B (109 of 121 versus 4 of 13). Color Doppler ultrasonography is useful to predict the reducibility of an intussuscepted intestine. The nonvisualization of blood flow by this method is not a contraindication for air reduction.

Diagnostic value of C-reactive protein in children with perforated appendicitis

The diagnostic value of serum C-reactive protein (CRP) levels in children with perforated appendicitis was prospectively studied in 78 consecutive patients with histologically confirmed appendicitis. The patients were divided into two groups: group A included 56 patients with perforated appendicitis and group B consisted of 22 patients with simple appendicitis. Serum CRP level and leucocyte count were assayed in all and abdominal ultrasonography was performed in 75. The mean age group A patient was significantly lower than that of group B patients (7.5 vs. 10.4 years, P < 0.001). Group A patients had a significantly higher mean serum CRP levels than group B patients (92 vs. 31 mg/l, P < 0.001), while the mean leucocyte count was comparable in the two groups. Of 75 examined patients, 73 (97%) had a pre-operative sonographic diagnosis of appendicitis.

CONCLUSION

Perforation is a common complication in children with appendicitis, especially in those of young age and with prolonged pain duration. Greatly increased serum CRP levels (> or = 50 mg/l) and abdominal ultrasonography are important diagnostic aids in such patients.

Risk factors leading to ceftriaxone-associated biliary pseudolithiasis in children

Between July, 1992 and June, 1994, 151 pediatric patients who had ceftriaxone therapy for probable or definite bacterial enteritis were prospectively evaluated by serial abdominal ultrasonography. All patients received a dose of > or = 50 mg/kg/day and for a duration of 3 or more days. Five patients developed gallbladder precipitates or pseudolithiasis during treatment. Fasting and patients older than 24 months were probably the significant risk factors associated with this phenomenon (p < 0.05). However, no significant differences in sex, dose (50 vs. > 50 mg/kg/day) or duration of therapy (< 5 vs. > 5 day) were observed between patients who received ceftriaxone with and without the development of this gallbladder abnormality.

Pneumatic reduction of intussusception in children

Over the past decade, pneumatic reduction has been increasingly accepted as the treatment of choice for pediatric intussusception. However the effectiveness of air compared with the more traditional barium reduction of intussusception continues to be a source of concern and debate. From August 1993 to November 1994, pneumatic reduction was used to treat 75 episodes in 73 patients with proven intussusception at Chang Gung Memorial Hospital, Taoyuan. Two patients underwent air reduction twice because of recurrence following an initial successful reduction. The recurrence rate was 3%. Successful reduction was achieved in 65/75 (87%) episodes. None of the patients experienced any complications following the procedure. In two of the 10 patients in whom reduction failed, one was subsequently found to have a Meckel's diverticulum and the other a duplication cyst as a leading point. This prospective study indicates that air enema is a safe and effective form of treatment for intussusception in infants and children. Pneumatic reduction should be the treatment of choice in the initial management of intussusception.

Congenital extracranial meningioma

The authors report a case of congenital meningioma in a newborn. This tumour is extremely rare and only six cases have been reported in the literature. Those reported cases were mainly intracranial. This is the first case of a neonatal extracranial meningioma that was evaluated preoperatively by computed tomography and magnetic resonance imaging.

Endoscopic injection sclerotherapy for esophageal variceal bleeding in children with extrahepatic portal vein obstruction

From October 1989 to March 1994, 30 endoscopic injection sclerotherapies were performed in four consecutive female children who had extrahepatic portal vein obstruction complicated with esophageal variceal bleeding. Eradication of varices was achieved in three patients. However, bleeding occurred again in two of these patients due to esophageal varix recurrence. One patient, who discontinued sclerotherapy because of hemoptysis during treatment, also had 12 episodes of esophageal bleeding which were controlled by shunt therapy. In addition to hemoptysis, other complications were bleeding during sclerotherapy and fever. The sclerotherapy complication rate in this study was 17%. Our results suggest that endoscopic injection sclerotherapy is an effective and safe method for the prevention of variceal bleeding in children with extrahepatic portal vein obstruction. Long-term regular endoscopy follow-up and even repeated sclerotherapy are needed to prevent bleeding due to recurrence of esophageal varices.

Intussusception in infants and children: risk factors leading to surgical reduction

Intussusception is commonly the etiology of intestinal obstruction in infants and children. To investigate demographic data, clinicopathologic features and therapeutic prognosis of patients with intussusception, we reviewed 361 intussusceptions in 333 patients over an 11-year period. Most patients were below two years of age and there was a male preponderance of 1.6:1. There was no seasonal difference between the number of cases. The clinical triad of vomiting, abdominal colicky pain and bloody stools was manifested in only one-third of our patients. Secondary intussusception contributed to 6.6% of cases and Meckel's diverticulum was the most common pathologic cause. Positive findings were recorded in 82% of 67 patients undergoing sonographic examination. Intussusception of the ileo-colic type was most frequently encountered. Most patients (79%) were diagnosed within 48 hours and almost all cases underwent primary barium enema reduction. The success rate was 45%. Laparotomy was performed in 207 patients (57%) refractory to enema reduction or with critical illness, and intestinal resection was required in 28 (14%). Long-standing duration of illness (> 24 hours), positive clinical triad, positive pathologic lead point, and radiologic finding of bowel obstruction were identified as risk factors leading patients to surgical reduction (p < 0.001). Postoperative complications and recurrent intussusception developed in some patients, and the overall mortality was 0.6%. The clinical characteristics of intussusception in children generally remained unchanged as compared to previous reports. Early identification of patients with risk factors for surgical treatment is important to decrease the need for intestinal resection.

Repeated technetium-99m pertechnetate scanning for children with obscure gastrointestinal bleeding

From 1980 to 1992, we found false negative results from Technetium (Tc)-99m abdominal scans in seven children with massive gastrointestinal bleeding from ectopic gastric mucosae. Other examinations--including endoscopy, gastrointestinal series studies, angiography, and Tc-99m-labeled red blood cell scans to search for the source of the bleeding--were all in vain. Positive results were only obtained after repeated Tc-99m abdominal scans. Surgical specimens confirmed that ectopic gastric tissue was the source of bleeding in five patients with Meckel's diverticulum and two patients with enteric duplication.

Pyogenic liver abscess in children

Our center's experience with 15 pyogenic liver abscesses in 14 children from 1979 to 1992 showed an incidence of 20 per 100,000 pediatric hospital admissions. Eight of the 15 liver abscesses were cryptogenic in origin. The clinical features and laboratory findings were non-specific. Improved imaging techniques such as real time sonography and computed tomography made early diagnosis feasible. Klebsiella pneumoniae was the most common pathogen in this study. Drainage combined with antibiotics provides the most important treatment for this disease. Before 1986, surgery was frequently used, but now percutaneous drainage is preferred. Surgery may be reserved for those who respond poorly to percutaneous drainage and medical treatment. One of the 14 patients in this study died.

Technetium-99m pertechnetate scan for ectopic gastric mucosa in children with gastrointestinal bleeding

The detectability of ectopic gastric mucosa by Technetium (Tc)-99m pertechnetate abdominal scanning was investigated by reviewing 62 such scans in 52 pediatric patients with gastrointestinal hemorrhage. The histologic diagnoses and clinical conditions were correlated to the findings of the scans. There were 21 true-positives, 35 true-negatives, one false-positive and five false-negative studies. The overall sensitivity of this scan for the detection of ectopic gastric mucosa was 81%, the specificity was 97% and the accuracy was 90%.

Nonoperative treatment of blunt hepatic injury in children

Between January 1983 and December 1986, 35 Children with blunt hepatic injury were treated in Chang Gung Memorial Hospital. After vigorous resuscitation, 10 Patients required emergency laparotomies: 9 for massive bleeding, and 1 for associated bowel injury. Exploratory surgery was necessary 5 days after the initial resuscitation in one patient due to rebleeding. The remaining 24 patients who responded well to resuscitations were managed nonoperatively. Imaging examinations (ultrasound, radioisotope scan or computerized tomography scan) provided the diagnosis of liver trauma in all. The hospital courses in all cases were uneventful and there were no complications. In every patient follow-up imaging examinations showed complete resolution of the lesions. We conclude that nonoperative management of selected patients with blunt hepatic trauma is reasonable. With the help of serial imaging examinations, this conservative approach is safe and practical.