Complete cartilage-ring tracheal stenosis associated with anomalous left pulmonary artery: the ring-sling complex

The persistent high mortality in infants with pulmonary artery "sling" (retrotracheal anomalous left pulmonary artery) is primarily due to the coexistence in such patients of long-segment tracheal stenosis due to complete cartilage rings. Five such patients are reported. Airway studies (by filtered high-kV radiography, bronchography, and/or CT) showed low carina, horizontal equal-length right and left mainstem bronchi, and long-segment tracheal stenosis. The length of the stenosis far exceeded the contact with the pulmonary sling. The suggested term "ring-sling complex" for such patients correctly places emphasis on detection of the tracheal malformation, which currently has no satisfactory surgical treatment.

Transient focal liver scan defects in children receiving chemotherapy (pseudometastases). Work in progress

Three pediatric patients with tumors (two rhabdomyosarcoma, one Wilms tumor) had significant focal defects on Tc-99m sulfur colloid scans while receiving chemotherapy (all three had received chemotherapy, including actinomycin D, within ten days prior to scanning). In all three, the defects resolved spontaneously; one biopsy showed fibrosis of a mild degree. The finding of defects on liver scans of pediatric patients receiving chemotherapy must not be automatically assumed to be metastatic disease; the changes may relate to hepatic response to recently administered chemotherapy.

Localized pneumothorax adjacent to a collapsed lobe: a sign of bronchial obstruction

In the presence of lobar collapse due to bronchial obstruction with increased recoil of the affected lobe, an unusual localized pleural collection of air may result. Three patients are reported in whom obstruction of the right upper lobe bronchus resulted in radiographic findings of a dense contracted right upper lobe with an adjacent apical intrapleural gas collection. The gas resolved after bronchoscopic removal of foreign bodies in two patients and after removal of an endotracheal tube from the intermediate bronchus in the third patient.

Unilateral vesicoureteral reflux and unilateral nonfunctioning kidney associated with posterior urethral valves--a syndrome?

From 1964 to 1982 we treated 8 patients with unilateral vesicoureteral reflux and posterior urethral valves. The majority of these ureters with reflux are associated with ipsilateral renal nonfunction and prompt upper tract decompression appears to salvage few such kidneys. Contralateral function has been excellent and the long-term prognosis appears good. Of the 8 patients 6 ultimately underwent nephrectomy. Surprisingly, there was no evidence for true dysplasia or significant inflammation in these specimens. The segmental changes were most consistent with an acquired process, secondary to reflux rather than primary dysplasia.

Neuroblastoma with intraspinal (dumbbell) extension

Twenty-three patients with neurogenic tumors having extradural extension (dumbbell tumors) were treated over a 30-year period. Three had ganglioneuroma, 6 had ganglioneuroblastoma, and 14 had neuroblastoma. Nineteen patients with malignant tumors had symptoms of spinal-cord compression; three patients with ganglioneuroma and one with a malignant tumor had no neurologic symptoms. Delays in diagnosis were frequent ranging from 6 weeks to 3 years in 10 patients. Sixteen patients had abnormal x-rays of the spine. All patients with malignant tumors had positive myelograms. Three patients with ganglioneuroma and 13 with malignant tumors are alive and free of disease. Seven patients with malignant tumors died: five with stage IV and 1 with stage III tumors from disease, and 1 with stage II tumor during laminectomy. Age and stage were important prognostic factors; location was not. Treatment consisted of excision and radiation or radiation only. Patients receiving lower-dose (less than 2000 rad) radiation did as well as those receiving much larger doses. Morbidity in patients with malignant tumors was high; 4 have spinal deformity (3 severe) and 8 of 13 surviving patients have residual neurologic deficits. Earlier diagnosis, a surgical approach which does not introduce morbidity, and low-dose radiation in younger patients are important factors in reducing morbidity.

The diagnostic approach to ectopic ureterocele and the renal duplication complex

The child with ectopic ureterocele frequently presents a diagnostic challenge. The use of standard excretory urography combined with newer modalities, such as ultrasonography and radionuclide renal scanning, provides an orderly diagnostic approach to ectopic ureterocele. This integrated approach should ensure the highest yield in a diagnostic sense and aid in assessing upper tract function, thus, helping with the selection of the proper surgical management.

Childhood typhlitis: its increasing association with acute myelogenous leukemia. Report of five cases

Five children with acute myelogenous leukemia (AML) are described in whom typhlitis developed early in the course of the disease. The plain and barium-enema radiographic findings of mass effect and bowel edema ("thumbprinting") were similar among the cases, although nonspecific. The increasing association of typhlitis with AML and its earlier appearance in the course of the disease should be recognized.

Urinary extravasation in the newborn male with posterior urethral valves

Neonatal urinary extravasation is a rare condition frequently associated with posterior urethral valves in males. At the Babies Hospital, Columbia Presbyterian Medical Center during a 16-yr period, 5 neonates with urinary extravasation and valves presented--of all valve patients. Presentation was characterized by abdominal distention and varying degrees of azotemia. Treatment consisted of upper tract drainage in two cases and lower tract decompression in three. The mortality of this series was zero. At follow-up all five patients had completely normal serum renal function studies; four out of five had essentially normal radiographic studies. Extravasation appeared to protect the upper tracts from significant damage. Successful management of this condition should be tailored to the individual patient.

HLA-B27-associated spondyloarthritis and enthesopathy in childhood: clinical, pathologic, and radiographic observations in 58 patients

HLA-B27 typing of all arthritic children helped to identify and focus attention on a subset whose disease was pathogenetically related to and demonstrated clinical features of ankylosing spondylitis and Reiter syndrome, but only rarely fulfilled current diagnostic criteria for those disorders (spondyloarthritis). In contrast to other forms of childhood arthritis, enthesopathy (inflammation at the sites of attachment of ligaments and tendons to bone) was a prominent feature in 75%; a family history of similar arthritis was obtained from 60%; boys were more frequently affected (2:1); urethritis, acute iritis, conjunctivitis, or keratoderma blennorrhagicum occurred at some time in 42%; and the initial attack followed an unexplained febrile illness, known dysentery or urethritis, or severe musculoskeletal trauma in 41%. The arthritis was generally pauciarticular, asymmetric, and primarily in the feet and large joints of the lower extremities. Distinctive radiographic features included periostitis, severe osteopenia, calcaneal erosions, and heel spurs; three of 58 had rapid destruction of a single joint. Only ten patients (all boys) were found to have radiographic sacroiliitis after an average of five years of disease, and only three had the Reiter triad. The lifetime risk of sacroiliitis and spinal ankylosis can only be determined by long-term follow-up of such prospectively identified groups of spondyloarthritic children.

The ureteral "J" sign: radiographic demonstration of iatrogenic distal ureteral obstruction after ureteral reimplantation

Progressive caliceal and ureteral dilatation in postoperative patients is assumed to be secondary to either postoperative distal ureteral stricture or ureteral atony. Any study used to differentiate obstruction from atony must be done with an awareness of the effect of a full bladder on the upper tracts, since it can by itself produce varying degrees of ureteral dilatation. We describe 2 patients who had virtually complete distal ureteral obstruction on anterograde pyelography with a "J" shaped distal ureteral segment. The striking observation was that the deformity and associated distal ureteral obstruction could be made to appear and disappear at will, merely by distending or emptying the bladder. We believe that this is an important factor in the progressive dilatation, as well as in the observed deterioration of renal function, and it is properly regarded as an iatrogenic complication.

Hypophosphatemic rickets in an adolescent cured by excision of a nonossifying fibroma

An adolescent girl complaining of chronic heel pain was found to have acquired hypophosphatemic rickets and a nonossifying fibroma of the femur. The hypophosphatemic rickets was completely corrected by surgical excision of the bone lesion. This case represents another example of tumor-induced osteomalacia.

Pulmonary edema in infants who receive contrast material

Radiologists should exercise care in the selection of a method for screening infants. Since pulmonary edema can occur in infants who receive typical doses of contrast materials for urograms, alternate methods of screening should be considered. When urograms are obtained, radiologists should observe guideline specific to pediatric urography.

Kayexalate: a new cause of neonatal bowel opacification

Two cases of neonatal bowel opacification secondary to oral and rectal administration of Kayexalate (sodium polystyrene sulfonate) are presented. Abdominal radiographs of both infants showed a faint, homogeneous increase in density within the bowel lumen. The properties of Kayexalate and its possible interactions with the gastrointestinal tract are discussed. Kayexalate administration should be included in the differential diagnosis of bowel opacification.

Low lung capacity and hypoxemia in children with thalassemia major

We evaluated lung function in 17 children with thalassemia major in stable condition receiving blood transfusions at regular intervals and subcutaneous desferoxamine daily. Total lung capacity (TLC) was below 2 SD of normal values for height in 7 of the 17 children and arterialized capillary PO2 was below the normal range in 15. We studied lung mechanics in 4 children with reduced TLC and found static and dynamic compliance below 2 SD of normal values for height in 3, and lung recoil at TLC above normal values and specific upstream conductance (Gus/TLC) above 2 SD of normal values in all 4. Although these alterations in lung function have been described in patients with pulmonary fibrosis, we found no fibrosis in autopsy specimens of lung from 8 other patients with thalassemia. The rate constant of carbon monoxide diffusion (kCO) was above the predicted mean in 14 of 15 children. These findings can be explained by a decrease in the growth of airspace relative to the vascular bed and major airways during childhood.

Acute lymphocytic leukemia masquerading as acute osteomyelitis. A report of two cases

Two children each developed a focal destructive bone lesion accompanied by intermittent fever, swelling, tenderness and elevated ESR. Blood counts were normal; bone marrow aspiration showed acute leukemia. The bone lesions healed in both patients after anti-leukemic therapy. We suggest that the similar roentgenographic appearance of osteomyelitis, bone infarction and focal destructive lesions in leukemia probably reflects a common, basically ischemic process of bone.

Plain film detection of right aortic arch in infants with esophageal atresia and tracheoesophageal fistula

The aortic arch can be clearly demonstrated in neonatal chest radiographs by use of a high kilovoltage-filtered film with air-gap magnification. This allows identification of the presence of right aortic arch in patients with esophageal atresia and tracheoesophageal fistula; awareness of this anomaly may influence choice of surgical approach.

Shunt metastases of pineal tumors presenting as a pelvic mass

Three children with pineal area tumors and ventriculoperitoneal shunts developed pelvic masses. In two, the solid masses reflected tumor cells seeded to the Pouch of Douglas while the third developed a loculation of fluid and tumor cells at the shunt tip.

Thymic uptake of gallium-67 citrate in a healthy 4 year old boy

Gallium uptake in a mediastinal mass has been most often seen with lymphoma. A case is reported of thymic uptake in an otherwise healthy 4 1/2 year old boy who had recently had pneumonia. Serial films always showed an unchanging prominent though normal thymus and follow up gallium scans showed disappearance of thymic uptake. This and other similar cases indicate the need to consider a non-neoplastic thymus when gallium accumulation is noted in the anterior mediastinum of a child.