Contrast-enhanced MR angiography (CE-MRA) in the evaluation of vascular complications of renal transplantation

Vascular complications associated with renal transplantation merit urgent investigation since they are often correctable, and timely intervention can help salvage the graft kidney. Contrast-enhanced MR angiography (CE-MRA) is a promising non-invasive technique, uses relatively non-nephrotoxic contrast agents and can rapidly demonstrate the underlying lesion in most instances. In this pictorial review we present the spectrum of abnormalities, as well as the pitfalls of interpretation of CE-MRA, that we encountered in 41 cases where there was clinical suspicion of vascular complications of renal transplantation. We believe that CE-MRA is a valuable, non-invasive screening technique in these cases, and further investigation and management of these patients can be confidently tailored to the results of the CE-MRA study.

Macrophage activation syndrome: a potentially fatal complication of rheumatic disorders

AIMS

To review the precipitating events, clinical features, treatment, and outcome of macrophage activation syndrome (MAS).

METHODS

Retrospective review of cases of MAS from a prospectively collected database of children with rheumatic diseases from 1980 to 2000.

RESULTS

Nine patients (eight girls) were considered to have evidence of MAS. The primary diagnosis was systemic onset juvenile idiopathic arthritis in seven, enthesitis related arthritis in one, and chronic infantile neurological cutaneous articular syndrome in one. Mean age of onset was 5.7 years, and duration prior to MAS, 4.2 years. No medication was identified as a trigger. Eight had infections prior to MAS; specific infectious agents were identified in four. High grade fever, new onset hepatosplenomegaly, and lymphadenopathy were common clinical features. Platelet counts fell dramatically, from an average of 346 to 99 x 10(9)/l. Mean erythrocyte sedimentation rate (in three patients) fell from 115 to 28 mm/h. Eight had abnormal liver function during the disease course, and six had coagulopathy. Bone marrow examination supported the diagnosis with definite haemophagocytosis in four of seven. All received high dose steroids (eight intravenous, one oral), five cyclosporin, two cyclophosphamide, and one antithymocyte globulin. Two of three patients with significant renal impairment died.

CONCLUSION

MAS is a rare and potentially fatal complication of childhood rheumatic disorders. Most of our patients were female, and most cases were preceded by infection. Bone marrow studies support the diagnosis. Deranged renal function may be a poor prognostic sign. Aggressive early therapy is essential.

Central nervous system complications in two cases of juvenile onset dermatomyositis

Central nervous system (CNS) complications are rarely reported in either juvenile or adult onset inflammatory myositides, such as dermatomyositis and polymyositis. We report two children, aged 4 and 10 yr respectively, with a diagnosis of juvenile dermatomyositis, both of whom subsequently developed clinical features of severe CNS involvement, possibly consistent with cerebral vasculopathy. One child died from apparent brainstem involvement; the other developed seizures, pseudoseizures and clinical depression which responded to aggressive immunosuppression. Although the vasculopathy or vasculitis underlying this disorder is known to have a systemic distribution, CNS involvement has rarely been reported and may be under-recognized.

MR spectrum in spinal dysraphism

Spinal dysraphism is a general term which encompasses a wide variety of anomalies of the spine, all of which result from imperfect midline fusion of the embryonic neural tube. This term refers to large defects that involve the spine and not to small vertical clefts commonly seen within the spinal process of L5 or S1. We present a spectrum of MR imaging findings selected from a retrospective review of 100 patients of spinal dysraphism evaluated at our institution.

The British version of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ)

We report herein the results of the cross-cultural adaptation and validation into the British language of the parent's version of two health related quality of life instruments. The Childhood Health Assessment Questionnaire (CHAQ) is a disease specific health instrument that measures functional ability in daily living activities in children with juvenile idiopathic arthritis (JIA). The Child Health Questionnaire (CHQ) is a generic health instrument designed to capture the physical and psychosocial well-being of children independently from the underlying disease. A total of 440 subjects were enrolled: 219 patients with JIA (17% systemic onset, 41% polyarticular onset, 33% extended oligoarticular subtype, and 9% persistent oligoarticular subtype) and 221 healthy children. The CHAQ clinically discriminated between healthy subjects and JIA patients, with the systemic, polyarticular and extended oligoarticular subtypes having a higher degree of disability, pain, and a lower overall well-being when compared to their healthy peers. Also the CHQ clinically discriminated between healthy subjects and JIA patients, with the systemic onset, polyarticular onset and extended oligoarticular subtypes having a lower physical and psychosocial well-being when compared to their healthy peers. In conclusion the British version of the CHAQ-CHQ is a reliable, and valid tool for the functional, physical and psychosocial assessment of children with JIA.

Alteration of sonographic texture of the endometrium in post-menopausal bleeding. A guide to further management

BACKGROUND

The purpose of this study was to assess the utility of transvaginal ultrasonography in the evaluation of endometrial morphology in addition to the standard criterion of endometrial thickness for selecting patients for endometrial sampling.

METHODS

Two hundred and seven consecutive cases of postmenopausal bleeding were evaluated by transvaginal ultrasound. Endometrial thickness was measured as the maximum anteroposterior thickness of the endometrium including both the anterior and posterior layers, in the sagittal long axis view. The morphology of the endometrium was studied and categorized as homogeneous, focally increased echogenecity, diffusely increased echogenecity or diffusely inhomogeneous. Patients were followed up for clinical course and endometrial histopathology.

RESULTS

Textural inhomogeneity was observed in all the three cases of endometrial cancers with endometrial thickness of less than 6 mm, and, in ten out of 11 cases of a more than 6 mm thick endometrium. On the other hand the endometrial texture was homogeneous in all cases of endometrial atrophy/tissue inadequate for diagnosis, with thickness of less than 6 mm.

CONCLUSION

This study adds the dimension of abnormal echogenecity of the endometrium to the currently followed criterion of endometrial thickness with a view to enhance accuracy, both for a better prediction of atrophy and a higher prediction for endometrial cancer. Expectant management can be offered to patients with a homogeneous endometrium which is 6 mm thick or less. Aggressive evaluation for a malignancy must be made if there is a focal increased echogenecity or a diffuse increased echogenecity even in a thin endometrium.

Deep-seated thoracic and abdominal masses: usefulness of ultrasound and computed tomography guidance in fine needle aspiration cytology diagnosis

Fine needle aspiration cytology (FNAC) was performed under ultrasound and CT guidance in 120 cases. These included abdominal masses (85 cases) and thoracic masses (35 cases) biopsied over a two and a half year period (March 1996 to September 1998). The aim of this study was to assess the contribution of clinico-imaging evaluation and image-guided FNAC to the management of patients with deep-seated mass lesions. Aspirations in the abdomen were performed from various anatomic sites such as liver (56 cases), lymph nodes (18 cases), gastrointestinal tract (three cases), pancreas (six cases), and kidney (two cases). In the thorax, biopsy was performed in the lung (19 cases) and mediastinum (13 cases). In 112 cases (93.4%) FNAC was diagnostic. Of the lesions that were successfully aspirated, 85% were < or = 5 cm in size. No major complication was encountered. All the successful aspirates could be defined as malignant or non-malignant, but tissue differentiation was possible in 63.7% of malignant lesions and 53.8% of benign lesions. Combined clinical and imaging evaluation for malignancy showed 80% sensitivity and 59% specificity. Although clinicoradiological parameters themselves have certain limitations in diagnosing benign versus malignant lesions, in conjunction with guided FNA they are very accurate and safe in diagnosing deep-seated mass lesions in the thorax and in the abdomen. However, the role of FNA in tissue differentiation of solid lesions such as lymphoma requires further study.

CT portography by direct intrasplenic contrast injection: a new technique

BACKGROUND

The evaluation of percutaneous contrast injection into splenic parenchyma as an alternative technique for computed tomographic (CT) portography in the preoperative assessment of primary hepatobiliary tumors.

METHODS

Thirty-two patients underwent a nonenhanced CT scan of the liver, after which a 19-gauge, 10-cm-long needle was introduced into the splenic parenchyma under CT guidance. One hundred forty milliliters of contrast medium (200 mgI/mL; 28 g/I) were injected through this needle: first, a 20-mL bolus (in 5 s) and then 2 mL/s for 60 s. At the end of the bolus injection (5 s), 8-mm-thick contiguous axial scans of the liver were obtained.

RESULTS

The success rate of the procedure was 93.7% (30/32; two technical failures). The average time required for the entire study was 13 min and 50 s (range = 7 min 53 s to 25 min 17 s). Hepatic parenchymal enhancement was good in 24/30 (80%), moderate in 3/30 (10%), and unsatisfactory in caudal sections of the liver in 3/30 (10%). Artifactual perfusion defects were seen in 4/30 (13%) due to inadvertant injection of small quantities of air. Intrasplenic subcapsular contrast accumulation occurred in 56.2% (18/32; minimal 15, moderate 3), extrasplenic contrast leakage in 12. 5% (4/32), and left shoulder pain in 18.7% (6/32). No major complications were observed.

CONCLUSIONS

Direct intrasplenic contrast injection for CT portography is a simple, effective, and safe technique with a high success rate and requires significantly less time and lower doses of contrast medium; it also eliminates angiography, indwelling arterial catheters, and patient transfers from angiography to the CT area.

Sonographic appearances and percutaneous management of primary tuberculous liver abscess

Primary tuberculous liver abscesses are rare. We report on 3 patients who presented with a nonresolving abscess in the liver. Clinical presentation and sonographic findings in each case were nonspecific. A diagnosis of tuberculosis was established with microbiologic examination of pus in 2 cases and examination of an excised abscess wall in 1 case. Needle aspiration (1 patient) and short-term (72 hours) catheter drainage (1 patient) were unsuccessful, and surgical excision was required in these patients. In the third patient, continuous catheter drainage over 18 days resulted in cure, indicating that long-term catheter drainage with antituberculous chemotherapy may be a viable alternative to surgery in the management of primary tuberculous liver abscess.

Chest wall tuberculosis simulating breast carcinoma: imaging appearance

Tuberculosis of the breast is a rare disease. Tubercular abscesses predominantly affecting the soft tissues are also very infrequent. A case of chest wall tuberculosis secondarily involving the breast presenting as a hard, fixed lump simulating mammary carcinoma is presented here. There was no evidence of pleural or pulmonary tuberculosis.

Occlusive arterial disease of the upper extremity: colour Doppler as a screening technique and for assessment of distal circulation

A prospective study was performed to evaluate the sensitivity of colour Doppler flow imaging (CDFI) in the detection of occlusive arterial disease in the upper limb (using angiography as the standard) and to quantify the severity of the disease. Twenty-one ischaemic and 15 healthy limbs were studied by intra-arterial digital subtraction angiograms (IADSA) and CDFI. Selective subclavian digital subtraction angiograms were performed by the percutaneous transfemoral route. CDFI was performed from the brachial artery superiorly to the subclavian artery origin. Special attention was paid to the study of spectral waveforms and peak systolic velocities at various levels. In each subject, IADSA and CDFI were performed by different radiologists without knowledge of the results of the other investigation. In normal limbs, all arteries demonstrated a characteristic sharp triphasic spectral pattern with mean peak systolic velocity of 105, 80 and 57 cm/s for the subclavian, axillary and brachial arteries, respectively. In ischaemic limbs, reduction in peak systolic value and broadening of the spectral trace with filling in of the spectral window were noted. More characteristic was the finding of a loss of diastolic flow reversal, which was the earliest sign of significant arterial stenosis. The pattern of diastolic blood flow correlated well with the degree of collateral formation and distal vascular runoff. In conclusion, CDFI has a high sensitivity and specificity in the detection of significant arterial stenosis and is thus an ideal, inexpensive screening procedure. Analysis of the diastolic wave-form distal to the stenosis is an indicator of the degree of collateral circulation and distal runoff and thus acts as a prognostic indicator, guiding further investigation and management.

Mesenteric plexiform neurofibroma: computed tomography appearance

Gastrointestinal involvement in von Recklinghausen's disease is usually in the form of neurofibromas and leiomyomas. Very rarely, plexiform neurofibromas may be seen involving the bowel wall and myenteric plexus with secondary minor involvement of the mesentery. This report describes the computed tomography morphology of a plexiform neurofibroma extensively involving the mesentery with minor involvement of the bowel wall.

Diagnosis of abdominal tuberculosis: sonographic findings in patients with early disease

OBJECTIVE

The diagnosis of abdominal tuberculosis is often difficult, because clinical manifestations and results of laboratory studies are nonspecific. If sonographic findings are sufficiently characteristic for diagnosis, sonography would be useful, especially in India, where abdominal tuberculosis is common and more expensive imaging techniques are not easily available. Accordingly, we performed sonography to establish the sonographic findings in cases of early tuberculosis in 56 patients with abdominal tuberculosis who had normal barium studies of the small bowel.

SUBJECTS AND METHODS

Fifty-six patients with clinical features suggestive of abdominal tuberculosis (history of fever, abdominal pain, and weight loss) with no history of intestinal obstruction and normal barium studies of the small bowel had abdominal sonography. All sonograms were independently assessed by three radiologists, and the findings were tabulated by consensus. Diagnosis of tuberculosis was confirmed by sonographically guided biopsy of mesenteric lymph nodes in 19 patients, analysis of aspirated ascitic fluid in 12, and response to antituberculous chemotherapy in 25. Sonography was repeated 1, 3, 6, and 12 months after antituberculous chemotherapy was begun. Abdominal sonograms were also performed in 30 healthy volunteers, and measurements of mesenteric thickness were recorded. The mesenteric thickness was statistically compared in two groups of patients: patients at presentation with patients at the end of antituberculous chemotherapy and patients at presentation with healthy individuals.

RESULTS

The mesenteric thickness in healthy individuals ranged from 5 to 14 mm. Sonographic findings in all patients with abdominal tuberculosis included an echogenic thickened mesentery (> or = 15 mm) with mesenteric lymphadenopathy. Other findings were dilated small bowel loops in 38 patients, minimal ascites in 17, matted small bowel loops in five, and omental thickening with altered echogenicity in three. Regression of these changes was noted on follow-up of all patients undergoing treatment.

CONCLUSION

The characteristic sonographic features of early abdominal tuberculosis are mesenteric thickness of 15 mm or more and an increase in the mesenteric echogenicity (due to fat deposition), combined with mesenteric lymphadenopathy. Presence of dilated small bowel loops and ascites further substantiate the diagnosis.

[A simple alteration in a ureteral double J stent to improve its clinical acceptability]

The authors describe a modification of the classical double J stent designed to improve its clinical acceptability. It consists of cutting the lower J so that the catheter, inserted in the ureter, does not protrude into the bladder. A loop of nonresorbable suture attached to the lower extremity of the stent is passed through the ureteric orifice, allowing its easy extraction. This procedure has been used in eight patients with no complications.

Hepatic granulomas due to visceral larva migrans in adults: appearance on US and MRI

Visceral larva migrans is a syndrome characteristically involving children with a history of pica, and usually presents with fever, abdominal pain, tender hepatomegaly, and hypereosinophilia. Hepatic granulomas of visceral larva migrans are rare in adults. We describe three adult patients with hepatic lesions which on histopathology demonstrated characteristic granulomas of visceral larva migrans. All patients had abdominal sonograms and two had additional MR scans of the liver. Both ultrasound and magnetic resonance imaging demonstrated characteristic appearances which have not been described previously (viz., ill-defined central necrotic areas surrounded by concentric thick walls and perifocal edema in the liver parenchyma).

Computed tomography of vertebral tuberculosis: patterns of bone destruction

A retrospective analysis was performed of CT scans of 30 consecutive patients with a clinical suspicion or diagnosis of spinal tuberculosis. Four patterns of bone destruction were noted, namely, fragmentary, osteolytic, subperiosteal and well-defined lytic with sclerotic margins. The fragmentary type was most common (47%). Intervertebral disc destruction was always associated with contiguous vertebral body destruction. Associated paravertebral soft-tissue masses were seen in all patients. Epidural extension of disease was seen in 66% and showed a very good correlation with neurological signs on clinical evaluation. Bone fragments were detected in the epidural soft-tissue mass in 65% of patients with epidural extension of disease. CT appearances of bone destruction are highly suggestive of tuberculous osteomyelitis in about half the patients.

Hemangioma of spleen with spontaneous, extra-peritoneal rupture, with associated splenic tuberculosis--an unusual presentation

We report a case of unusual presentation of a patient with hemangioma of the spleen. The patient had presented with recurrent gastric hemorrhage and significant weight loss, due to ruptured hemangioma of the spleen and associated splenic tuberculosis. The true nature of the lesions remained a diagnostic dilemma despite complete radiological workup and review of literature.

CT diagnosis of macrodystrophia lipomatosa. A case report

Radiographs and CT scans of a 45-year-old male with progressive enlargement of his right upper limb and shoulder are presented. Extensive soft-tissue hypertrophy with linear radiolucent bands (fat) limited to the lateral aspect of the limb were seen. Exostoses-like bony overgrowth were also seen along interphalangeal joints. At CT, hypertrophic adipose tissue intermingling with muscle fibers was demonstrated, a diagnostic finding distinguishing the lesion from plexiform neurofibrolipomatosis, Klippel-Trenaunay syndrome and other angiomatous lesions.

Influence of intraperitoneal drainage after cholecystectomy; a prospective ultrasonographic study

One hundred and fifty patients were prospectively randomised into 3 groups (50 in each group); to receive a passive drain, closed suction drain or no drain after elective cholecystectomy. The drain was removed within 24 hours in 84% of patients and was continued longer only if the amount of drainage was excessive or bilious. On the 3rd post-operative day, an ultrasound examination was performed in all patients for detection of subhepatic/subphrenic collection. Collections were more frequently encountered in the patients without any drain (42%) followed by passive drain (26%) and suction drain group (20%). Chest complications were frequently noted (passive drain; 6% suction drain, 12%, and no drain, 8%), however, occurrence of this complication in various groups was similar (p > 0.1). Two patients (4%) without drain required ultrasound guided aspiration of subhepatic collection. Mean post-operative hospital stay was nearly equal for all the groups (passive drain: 4.22 +/- 1 days, suction drain: 4.26 +/- 1.4 days and no drain: 4.62 +/- 2.3 days). Drainage reduced the incidence of post-cholecystectomy collections and need for invasive intervention for collection related complications. However, the type of drainage (active or passive) did not influence the incidence of collection, frequency of complications and duration of post-operative hospital stay.