A description of CT features of Clostridium difficile infection of the small bowel in four patients and a review of literature

Clostridium difficile associated disease is an increasingly common cause of morbidity and mortality. Pseudomembranous colitis following hospital-administered antibiotic treatment is the most common symptomatic manifestation. Small bowel enteritis caused by C. difficile, however, is rarely described. Here, we present a series of four patients with hospital-acquired small bowel enteritis caused by C. difficile, discuss its CT and histopathological features, and review the current literature.

Post-transplant lymphoproliferative disease in liver transplantation

Post-transplant lymphoproliferative disease (PTLD) is a well recognized complication of solid organ transplantation and therapeutic immunosuppression, first reported in 1968. PTLD incorporates a spectrum of abnormalities ranging from a benign infectious mononucleosis-like illness to non-Hodgkin's lymphoma with nodal and extranodal site involvement. The first liver transplant was performed at our institution in January 1982. This retrospective study examined the incidence of PTLD, reason for the original transplants, presenting symptoms, radiological findings, immunosuppression regimens and outcomes of these patients. From a total of 2005 adult liver transplants, 23 patients (1.1%) were identified with PTLD. The average age of these patients at the time of transplant was 46.5 years, with a ratio of female-to-male of 14:9. Indication for transplant ranged from primary biliary cirrhosis (eight patients) to epitheloid haemangioendothelioma (one patient). The average time interval between transplant and diagnosis of PTLD was 50 months. Imaging abnormalities identified included generalized lymphadenopathy, liver and portal masses, splenic enlargement, bowel, eye, cerebral and neck involvement; and in two patients, no radiological abnormality. The most common histological findings ranged from B-cell non-Hodgkin's lymphoma (five patients) to early PTLD in one patient. Our rate of PTLD is lower compared with published literature and demonstrates a much longer time interval from transplant to occurrence of PTLD than previously appreciated. This could be secondary to a low immunosuppression therapy followed at our institution. From a few months to several years after liver transplantation, the radiologist needs to be alert to the possibility of PTLD and thorough imaging is required to detect the wide variety of potential presentations.

Air bag injury as a cause of inflammatory myofibroblastic pseudotumour of the subglottic larynx progressing to myositis ossificans

Inflammatory myofibroblastic pseudotumour (IMFPT) is a rare condition. The clinical presentation can be indistinguishable from that of a malignant neoplasm. The most frequently affected organ is the lung; a much less common site is the larynx and subglottic involvement is particularly rare. Trauma is purportedly one potential aetiological factor, although there have been no previous reports of IMFPT occurring in the larynx secondary to external laryngeal trauma. We present a case of IMFPT of the subglottis which occurred subsequent to external trauma of the neck sustained during air bag inflation in a road traffic accident. This mechanism has not been previously reported. Furthermore, the lesion progressed uniquely to show myositis ossificans-like maturation over time. The patient was ultimately treated by means of complete local excision.

Non-infectious manifestations of stem cell transplantation

Stem cell transplantation (SCT) is now commonplace within medical practice. With growth in transplant activities, outcomes are likely to continue to improve. Increasing numbers of the population now face life after transplantation. The aetiology of post transplant complications is multifactorial. Background knowledge of SCT and common, radiographically detectable, non-infective complications are important in everyday clinical practice. A review of these complications using a variety of imaging modalities is presented and the process of SCT briefly described. Tumour recurrence is outside the remit of this review.

Parapharyngeal abscess: diagnosis, complications and management in adults

Parapharyngeal abscess may cause life-threatening complications. Peritonsillar abscess and tonsillitis may result in parapharyngeal abscess. Since the introduction of antibiotics, the incidence of parapharyngeal abscess secondary to tonsillitis and peritonsillar abscess has decreased dramatically. We present five cases of parapharyngeal abscess resulting from tonsillitis and peritonsillar infection extending to the parapharyngeal space in adult patients. Two were complicated by mediastinitis despite early treatment by wide spectrum antibiotics. We believe that early diagnosis and aggressive antibiotic treatment with early surgical drainage in cases associated with pus collection are the key points in preventing serious and fatal complications. We emphasize the diagnostic role of computerized tomography (CT) scan and the importance of early and proper drainage of these abscesses.

Expression of pituitary tumour transforming gene (PTTG) and fibroblast growth factor-2 (FGF-2) in human pituitary adenomas: relationships to clinical tumour behaviour

OBJECTIVE

Pituitary tumour transforming gene (PTTG) encodes a multifunctional protein that is implicated in initiating and perpetuating pituitary adenoma growth. PTTG appears to have key regulatory functions in determining control of many fundamental cellular events including mitosis, cell transformation, DNA repair and gene regulation. Several of these events are mediated through interactions with PTTG binding factor (PBF) and fibroblast growth factor-2 (FGF-2). Given this background, we have determined the expression of PTTG, PBF, FGF-2 and its receptor FGF-R-1 in a large cohort of pituitary adenomas and have sought associations between levels of gene expression and clinical markers of tumour behaviour.

PATIENTS AND METHODS

We used real-time reverse transcriptase-polymerase chain reaction (RT-PCR) and Western blot analyses to measure PTTG, PBF, FGF-2 and FGF-R-1 expression in ex vivo pituitary tumours (N = 121). Clinical data, including accurate radiological assessment of tumour characteristics, were used to determine any associations between gene expression and tumour behaviour.

RESULTS

PTTG was increased significantly (fivefold, P = 0.005) in adenomas compared with normal pituitaries. We also demonstrated that PBF was similarly raised in adenomas (sixfold, P = 0.0001), and was significantly correlated with PTTG expression. FGF-2 and its receptor FGF-R-1 were also raised in adenomas compared with normal pituitary tissue. Moreover, significantly enhanced expression of FGF-R-1 was observed in invasive adenomas compared with other pituitary tumours.

CONCLUSIONS

Our data support a fundamental role for PTTG-mediated upregulation of FGF-2 signalling in pituitary tumorigenesis and growth, and suggest that receptor-mediated mechanisms of growth factor action may be critically important. Further prospective studies are required to determine whether measurement of FGF-R-1 mRNA will be of clinical use as a prognostic marker in patients with pituitary adenomas.

Invasion of the recurrent laryngeal nerve by adenoid cystic carcinoma. An unusual cause of true vocal fold paralysis

True vocal fold paralysis and goitre are both common problems encountered in ENT practice. Their co-existence, however, should arouse suspicion of the presence of malignant thyroid disease. A rare case of true vocal fold paralysis caused by a clinically occult subglottic adenoid cystic carcinoma, in a 72-year-old, is described. The existence of multinodular goitre in this patient was co-incidental and confounded the diagnostic process.

Anal sphincter defects. Correlation between endoanal ultrasound and surgery

OBJECTIVE

This study was performed to (1) correlate and sphincter defects, identified by endoanal ultrasound with operative findings, and (2) define the appearance of such sphincter defects as seen at operation.

SUMMARY BACKGROUND DATA

Endoanal ultrasonography is a minimally invasive method of imaging the anal sphincter complex and enables identification of anal sphincter defects. Little is known about the accuracy and limitations of endoanal ultrasound in identifying such defects. Furthermore, there are no data about the appearances of these endosonic sphincter defects as seen at operation.

METHODS

Forty-four patients (40 women; age range, 26 to 80 years; mean age, 56 years) with fecal incontinence, undergoing pelvic floor repair, were investigated by endoanal ultrasound before operation. Endosonic findings were correlated with the appearances of external anal sphincter, internal anal sphincter, and intersphincteric space, at operation. Diagnosis of the site and type of defect was made by macroscopic appearances. Uncertainty about the type of sphincter defect was resolved by obtaining muscle biopsies for histology.

RESULTS

All external sphincter defects seen by endoanal ultrasound (n = 23) were confirmed at operation. Twenty-one of 22 internal sphincter defects identified by endosonography also were confirmed at operation. In ten patients with a neuropathic anal sphincter complex, the morphology was normal on endosonography, and this was confirmed at operation. (Sensitivity and specificity of 100% for external anal sphincter; 100% and 95.5%, respectively, for internal and sphincter)

CONCLUSIONS

These data show that endoanal ultrasound is an accurate method of identifying anal sphincter defects.

The prevalence of anal sphincter defects in faecal incontinence: a prospective endosonic study

Forty six patients (median age 61 years; 42 women) with faecal incontinence and 16 age and sex matched controls undergoing a restorative proctocolectomy were assessed by clinical examination, anorectal physiology, and anal endosonography. Forty patients (87%) with faecal incontinence had a sphincter defect demonstrated on anal endosonography (31 external and 21 internal anal sphincter defects). The commonest cause of faecal incontinence was obstetric trauma. This occurred in 35 women, 30 of whom exhibited a morphological defect in the anorectal sphincter complex. In 22 of these patients with a history of a perineal tear or episiotomy, 21 (95%) had a sphincter defect. Sphincter defects were commonly located at the level of the midanal canal.

A prospective comparison between magnetic resonance imaging, meta-iodobenzylguanidine scintigraphy and marrow histology/cytology in neuroblastoma

A prospective comparison between magnetic resonance imaging (MRI), 123I meta-iodobenzylguanidine (mIBG) scintigraphy and posterior iliac crest marrow aspiration and trephine biopsy in 30 assessments (19 patients) showed concordance between the three techniques in 16 assessments (53.3%). In 10 (33.3%), MRI and mIBG revealed abnormalities not detected by marrow biopsy. MRI was the only technique to demonstrate marrow abnormality in four assessments (13.3%). In addition, MRI revealed more sites of abnormality in 16 parallel assessments. We conclude that MRI shows promise as a non-invasive means of detecting bone marrow infiltration by neuroblastoma, but that further evaluation of the specificity of MRI in this setting is indicated.

Inguinal and iliac lymph node involvement in germ cell tumours of the testis: implications for radiological investigation and for therapy

The clinical details of 1191 patients with primary germ cell tumours of the testis seen at the Royal Marsden Hospital between 1977 and 1989 were reviewed in order to determine the incidence of inguinal or iliac node metastases. This was detected in 22 patients, 11 with inguinal and 11 with iliac lymphadenopathy. Seven of these patients had a history of maldescent and orchidopexy, and one patient had congenitally fused testes. Of the remaining 14 patients, eight had bulky para-aortic lymphadenopathy (5 cm or greater in diameter), one had histological evidence of breach of the tunica vaginalis by tumour, and in five patients no predisposing factors were identified. Eight patients had a seminoma, 11 a non-seminoma, and two a combined tumour. Inguinal or iliac nodes were significantly more common in the group of patients defined by bulky para-aortic disease or a history of maldescent and orchidopexy (15/267) than those without either factor (7/924, P less than 0.0004). Patients with a history of maldescent, congenital anomalies of the genitourinary system, or with bulky para-aortic disease, should routinely have the pelvis and inguinal regions included in a staging or follow-up CT scan. These factors should also influence the extent of the radiation field or of surgical dissection when these modalities are employed.