Idiopathic myelofibrosis with generalized periostitis in a 4-year-old girl

Idiopathic myelofibrosis, a chronic myeloproliferative disorder of unknown origin, is characterized by splenomegaly, extramedullary hematopoiesis, leukoerythroblastosis, teardrop erythrocytes, and myelofibrosis. It is a rare disorder in childhood. The authors describe a 4-year-old girl with features consistent with idiopathic myelofibrosis, who also had generalized solid laminated periosteal reaction involving all long bones. The presence of thrombocytopenia at the onset and lack of leukocytosis were in contrast to the reported features seen in children. Recent case reports describe a relatively indolent course in children. Spontaneous remissions have also been described in pediatric cases. The fulminant course of this patient without any features of malignant transformation was noteworthy in this regard.

Chemotherapy-induced palmer planter erythrodysesthesia

We report a case of palmar plantar erythrodysesthesia (PPE) in a case of acute lymphoblastic leukemia treated with VALP regime. The treating physician must be aware of this uncommon complication of chemotherapeutic agents to avoid unnecessary investigations.

Congenital hypofibrinogenemia

Congenital afibrinogenemia/hypofibrinogenemia is an extremely rare coagulation disorder. We describe a case of congenital hypofibrinogenemia in a 6-year female child, who presented with recurrent ecchymotic spots with no frank bleeding.

Solitary calvarial metastases: an unusual presentation of thoracic neuroblastoma

A primary thoracic origin occurs only in 20% of neuroblastomas, and their classical presentation is mediastinal or cord compression. Skeletal metastases of neuroblastomas are characteristically multiple, and calvarial deposits usually show simultaneous involvement of orbit. Solitary metastases in neuroblastoma, is an unusual entity and its presentation as a large calvarial mass, especially from a thoracic primary, is rare. Furthermore, calvarial metastases are relatively uncommon in children compared to adults. We discuss the clinical, radiographic, CT features, and differential diagnosis of a large calvarial mass with sunray spiculation in a child, which was due to a solitary metastases from an occult thoracic neuroblastoma. The possibility of neuroblastoma presenting in this unique fashion and the importance of considering a chemosensitive tumor such as neuroblastoma in the differential diagnosis of a solitary calvarial mass in a child is highlighted by our report.

Development of a Personal Digital Assistant (PDA) based client/server NICU patient data and charting system

Personal Digital Assistants (PDAs) offer clinicians the ability to enter and manage critical information at the point of care. Although PDAs have always been designed to be intuitive and easy to use, recent advances in technology have made them even more accessible. The ability to link data on a PDA (client) to a central database (server) allows for near-unlimited potential in developing point of care applications and systems for patient data management. Although many stand-alone systems exist for PDAs, none are designed to work in an integrated client/server environment. This paper describes the design, software and hardware selection, and preliminary testing of a PDA based patient data and charting system for use in the University of Washington Neonatal Intensive Care Unit (NICU). This system will be the subject of a subsequent study to determine its impact on patient outcomes and clinician efficiency.

Choroid plexus changes after temporal lobectomy

BACKGROUND AND PURPOSE

Postoperative contrast-enhanced MR imaging of the brain is routinely used when evaluating for residual or recurrent brain tumor. It is imperative to be aware of morphologic changes and imaging features that typically occur in response to surgical manipulation at the postoperative site to avoid misinterpretation of imaging findings. Our purpose was to determine normal postoperative changes and alterations in the choroid plexus among patients who had undergone temporal lobectomy in order to distinguish this appearance from pathologic changes that may be seen in the presence of infection or recurrent tumors.

METHODS

We reviewed 159 MR scans from 95 patients with hippocampal sclerosis or gliosis who underwent temporal lobectomy for treatment of intractable epilepsy. Choroid plexus location and size were assessed on contrast-enhanced T1-weighted images.

RESULTS

After temporal lobectomy, the choroid plexus enlarged and sagged into the resection site. Increase in the size of the choroid plexus occurred in 58% of cases overall. The degree of enhancement also increased after surgery, sometimes resulting in a nodular pattern of enhancement. The changes were most marked during the 1st week after temporal lobectomy, and showed an enlarged, markedly enhancing choroid plexus on 86% of the scans.

CONCLUSION

Postoperative changes of the choroid plexus after temporal lobectomy include sagging into the resection site, an increased size, and an increased degree of enhancement. Normal postoperative morphologic characteristics may mimic neoplastic enhancement pattern. Familiarity with this appearance is important to avoid a pitfall in diagnosis of recurrent postoperative temporal lobe neoplasms.

Embolotherapy in the bronchial and pulmonary circulations

This two-part article first discusses the role of bronchial artery transcatheter embolotherapy in the management of patients with hemoptysis. Following this discussion, the authors review pulmonary arteriovenous malformations, their embolization, follow-up protocols, and outcome criteria as currently practiced at the authors' Vascular Malformation Center.

Embolotherapy of pulmonary arteriovenous malformations with detachable balloons: long-term durability and efficacy

PURPOSE

To determine long-term durability and efficacy of pulmonary arteriovenous malformation (PAVM) embolotherapy using detachable gold valve latex (GVB) and silicone balloons (DSB).

MATERIALS AND METHODS

Eighty-two patients were treated with either GVBs or DSBs between 1991 and 1996. Complete follow-up, consisting of chest radiography or high-resolution chest computed tomography, was obtained in each patient between 1996 and 1998. The PAVM was considered cured if the aneurysmal portion was involuted with or without a small residual scar.

RESULTS

Eighty-two of the 85 DSBs (96%) were inflated 2-4 years later, and none of the 56 GVBs remained inflated 1-3 years after placement. Despite early deflation of the GVB (91% at 1 month), only one PAVM persisted in both groups (DSB and GVB). Clinical and radiographic involution of the PAVMs was complete in all patients except one, who was easily re-treated. No migration of DSBs or GVBs to the systemic circulation occurred.

CONCLUSIONS

DSBs and GVBs provide immediate cross-sectional occlusion of PAVM and are equally effective in "curing" the PAVM. The DSBs remain inflated 2-4 years after placement provided isoosmotic contrast material is used to inflate them and volume recommendations are adhered to. No early or late migration of the DSB or GVB occurs, provided they are securely placed.

Haemorrhage during cranial CT : spontaneous or contrast related?

Two cases of haemorrhage during cranial computed tomography (CT) occurring during the enhancement phase of CT examination immediately after the administration of intravenous contrast medium are reported. In both cases, the preceding unenhanced scansshowed evidence of haemorrhage. The risk of aneurysmal rupture as a result of retching and vomiting induced by intravenous contrast is stressed. Judicious use of contrast enhanced CT is suggested in patients with suspected aneurysmal subarachnoid haemorrhage.

Percutaneous needle aspiration of small interloop abscesses in children

Treatment of small postoperative interloop abscesses (ILA) can be challenging. In children, these collections have usually been drained surgically at a second operation. This article describes three children with small postoperative ILAs who were treated by percutaneous needle aspiration and parenteral antibiotics, with good outcomes. The advantages of this technique and its utilization in the management of children with ILAs are discussed.

Hemophilia presenting in an infant as a radial artery pseudoaneurysm following arterial puncture

The case presented is of an infant who developed a radial artery pseudoaneurysm following arterial puncture and was subsequently diagnosed with hemophilia. A discussion of radial artery pseudoaneurysms follows.

Structure-activity relationships among 2-substituted 5,6-dichloro-, 4,6-dichloro-, and 4,5-dichloro-1-[(2-hydroxyethoxy) methyl]- and -1-[(1,3-dihydroxy-2-propoxy) methyl]benzimidazoles

The sodium salt of 2,5,6-trichlorobenzimidazole (8a) was condensed with [2-(benzyloxy)ethoxy]-methyl chloride (9) and [1,3-bis(benzyloxy)-2-propoxy]methyl chloride (18) to provide the corresponding protected acyclic nucleosides 10a and 19a, which on debenzylation afforded 2,5,6-trichloro-1-[(2-hydroxyethoxy)methyl]benzimidazole (11a) and 2,5,6-trichloro-1-[(1,3-dihydroxy-2-propoxy)methyl] benzimidazole (20a), respectively. A similar condensation of 2,4,6-trichlorobenzimidazole (2a) and 2,4,5-trichlorobenzimidazole (7a) followed by debenzylation yielded 11b, 20b, 11c, and 20c, respectively. A nucleophilic displacement of the 2-chloro group of 11a-c and 20a-c with liquid ammonia, methylamine, dimethylamine, and thiourea furnished several interesting 2-substituted compounds in good yields, e.g., 12-14(a-e), 21-23(a-e), 15-17, and 24-26. Alkylation of the 2-thio analogs 15-17 and 24-26 with benzyl chloride furnished the 2-alkylthio acyclic nucleosides 12d-14d and 21d-23d. Desulfurization of 15 and 24 with Raney Ni furnished 5,6-dichloro-1[(2-hydroxyethoxy)methyl]benzimidazole (12e) and 5,6-dichloro-1-[1,3-dihydroxy-2-propoxy)methyl]benzimidazole (21e), respectively (acyclic analog of 5,6-dichloro-1-beta-D-ribofuranosylbenzimidazole). Similarly the dihalo compounds 13e, 14e, and 23e were prepared in moderate yields from the 2-thio analogs 16,17, and 26. Treatment of 2-bromo-5,6-dichlorobenzimidazole (8b) with 27 and 30 gave the protected acyclic compounds 28a and 31a, which on deacetylation with sodium carbonate and potassium cyanide yielded 2-bromo-5,6-dichloro-1-[(2-hydroxyethoxy)methyl]benzimidazole (29a) and 2-bromo-5,6-dichloro-1-[(1,3-dihydroxy-2-propoxy)methyl]benzimidazole (32a), respectively, in moderate yields. The 2-bromo-4,6-dichlorobenzimidazole and 2-bromo-,5-dichlorbenzimidazole analogs 29b,c and 32b,c were prepared in a similar manner. Compounds were tested for activity against human cytomegalovirus (HCMV) and herpes simplex virus type 1 (HSV-1) and for cytotoxicity. In marked contrast to the ribosylbenzimidazoles, none of the acyclic analogs were specific and potent inhibitors of HCMV. Only the 2-thiobenzyl analogs 12d, 13d, 14d, and 23d and the 2-Br analogs 32a,b were active, but activity was not well separated from cytotoxicity. The lack of specific and potent antiviral activity strongly suggests that these acyclic nucleoside analogs are not phosphorylated by HCMV or HSV-1 gene products and that the ribosylbenzimidazoles do not require phosphorylation for antiviral activity.

Tuberculous mainstem bronchostenosis in a ten-year-old girl

Tuberculous bronchostenosis involving the main bronchus is rare in children. We describe a 10-year-old girl who developed left mainstem tuberculous bronchostenosis inspite of effective and adequate chemotherapy for which she underwent a left pneumonectomy.

Small cell lung cancer presenting as Cushing's syndrome

A rare case of small cell carcinoma of the lung who presented with Cushing's syndrome and superior vena cava syndrome is described. The relevant literature is reviewed.

Evaluation of a polymerase chain reaction for the diagnosis of tuberculosis

A polymerase chain reaction for the specific detection of Mycobacterium tuberculosis has been developed and evaluated for clinical applicability. Primers were designed to amplify a 240 base pair region in the MPB 64 protein coding gene (nts 460-700). From among 15 different DNA templates tested (including 10 species of mycobacteria) PCR amplified the DNA from M. tuberculosis complex only, demonstrating its exquisite specificity. Sensitivity studies using serial ten-fold dilutions of M. tuberculosis bacilli determined the limit of detectability to be 10 organisms. A total of 143 clinical specimens were analysed. This consisted of 26 known non-tuberculous specimens (control group) and 117 specimens received at the Tuberculosis Diagnostic Service of AIIMS (test group). None of the specimens in the control group was positive by PCR. Out of 117 specimens in the test group, 19 were culture positive for mycobacteria and 17 of these isolates were identified as M. tuberculosis. All the specimens from which M. tuberculosis was grown were also PCR positive. The remaining two isolates were identified as mycobacteria other than M. tuberculosis and these two specimens were PCR negative. An additional 14 culture negative specimens were PCR positive yielding an overall M. tuberculosis positivity rate of 26.5% (31/117) compared to 14.5% (17/117) by culture. The superior sensitivity of PCR over culture was more evident in non-pulmonary cases where PCR picked up 10 cases in addition to three culture positives out of 69 specimens. On the other hand, out of 48 pulmonary specimens only four cases in addition to 14 culture positives were picked up by PCR.