CT in the evaluation of pleural versus pulmonary disease in children

Post pneumonic empyema in children is the result of infection by Staphylococcus aureus in approximately 80% of cases. Approximately 93% of children with empyema respond well to treatment with appropriate antibiotics and drainage of the pleural space. We present seven children in whom such therapy failed to produce an adequate response. Computed tomography alone clearly excluded persistent pneumonia as a cause of symptoms while in all seven patients revealing an unexpectedly extensive empyema rind. This information, coupled with the lack of clinical improvement and the specific organism isolated, led to a change in clinical management. These children were infected by organisms other than Staphylococcus aureus and required surgical decortication of the fibrinous pleural rind to alleviate persistent symptoms.

The evolution of neonatal herpes encephalitis as demonstrated by cranial ultrasound with CT correlation

Three neonates with herpes encephalitis had serial cranial ultrasound and CT studies performed during their hospitalization. Initially, subtle changes of diffuse brain edema were present but with no ventricular compression. A second phase revealed progressive brain edema with ventricular compression. A third phase with enlarging ventricles indicates developing encephalomalacia. Occasionally cyst formation may be noted within the cerebral white matter, a phenomenon initially more readily evident by ultrasound.

Complications of vaginal atresia in association with a duplicated mullerian duct

A mullerian duct duplication with a vaginal atresia can present as a painful abdominal mass in a female caused by a hematometrocolpos and a hemosalpinx. This set of signs and symptoms, if caused by an associated unilateral vaginal atresia, may be found in a female with normal menstrual periods, and (1) can be misdiagnosed with often tragic consequences caused by unnecessary salpingectomy, or even hysterectomy; (2) can be successfully treated by creating an adequate channel for drainage through the area of vaginal atresia; and (3) has a high association with unilateral renal agenesis. Because of this last point, recognition of either a mullerian duct duplication or unilateral renal agenesis should prompt an investigation for the other abnormality.

Low-dose flying spot digital radiography of the chest: sensitivity studies

Standard film examinations of the chest were compared with low-dose flying spot digital radiographic examinations obtained with a prototype unit in 174 patients. Analysis of pooled data from a double-blind study of 120 patients showed that film was more sensitive than digital images in the detection of pulmonary parenchymal abnormalities, that is, abnormal opacities, atelectasis, scar, and interstitial lung disease (P less than .05). Analysis of pooled data from a side-by-side study of 54 patients showed that the digital images were more sensitive than film in the detection of normal mediastinal and pleural soft-tissue contours, including the azygoesophageal recess, paraspinal line, and vertebral disk spaces (P less than .05). However, film was more sensitive than digital images in the detection of abnormalities of the lung, including scar, interstitial lung disease, septal lines, and the presence of vascular catheters (P less than .05). These findings suggest that low-dose flying spot digital radiography of the chest, as performed with this specific prototype unit, is not adequate to replace film in the detection of abnormalities of the lung parenchyma.

Hand radiographs in Russell-Silver syndrome

Left-hand radiographs were analyzed for bone age of 15 patients with Russell-Silver syndrome. No single finding was pathognomonic. However, in children between 2 and 10 years of age, the concordance of significantly delayed maturation, clinodactyly, fifth middle or distal phalangeal hypoplasia, ivory epiphyses, and a second metacarpal pseudoepiphyses is suggestive and should prompt a search for the well-recognized clinical features of this condition.

Radiation dose reduction in the evaluation of scoliosis: an application of digital radiography

This report documents the clinical testing of scanning beam digital radiography as an imaging method in patients with scoliosis. This type of digital imaging requires a skin exposure of only 2.4 mR (0.619 microC/kg) per image, compared with the lowest possible posteroanterior screen-film exposure of 10 mR (2.58 microC/kg) at the chest and 60 mR (15.48 microC/kg) at the lumbar spine. Digital radiographic and screen-film images were obtained on multiple test objects and 273 patients. Scoliosis measurements using screen-film radiographs and digital radiographs were comparable to within a mean difference of 1 degrees at many different degrees of severity. The low-dose digital images were found to be useful and accurate for the detection and measurement of scoliosis after the first screen-film radiographs have excluded tumors and structural abnormalities.

Radiation dose reduction during hysterosalpingography: an application of scanning-beam digital radiography

Hysterosalpingography was performed in 31 patients by means of a low-dose scanning-beam digital radiographic system. The technique permits adequate evaluation of gynecologic abnormalities while allowing significant reduction in radiation: 2.4-mR (6.1 X 10(-7) C/kg) exposure to the skin and 0.7-mrad (7 X 10(-6) Gy) mean dose to the ovaries per image obtained. Sixteen patients demonstrated readily recognizable and documented abnormalities, corroborated by laparoscopy, laparotomy, or other supportive evidence.

Correlation of pulmonary signs and symptoms with chest radiographs in the pediatric age group

One hundred twenty-five pediatric emergency department patients were studied prospectively to determine whether any findings on the physical examination were predictive of abnormalities seen on chest radiograph. We attempted to find possible correlations between such clinical examination findings, recorded prior to radiographic examination, and three subgroups of radiographic findings: pneumonia, any major radiographic abnormality, and any radiographic abnormality whatsoever. The best screen for pneumonia was presence of fever (temperature greater than two standard deviations above age-related norms), with a sensitivity of 94% and a negative predictive value of 97%. The sign with highest positive and negative predictive value for the presence of any radiographic abnormalities was tachypnea. A subgroup with either normal breath sounds, or findings limited to wheezing, prolonged expiration, cough and/or rhonchi on chest examination proved to be at low risk for any major chest radiographic abnormality. Patients with other chest examination findings comprised a high-risk group with a 34% risk of a major radiographic abnormality, as compared to a 7% incidence in the low-risk group. Thus, absence of fever suggests absence of pneumonia, while chest examination findings other than wheezing, cough, prolonged expiration, or rhonchi significantly increase the likelihood of pneumonia in this population. Physical examination findings can help the clinician determine the need for chest radiography in the pediatric emergency patient.

Neonatal aortoiliac compression caused by a distended bladder

Neonatal aortoiliac insufficiency caused by a distended urinary bladder is an unusual occurrence that can be difficult to distinguish from aortoiliac thrombosis. Real-time sonography can permit recognition of the abnormality, demonstration of the related pathophysiology, and exclusion of other causes of aortoiliac occlusion.

Neonatal intracranial hemorrhage and phenobarbital

We enrolled 280 intubated babies with birth weights of less than 1,751 g in a double-blind randomized prospective clinical trial to evaluate whether phenobarbital influences the likelihood of developing subependymal-intraventricular-intraparenchymal hemorrhage. Phenobarbital was associated with an increased risk of developing any subependymal-intraventricular-intraparenchymal hemorrhage and was not associated with a diminished risk of either severe hemorrhage or germinal matrix hemorrhage. This increased risk was apparent even after we considered the influence of phenobarbital levels, timing of phenobarbital administrations, institutional differences, quality of ultrasound scans, gestational age- and birth weight-specific effects, ascertainment bias, and other possible confounders of phenobarbital administration.

Acquired ureteropelvic junction obstruction in childhood

Ureteropelvic junction (UPJ) obstruction is generally considered to be a congenital lesion or occasionally an intermittent phenomena relating to periods of increased urine flow. Acquired ureteropelvic junction obstruction without a recognizable secondary cause is quite unusual. We present a 5.5-year-old boy who, 4 years after repair of a right sided UPJ obstruction, developed a significant left-sided UPJ obstruction in a system which previously had been normal.

Pelvic kidney in cloacal exstrophy

Four of five patients with cloacal exstrophy seen at the Massachusetts General Hospital since 1978 have had pelvic kidneys. This association is discussed and a possible embryological explanation considered.

Computed tomography in stage III neuroblastoma

This multicenter study was designed to determine if CT can assess operability in stage III neuroblastoma. Nineteen children (11 boys, eight girls), aged 2-51 months, considered to have, by conventional clinical and radiographic examinations, localized neuroblastoma that crossed the midline were examined by CT. After intravenous and oral contrast media enhancements, CT was able to show the relation of the tumor to the adjacent vital vessels: aorta, celiac axis, and superior mesenteric artery. In all 15 patients, tumors that encased the aorta or its major branches were unresectable. However, three of four tumors crossing the midline but not coming into contact with the aorta or adherent only to one side of the vessel could be resected. Because surgery currently plays the major role in the treatment of neuroblastoma, the relation of the tumor to the aorta and great vessels is a more reliable and important factor in predicting the outcome of these children than the extension and location of the tumor with reference to the midline. CT after intravenous contrast enhancement can establish this relation and assess resectability.

Low-dose transaxial tomography. An alternative to computed tomography for the evaluation of anteversion of the femur during childhood

Low-dose transaxial tomography is a technique that can produce cross-sectional images of the hips and femurs in children to permit calculation of the angle of femoral anteversion. Transaxial tomography was compared with computed tomography in terms of measured radiation dose and image quality. Transaxial tomography was found to require at least 90% less radiation dose, and the images were judged to be acceptable for the determination of anteversion.

[False mass of the thoracic wall in obese adolescent girls]

Each of four obese adolescent females were thought to have pre-sternal anterior chest wall "masses" when evaluated by lateral chest radiograph. All had normal physical examinations. The apparent chest wall masses were found to be an artifact created by partial midline contact of both, large breasts, surrounded by a partial midline air space adding contrast to the adjacent soft tissue. Manual abduction of the breasts was followed by disappearance of the apparent radiographic abnormality.

CT of neonatal herpes encephalitis

Seven neonates with proven herpes (HSV type 2) encephalitis exhibited a characteristic sequence of findings on cranial computed tomography (CT). The initial CT abnormalities in all infants were fingerlike areas of cortical increased attenuation noted on unenhanced scans obtained 2-30 days after presentation. These usually were accentuated by increased white-matter lucency. Subsequently (more than 30 days after presentation), extensive cerebral destruction, multicystic encephalomalacia, and calcification were seen on follow-up CT scans obtained in five infants.

Small carpal bone surface area, a characteristic of Turner's syndrome

An abnormality which has received little attention but may be easily recognized on radiographs of the hand of patients with Turner's syndrome is described. Eleven of thirty-one patients (35.5%) with Turner's syndrome were shown on radiographs of the hand to have a visually detectable smallness on the bone surface area of the carpus when compared to the area of the second through fifth metacarpals. Values for the "C/M" ratio (the area of the carpals divided by the area of the second through fifth metacarpals) were calculated for films of 31 individuals with gonadal dysgenesis and compared with those from bone age-matched films of seventy-six individuals with normal development of the hand and wrist. A consistent difference with minimal overlap was documented. For all of the films of patients with Turner's syndrome the C/M ratio averaged 89% of the value in the films of the controls. In the 11 patients in whose films smallness was visually apparent, the C/M ratio averaged 82% of controls while in those where the diminution was detected only by planimetry the C/M ratio averaged 91% of controls. The incidence of a diminished C/M ratio was compared with the incidence of four other previously described signs of Turner's syndrome; although not seen as often as the coarse reticular pattern or delayed bone age, the C/M sign was recognizable without planimetry at least as commonly as the "metacarpal sign," and a decreased carpal angle and/or Madelung's deformity. Taken together, these several criteria suggest the radiographic diagnosis of Turner's syndrome in more than 93% of cases.

Premature sternal fusion in gonadal dysgenesis with coarctation

Gonadal dysgenesis and coarctation of the aorta were found in four patients to be associated with premature sternal fusion but possible etiologic relationship to shield chest deformity in suggested.

Esophageal stricture secondary to drug-induced toxic epidermal necrolysis

Toxic epidermal necrolysis is a cutaneous disorder with high morbidity and mortality. Esophageal stricture has rarely been reported following recovery from this abnormality. A case is presented demonstrating the occurrence of an esophageal stricture following successful therapy. New methods of treatment are changing the mortality and morbidity such that esophageal stricture will be observed more frequently.

Gastroesophageal reflux in children: results of a standardized fluoroscopic approach

This retrospective study of 470 children undergoing barium upper gastrointestinal examinations was performed with three goals in mind: (1) to document the incidence of gastroesophageal reflux discovered during standardized upper gastrointestinal examination; (2) to compare the amount of gastroesophageal reflux detected in patients with symptoms suggestive of reflux as opposed to those who had no such symptoms; and (3) to ascertain the effect on reflux of the presence of a lower esophageal "beak." About 65% of the children studied had gastroesophageal reflux. Reflux was seen more commonly when symptoms of reflux were present (75.9%) than when not (36.8%). The amount of reflux seen over 5 min was greater if symptoms were present (mean incidence 2.72 bouts) than when not (mean incidence 0.76 bouts). Most importantly, there was a significant decrease in the amount of reflux seen with increase in patient age; age-related criteria for "acceptable" gastroesophageal reflux are presented. The presence of an esophageal "beak" is associated with an increased amount of reflux (94.4%) as opposed to no such "beak" (67.8%). The data suggest that gastroesophageal reflux is present in a large percentage of pediatric patients, whether there are symptoms to suggest reflux or not. Since reflux diminishes with increasing age, age-related criteria for an "acceptable" amount of reflux should be used rather than a universal judgment based on three episodes. Reflux to the cervical esophagus occurs frequently, both with and without symptoms of reflux, and may not be a reliable solitary indication for therapy. An esophageal "beak" is associated with an increase in reflux and may have important prognostic implications.

Duplication of the müllerian ducts and genitourinary malformations. Part II: analysis of malformations

Forty-seven females with duplication of the uterus and cervix were retrospectively studied to obtain a better understanding of the reasons for failure of fusion of the müllerian ducts by analyzing the associated genitourinary malformations. Thirty-one of the 47 patients had major genitourinary malformations that corresponded to three main complexes of anomalies. Cloacal anomalies were present in 16 patients, exstrophy in two, and combined cloacal and exstrophic deformities in another two. Renal malformations ipsilateral to a unilateral occluded müllerian duct were seen in 11 patients, and in four of these an ectopic ureter opened into the occluded duct. From the analysis of these anomalies it is proposed that duplication of the female genital system, when not an isolated event, may be secondary to interference of the normal process of müllerian fusion by a persistent cloacal duct, an abnormal pelvic girdle, or an ectopic ureter.