Ultrasound-MRI Agreement in Individuals Undergoing Surveillance of Fontan-associated Liver Disease

OBJECTIVE

To assess agreement between abdominal ultrasound and MRI for the detection of focal liver lesions and manifestations of portal hypertension in patients with Fontan circulation.

MATERIALS AND METHODS

To perform this single-center, retrospective study, we identified patients with Fontan circulation who underwent clinical abdominal ultrasound and MRI examinations within ±12 months between January 1, 2018 and June 30, 2023. Imaging reports were reviewed for the presence of liver lesions (specifically noting lesions >1 cm and radiologist-indicated suspicious lesions), features of portal hypertension (ie, presence of ascites and spleen length), abnormal liver contour, and liver stiffness. Intermodality agreement, sensitivity and specificity of ultrasound relative to MRI, and Spearman correlation were used to compare ultrasound and MRI measurements. Follow-up of detected lesions was also performed using electronic health records.

RESULTS

There were 58 patients included. Agreement between MRI and ultrasound for the findings of Fontan-associated liver disease (FALD) was as follows: presence of a liver lesion of any size [k = 0.20 (95% CI: 0.08 to 0.32)], presence of a liver lesion >1 cm [k = 0.43 (95% CI: 0.18 to 0.68)], radiologist-indicated suspicious liver lesion(s) [k = 0.07 (95% CI: -0.13 to 0.27)], presence of ascites [k = 0.57 (95% CI: 0.32 to 0.81)], abnormal liver contour [k = 0.31 (95% CI: 0.03 to 0.59)], and spleen length [intraclass correlation coefficient = 0.81 (95% CI: 0.58 to 0.92)]. Sensitivity and specificity of ultrasound using MRI as the reference standard were as follows: 34% (95% CI: 20% to 50%) and 100% (95% CI: 77% to 100%) for the presence of a liver lesion of any size, and 39% (95% CI: 17% to 64%) and 98% (95% CI: 87% to 100%) for the presence of a liver lesion >1 cm. There was a poor correlation between ultrasound and MRI liver stiffness measurements [rho = 0.22 (95% CI: -0.14 to 0.53); P = 0.23]. Of 44 patients with liver lesions, 3 (6.8%) had biopsy-confirmed hepatocellular neoplasms, including 2 adenomas and 1 hepatocellular carcinoma. All 3 lesions were detected by both MRI and ultrasound.

CONCLUSIONS

There is poor to fair agreement between ultrasound and MRI for detecting manifestations of FALD, with ultrasound having poor sensitivity compared with MRI. While ultrasound detected all 3 clinically important liver lesions in our study, our results raise questions about whether ultrasound is an appropriate screening tool for FALD in patients post-Fontan.

A Case of Lateral Meningocele Syndrome without Lateral Meningoceles

Introduction

Lateral meningocele syndrome (LMS), also known as Lehman syndrome, is caused by pathogenic variants in exon 33 of NOTCH3. Variants in this final exon of NOTCH3 interrupt the regulatory PEST domain, leading to enhanced NOTCH3 signaling due to prolonged cellular half-life. Individuals with LMS are expected to have multiple lateral meningoceles, developmental delay, neonatal hypotonia, dysmorphic facial features, and feeding difficulties.

Case Presentation

We report an 8-year-old male with a history of autism, feeding difficulties, developmental delay, severe intellectual disability, and self-injurious behavior. Genetic testing revealed a NOTCH3 c.6663C>G (p.Y2221*) pathogenic variant in exon 33, consistent with a diagnosis of LMS. A follow-up spine MRI showed a ventral sacral extradural arachnoid cyst but no lateral meningoceles. This individual's most recent exam noted multiple dysmorphic features including prominent metopic ridging, broad forehead, downslanting palpebral fissures, high-arched palate, long narrow philtrum, mild pectus excavatum, and wide-based gait.

Discussion/Conclusion

This individual shares the dysmorphic facial features, ongoing G-tube dependence, failure to thrive, and developmental delay seen in other individuals with LMS. His lack of lateral meningoceles expands the phenotype for this condition, as all previously reported individuals with molecularly confirmed LMS had multiple lateral meningoceles before age 8 years with an average age of identification at 4 years.

Retinoid orphan receptor gamma t (rorγt) promotes inflammatory eosinophilia but is dispensable for innate immune-mediated colitis

Inflammatory bowel diseases (IBD) result from uncontrolled inflammation in the intestinal mucosa leading to damage and loss of function. Both innate and adaptive immunity contribute to the inflammation of IBD and innate and adaptive immune cells reciprocally activate each other in a forward feedback loop. In order to better understand innate immune contributions to IBD, we developed a model of spontaneous 100% penetrant, early onset colitis that occurs in the absence of adaptive immunity by crossing villin-TNFAIP3 mice to RAG1-/- mice (TRAG mice). This model is driven by microbes and features increased levels of innate lymphoid cells in the intestinal mucosa. To investigate the role of type 3 innate lymphoid cells (ILC3) in the innate colitis of TRAG mice, we crossed them to retinoid orphan receptor gamma t deficient (Rorγt-/-) mice. Rorγt-/- x TRAG mice exhibited markedly reduced eosinophilia in the colonic mucosa, but colitis persisted in these mice. Colitis in Rorγt-/- x TRAG mice was characterized by increased infiltration of the intestinal mucosa by neutrophils, inflammatory monocytes, macrophages and other innate cells. RNA and cellular profiles of Rorγt-/- x TRAG mice were consistent with a lack of ILC3 and ILC3 derived cytokines, reduced antimicrobial factors, increased activation oof epithelial repair processes and reduced activation of epithelial cell STAT3. The colitis in Rorγt-/- x TRAG mice was ameliorated by antibiotic treatment indicating that microbes contribute to the ILC3-independent colitis of these mice. Together, these gene expression and cell signaling signatures reflect the double-edged sword of ILC3 in the intestine, inducing both proinflammatory and antimicrobial protective responses. Thus, Rorγt promotes eosinophilia but Rorγt and Rorγt-dependent ILC3 are dispensable for the innate colitis in TRAG mice.