Anomalous origin of the circumflex artery from the right pulmonary artery

Anomalous origin of the circumflex artery from the pulmonary artery (ACxAPA) is a rare but clinically significant condition in which the circumflex artery arises from either the main pulmonary artery or one of its main branches. Untreated patients with ACxAPA may develop severe heart failure or sudden cardiac death. Diagnosis is established with either catheter or CT angiography. We present a case of an adult male with no prior known cardiac history who was found to have ACxAPA after presenting to our institution in acute decompensated heart failure.

The Relationship Between Anti-SSA-52 and Interstitial Lung Disease

OBJECTIVE

The aims of this study were to assess whether a relationship between anti-SSA-52 and interstitial lung disease (ILD) can be further defined, and to enhance screening, detection, and potentially guide treatment.

METHODS

A historical cohort study of 201 patients was conducted at a single tertiary care center between January 1, 2016 and December 31, 2020. All included patients were anti-SSA-52 antibody positive. Chart review was performed for laboratory values, symptoms, pulmonary function tests, treatment, and imaging. Chest computed tomographies were reviewed by chest radiologists.

RESULTS

Among anti-SSA-52 antibody-positive patients, ILD was found in 125 (62.2%) compared with 76 (37.8%) with no ILD (p = 0.001). For those with ILD, 78 (62.4%) were diagnosed with connective tissue disease (CTD)-associated ILD, 28 (22.4%) were diagnosed ILD only, and 19 (15.2%) met the criteria for interstitial pneumonia with autoimmune features. In patients with CTD-ILD, 18 (23.0%) had their ILD diagnosis made over 6 months before a CTD diagnosis, and an additional 43 (55.1%) had their ILD and CTD diagnosed within 6 months of each other (p < 0.001). Common computed tomography patterns were nonspecific interstitial pneumonia/organizing pneumonia overlap in 44 (35.2%), 25 (20.0%) nonspecific interstitial pneumonia, and 15 (12%) usual interstitial pneumonia. Twenty-eight (35.9%) had antisynthetase syndrome, followed by 16 (20.5%) with dermatomyositis, 10 (12.8%) with CTD overlap, and 6 (7.7%) with systemic scleroderma.

CONCLUSIONS

There was a significant association between anti-SSA-52 antibodies and ILD across a wide spectrum of rheumatological diagnoses. A significant portion of patients were diagnosed with ILD either at the same time or before their CTD diagnosis. Further study will be needed to assess effective treatment and response.

Thoracic periosteal reaction secondary to voriconazole use in an adult transplant patient

Periosteal reaction may result from multiple causes including infection, trauma, medications, and neoplasms. One important etiology that must be considered in the differential diagnosis of symmetric periosteal reaction, especially in immunocompromised patients, is voriconazole use. We present a case of a 65-year-old man who underwent liver transplantation complicated by acute hypoxic respiratory failure and Aspergillus infection. Long term voriconazole therapy was initiated with resultant development of thoracic periosteal reaction which improved following discontinuation of the medication. Given the preferential upper body distribution of periosteal reaction induced by voriconazole, chest radiologists might be the first ones to recognize this adverse effect.

Thoracic Complications of Liver-Directed Therapy and Interventions

ABSTRACT

Liver-directed percutaneous and endovascular therapies are effective methods to diagnose and treat various hepatic disorders and malignancies. Because of the close anatomic proximity of the liver to the right hemidiaphragm, pleura, and lung bases, complications can arise involving these structures. Although they are rare, awareness of intrathoracic complications associated with liver-directed therapies and their imaging features will ensure timely detection and management. We aim to review the clinical and imaging features of thoracic complications related to liver-directed therapy and interventions.

Imaging modalities (MRI, CT, PET/CT), indications, differential diagnosis and imaging characteristics of cystic mediastinal masses: a review

Cystic mediastinal masses have traditionally represented a diagnostic dilemma with differentiation of malignant masses a particular area of concern. Each imaging modality has strengths and weaknesses in mediastinal imaging-computed tomography (CT) offers increased spatial resolution at the cost of poorer soft tissue differentiation and requiring ionizing radiation, while magnetic resonance imaging (MRI) offers superior soft tissue contrast/characterization at significantly greater cost. Ultrasound offers real-time visualization but is operator and tissue dependent. [18F]fluoro-D-glucose (F-18 FDG) positron emission tomography (F-18 FDG PET) CT provides functional information, but poorer spatial resolution. Recent advances have focused upon the use of magnetic resonance imaging to aid in characterization of cystic mediastinal lesions, particularly in the context of indeterminate CT findings. The mediastinum may be divided into three anatomic compartments: prevascular, visceral, and paravertebral. All three compartments extend superiorly from the thoracic inlet and inferiorly to the diaphragm. These compartments provide a useful framework for categorizing normal and pathologic mediastinal processes. In this article, we will review the imaging characteristics of mediastinal cystic lesions via a case-based review divided by anatomical mediastinal compartments. Characteristic imaging features and troubleshooting are particular areas of focus. Normal variants that may mimic cystic pathology are discussed. The roles of CT and MRI will be emphasized. Cases from our institution are presented as illustrative examples.

Invasive Nocardiosis Versus Colonization at a Tertiary Care Center: Clinical and Radiological Characteristics

Objective

To describe the clinical and radiographic findings in a large cohort of patients with positive cultures for Nocardia emphasizing the differences between invasive disease and colonization.

Patients and Methods

We conducted a single-center, retrospective cohort study of 133 patients with a positive Nocardia isolate between August 1, 1998, and November 30, 2018, and a computed tomography (CT) of the chest within 30 days before or after the bacteria isolation date.

Results

Patients with colonization were older (71 vs 65 years; P=.004), frequently with chronic obstructive pulmonary disease (56.8% vs 16.9%; P<.001) and coronary artery disease (47.7% vs 27%, P=.021), and had Nocardia isolated exclusively from lung specimens (100% vs 83.1%; P=.003). On CT of the chest, they had frequent airway disease (84.1% vs 51.7%; P<.001). Patients with invasive nocardiosis had significantly (P<.05) more diabetes, chronic kidney disease, solid organ transplant, use of corticosteroids, antirejection drugs, and prophylactic sulfa. They had more fever (25.8% vs 2.3%; P<.001), cutaneous lesions (14.6% vs 0%; P=.005), fatigue (18% vs 0%; P=.001), pulmonary nodules (52.8% vs 27.3%; P=.006), and free-flowing pleural fluid (63.6% vs 29.4%; P=.024). The patterns of nodule distribution were different-diffuse for invasive nocardiosis and peribronchiolar for Nocardia colonization.

Conclusion

The isolation of Nocardia in sputum from a patient with respiratory symptoms does not equal active infection. Only by combining clinical and chest CT findings, one could better differentiate between invasive nocardiosis and Nocardia colonization.

Leptospira Infection in Rural Areas of Urabá Region, Colombia: A Prospective Study

The objective of this study was to analyze the eco-epidemiological aspects of Leptospira seroprevalence and seroincidence and its associated factors in two municipalities of northwest Colombia. A prospective study was performed in rural areas of Urabá, Antioquia, Colombia. The study enrolled 597 people between November 2015 and January 2016, of which 274 were followed up 1 year later. Serologic testing was performed by a microscopic agglutination. The outcomes were seroprevalent and seroincident cases, and the primary exposure was an outdoor occupation. A binary and mixed-effect multinomial logistic regression model was used to estimate factors associated with seroprevalent or seroincident cases of Leptospira infection. The overall Leptospira seroprevalence was 27.81% (95% confidence interval: 23.62-32.49), and the overall cumulative seroincidence for Leptospira was 14.60% (95% confidence interval: 10.33-20.23). Multivariable analysis showed that factors associated with L. interrogans serogroups seropositivity were outdoor occupation, male gender, older age, the presence of dirt floor in the household, and the presence of piglets and opossums. It also showed that factors associated with other Leptospira species serogroups were the presence of pit latrines and of turkeys. In addition, the multivariable model of seroincident cases of L. interrogans serogroups evidenced outdoor occupations, the presence of rats, and corn cultivation as risk factors. Likewise, the multivariable model for seroincident cases of other Leptospira species showed that the presence of hunting canines and cassava cultivation were risk factors. We found specific factors associated with the transmission of Leptospira serogroups contribute to the understanding of the epidemiology of Leptospira infection in rural areas of Urabá, Colombia.

Atypical Causes of Dyspnea: A Review of Neuromuscular and Chest Wall Disorders that Compromise Ventilation

Dyspnea is a common presenting symptom among patients with cardiopulmonary diseases. However, several neuromuscular and chest wall conditions are often overlooked and under-recognized causes of dyspnea. These disorders frequently adversely affect the structure and function of the ventilatory pump (diaphragm, accessory muscles of ventilation) and can precipitate respiratory failure despite normal lung parenchyma. Weakened musculature impairs clearance of airway secretions leading to aspiration and pneumonia, further compromising respiratory function. Radiologists should be aware of the pathophysiology and imaging manifestations of these conditions and might suggest them to be causes of dyspnea which otherwise may not have been considered by referring clinicians.

Interstitial Lung Disease in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis Patients: Comparison With Idiopathic Pulmonary Fibrosis

BACKGROUND/OBJECTIVE

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) may involve the kidney, respiratory tract, skin, or central and peripheral nervous system. Reports of interstitial lung disease (ILD) in AAV (AAV-ILD) have been increasing.

METHODS

We reviewed the medical records of all patients with AAV-ILD between January 1, 2007, and December 31, 2017, and compared their pulmonary involvement to patients with idiopathic pulmonary fibrosis (IPF).

RESULTS

We identified 24 patients with AAV-ILD: 14 with microscopic polyangiitis, 8 with granulomatosis with polyangiitis, and 2 with eosinophilic granulomatosis with polyangiitis. Perinuclear or myeloperoxidase ANCA was present in 16 cases (66.7%), whereas cytoplasmic or proteinase 3 ANCA was positive in 8 (33.3%). Usual interstitial pneumonia (UIP) was seen in 11 (45.8%), probable UIP in 1 (4.2%), indeterminate UIP in 2 (8.3%), and an alternate diagnosis in 10 (41.7%), and was further characterized as chronic hypersensitivity pneumonitis-like pattern seen in 6 (25%), nonspecific interstitial pneumonia-like pattern in 3 (12.5%), and cryptogenic organizing pneumonia-like pattern in 1 (4.2%). Forced vital capacity and diffusing capacity declined over time in patients with AAV-ILD. When compared with the IPF cohort, patients with AAV-ILD had intermediate survival and speed of lung function decline (3-year survival in AAV-ILD group was 94% vs 69% in IPF).

CONCLUSIONS

Antineutrophil cytoplasmic antibody-associated vasculitis ILD is a progressive and potentially fatal condition. Although most cases in the literature are associated with p-ANCA and positive myeloperoxidase, we found that a third of patients had c-ANCA or granulomatosis with polyangiitis. Our cohort adds experience in this rare manifestation of AAV.

Epidemiology of Rickettsial Infection in the Municipality of Uramita, Colombia

This study aimed to analyze epidemiological indicators related to seroprevalent and seroincident cases of spotted fever group rickettsiae (SFGR) and to identify housing conditions related to tick infestation. A prospective study (2016-2018) was conducted to examine rickettsial seropositivity in humans, domestic animals, and wild mammals in the municipality of Uramita, Antioquia, Colombia, where a previous Rickettsia rickettsii outbreak was reported from 2014 to 2015. The seroprevalence and its associated factors were estimated at baseline, and the seroincidence and its risk factors for humans were estimated 20 months later. A cross-sectional analysis was performed to evaluate the housing conditions linked to tick infestation. The SFGR seroprevalence was 26.70% (95% confidence interval [CI], 20.79-31.37), and the factors associated with SFGR seropositivity were male sex (adjusted prevalence ratio [PRa], 1.67; 95% CI, 1.19-2.32), age (evaluated in 5-year increments) (PRa, 1.05; 95% CI, 1.01-1.09), and household proximity (PRascattered vs. very near=3.87; 95% CI, 1.12-8.66). The overall seroincidence was 7.40% (95% CI, 4.71-11.06), and the factors associated with SFGR seroincident cases were the presence of wild animals (adjusted relative risk [RRa], 2.46; 95% CI, 1.06-4.72) and the presence of trees in the peri-domiciliary area (RRa, 0.47; 95% CI, 0.23-0.94). The prevalence of house tick infestation was 27.81% (95% CI, 21.93-34.80), and the factors associated with infestation were dirt floors (PRa, 5.88; 95% CI, 2.28-10.31), fiber cement roofs (PRa, 1.76; 95% CI, 1.07-2.83), and the presence of canines in peri-domiciliary or intra-domiciliary areas (PRa, 5.05; 95% CI, 3.31-7.19). Seropositivity rates for canines and opossums were 35.62% (26/73) and 100% (6/6), respectively. Identification of these factors will help to implement efficient surveillance programs in Colombia.

Three-dimensional printing facilitates surgical planning for resection of an atypical cardiac myxoma

BACKGROUND

Cardiac myxomas are common and account for 50% of primary intracardiac tumors. Atypical locations of cardiac myxoma increase the risk of intraoperative iatrogenic injuries. Herein, we report a case of using three-dimensional printing (3D) to facilitate the removal of an atypical cardiac myxoma in a 63-year-old woman.

METHODS AND RESULTS

Mass in the high posterior atrial septum was confirmed through imaging. Due to the potential involvement of the mass to surrounding vital structures, 3D printing of the cardiac mass was performed. The tumor was completely resected via median sternotomy and the resulting defect was repaired with the bovine pericardium. The patient had an uncomplicated postoperative course except for the development of sick sinus syndrome. One-year follow-up showed no tumor recurrent.

CONCLUSION

3D printing technology in patients with atypical cardiac tumors enhances our understanding of the extent of the tumor invasion and facilitates planning the operation to avoid intraoperative complications.

Cardiac magnetic resonance imaging in Chagas' disease: a parallel with electrophysiologic studies

Chagas' disease (CD), caused by the parasite Trypanosoma cruzi, is the leading cause of cardiac disability from infectious diseases in Central and South America. The disease progresses through an extended, asymptomatic form characterized by latency without clinical manifestations into a symptomatic form with cardiac and gastro-intestinal manifestations. In the terminal phase, chronic Chagas' myocarditis results in extensive myocardial fibrosis, chamber enlargement with aneurysms and ventricular tachycardia (VT). Cardiac magnetic resonance imaging (CMR) has proven useful in characterizing myocardial fibrosis (MF). Sub-epicardial and mid-wall fibrosis are less common patterns of MF in CHD than transmural scar, which resembles myocardial infarction. Commonly involved areas of MF include the left ventricular apex and basal infero-lateral wall, suggesting a role for watershed ischemia in the pathophysiology of MF. Electrophysiology studies have helped refine the relationship between MF and VT in this setting. This article reviews the patterns of MF in CHD and correlate these patterns with electrogram patterns to predict risk of ventricular arrhythmias and sudden death.

Risk of infection and disease progression in children exposed to tuberculosis at home, Colombia

Aim:

To assess the risk of tuberculosis (infection and disease) in children less than 15 years’ old who are household contacts of pulmonary tuberculosis patients in three Colombian cities (Medellín, Cali, and Popayán).

Methods:

A cohort of 1,040 children household contacts of 380 adults with smear-positive pulmonary tuberculosis was followed up for 24 months. Study period 2005-2009.

Results:

Tuberculin skin test was positive (≥10 mm) in 43.7% (95% CI: 39.2-48.2). Tuberculin skin test positivity was associated with age 10-14 years (Prevalence Ratio -PR= 1.43, 95% CI: 1.1-1.9), having a BCG vaccine scar (PR= 1.52, 95% CI: 1.1-2.1), underweight, closer proximity to the index case and exposure time >3 months. The annual risk of infection (tuberculin skin test induration increase of 6 mm or more per year) was 17% (95% CI: 11.8-22.2) and was associated with a bacillary load of the adult index case (Relative Risk -RR= 2.12, 95% CI: 1.0-4.3). The incidence rate of active tuberculosis was 12.4 cases per 1,000 persons-year. Children <5 years without BCG vaccine scar had a greater risk of developing active disease (Hazard Ratio -HR= 6.00, 95% CI: 1.3-28.3) than those with scar (HR= 1.33, 95% CI: 0.5-3.4). The risk of developing active tuberculosis augmented along with the increase from initial tuberculin skin test (tuberculin skin test 5-9 mm HR= 8.55, 95% CI: 2.5-29.2; tuberculin skin test ≥10 mm HR= 8.16, 95% CI: 2.0-32.9).

Conclusions:

There is a need for prompt interruption of adult-to-children tuberculosis transmission within households. Conducting proper contact investigation and offering chemoprophylaxis to infected children could reduce tuberculosis transmission.

Organizing Pneumonia Induced by Ablative Radioembolization for the Treatment of Hepatic Metastatic Renal Cell Carcinoma

Organizing pneumonia is a recognized complication after external beam radiotherapy of breast and lung cancer but has not been described after radioembolization. A 67-year-old female who underwent ablative trans-arterial radioembolization for the treatment of hepatic metastatic renal cell carcinoma adjacent to the diaphragm presented with computed tomography findings of asymptomatic organizing pneumonia in the lower lobes. A follow-up computed tomography 8 months after conservative management demonstrated near-total resolution of the previous pulmonary parenchymal disease. The patient continues to remain asymptomatic and shows no evidence of residual tumor 10 months after radioembolization.

Adipositas Cordis: A Rare and Poorly Understood Cardiomyopathy

Adipositas cordis is a rare cardiomyopathy characterized by diffuse fatty infiltration of the ventricular myocardium or interventricular septum. This occurs without myocardial cell destruction, unlike arrhythmogenic right ventricular cardiomyopathy. A 40-year-old obese woman was found to have a II/VI systolic murmur that worsened with standing. A transthoracic echocardiogram showed interventricular septal hypertrophy with a preserved left ventricular ejection fraction. Cardiac magnetic resonance imaging revealed a fatty mass in the interventricular septum. An endomyocardial biopsy revealed structurally normal myocytes with diffuse adipose cell infiltration and no evidence of malignant cells. Left and right cardiac catheterizations and stress echocardiography showed no abnormalities. This case shows the importance of considering a broad differential when approaching rare diseases. It also demonstrates the utility of noninvasive imaging and its impact on clinical decision making.

PPD-induced monocyte mitochondrial damage is associated with a protective effect to develop tuberculosis in BCG vaccinated individuals: A cohort study

Introduction

The mechanisms of mononuclear phagocyte death have been associated with the permissiveness and resistance to mycobacterial replication, but it remains unknown whether or not they help predict the risk of developing TB.

Objective

To describe the factors associated with the induction of monocyte mitochondrial and membrane damage in response to PPD as well as determine if this type of damage might predict the susceptibility of developing active tuberculosis in a cohort of household contacts (HHCs) from Medellin, Colombia from 2005 to 2008.

Methods

The prospective cohort study contains 2060 HHCs patients with pulmonary tuberculosis who were meticulously followed for two years. A survey of the socio-demographic, clinical, epidemiological factors and blood samples were collected. Mononuclear cell cultures were stimulated with or without PPD and the type of monocyte death was determined by the flow of cytometry, an indicator was also used for its analysis. Logistic regression was adjusted by the Generalized Estimations Equations and the survival was estimated with the Kaplan-Meier and Cox regression. Confidence intervals were used for estimating the association.

Results

1,859 out of 2,060 blood samples of the HHCs patients analyzed showed monocyte death. In response to PPD, 83.4% underwent mitochondrial damage while 50.9% had membrane damage. The membrane damage in response to PPD was higher in children under 4 years (OR: 1.57; (95% CI: 1.1 to 2.4) and the HHCs who slept regularly in the same household has an index case of (OR: 1.54; 95% CI: 1.0 to 2.3). After adjustment by age, comorbidities, nutritional status, proximity to index case and overcrowding, the risk of developing active TB among BCG vaccinated HHCs individuals with induction of mitochondrial damage was HR = 0.19 (95% CI: 0.1 to 0.5).

Conclusions

The induction of monocytes mitochondrial damage by PPD stimulation correlates with protection of TB disease development in BCG-vaccinated HHCs. This represents a potential tool to predict susceptibility of developing active disease in this population.

Middle Lobe Torsion after Unilateral Lung Transplant

Lobar torsion is well documented after pneumonectomy, but is very rare after lung transplant. To the best of our knowledge, this is the twelfth reported case of lobar torsion after lung transplant. In our case, bronchoscopies and chest radiographs were inconclusive; however, CT scan clearly demonstrated findings consistent with right middle lobe torsion. We review the literature and discuss the epidemiology, clinical presentation, imaging features, and treatment considerations for this condition. We also propose that if a clinical picture could be secondary to torsion and bronchoscopies and chest x ray are inconclusive that a CT scan should be obtained as soon as possible since early recognition increases the likelihood of being able to successfully detorse the lung and avoid lobectomy.

To breathe or not to breathe: a review of artificial airway placement and related complications

Artificial airway devices are commonly used to provide adequate ventilation and/or oxygenation in multiple clinical settings, both emergent and nonemergent. These frequently used devices include laryngeal mask airway, esophageal-tracheal combitube, endotracheal tube, and tracheostomy tube and are associated with various acute and late complications. Clinically, this may vary from mild discomfort to a potentially life-threatening situation. Radiologically, these devices and their acute and late complications have characteristic imaging findings which can be detected primarily on radiographs and computed tomography. We review appropriate positioning of these artificial airway devices and illustrate associated complications including inadequate positioning of the endotracheal tube, pulmonary aspiration, tracheal laceration or perforation, paranasal sinusitis, vocal cord paralysis, post-intubation tracheal stenosis, cuff overinflation with vascular compression, and others. Radiologists must recognize and understand the potential complications of intubation to promptly guide management and avoid long-term or even deadly consequences.

Heart failure due to tension hydrothorax after left pneumonectomy

Tension hydrothorax is a rare complication of pneumonectomy for pleural mesothelioma and an exceptionally rare cause of heart failure. We describe a patient who had undergone extrapleural pneumonectomy, chemotherapy, and radiation for pleural mesothelioma and who developed heart failure symptoms within months of the completion of treatment. Investigation showed a massive left pleural effusion resulting in tension hydrothorax, mediastinal shift, and evidence of right heart failure with constrictive physiology and low cardiac output. Therapeutic thoracentesis resulted in increase in cardiac output and symptomatic improvement.

Pertinent reportable incidental cardiac findings on chest CT without electrocardiography gating: review of 268 consecutive cases

BACKGROUND

Pertinent reportable cardiac findings on non-electrocardiography (ECG)-gated chest CT examinations have become easier to detect given recent advancements in multidetector CT technology. However, those findings are easily overlooked on routine chest CT without ECG gating given residual inherent cardiac motion artifact and non-cardiac indications.

PURPOSE

To describe and quantify the types of pertinent reportable cardiac findings that can be detected on chest CT examinations without ECG gating and evaluate how often they were reported.

MATERIAL AND METHODS

Two radiologists retrospectively reviewed (blinded to the original interpretation) 268 consecutive routine adult chest CT examinations without ECG gating for the presence of pertinent reportable cardiac findings. Retrospective interpretations were then compared with the original radiological reports.

RESULTS

One hundred and sixty-three patients (61%) had pertinent reportable cardiac findings. The findings encountered included: coronary artery disease (n = 131; 80.0%), coronary artery bypass grafts (n = 10; 6.1%), left ventricular aneurysm (n = 1; 0.6%), valve calcification (n = 131; 80.0%), valve repair/replacement (n = 5; 3.1%), pericardial effusion (n = 33; 20.2%), left atrial appendage thrombus (n = 1; 0.6%), cardiac mass (n = 1; 0.6%), and cardiac chamber enlargement (n = 29; 17.8%). On the original radiological reports 22.3% of the pertinent reportable cardiac findings, detected by the two radiologists retrospectively, were not reported.

CONCLUSION

Detection of pertinent reportable cardiac findings on routine chest CT examinations without ECG gating is possible. The high volume of chest CT examinations without ECG gating represents an opportunity for radiologists to comment on the presence or absence of cardiac disease which may influence future clinical decisions.

Cardiac CT of non-shunt pathology of the interatrial septum

The development and anatomy of the interatrial septum is complex. With the increasing use of cardiac CT and its precise delineation of the anatomy, it is important for the cardiac imager to become familiar with the normal anatomic structures that compose the interatrial septum and their variants. Furthermore, it is important to recognize pathologic processes occurring in this region other than atrial septal defects and potential imaging pitfalls. This pictorial essay provides a detailed review of these topics with emphasis in CT appearance and related technical aspects.

Seroprevalence of human toxocariasis in Andean communities from the Northeast of Lima, Peru

The aim of this study was to assess the seroprevalence of human toxocariasis in three Andean communities from the Northeast of Lima, Peru. A total of 303 subjects including children and adults were studied and blood samples were collected to detect anti-Toxocara antibodies by ELISA-IgG test and by hematological examination; stool samples were collected also for parasitological examination. The overall seroprevalence of toxocariasis observed in the total population was 20.46%, with a significant high proportion in children from one to 10 years old (p = 0.034). Among the subjects with positive serology, 32.26% of them had respiratory disturbances, 22.58% hepatomegaly, 17.74% ocular signs or symptoms, 14.51% abdominal pain, 9.68% neurological involvement, and 4.84% cutaneous signs, but none of these clinical features were associated to a positive serology by multivariate analysis. Furthermore, 79.03% of seropositive subjects also harbored at least one intestinal parasite, which was associated to a positive serology (p < 0.05). The presence of pets within the houses, a previous history of pica or geophagia and the use of public places were also present in this population, but only the latter was associated to the serology (p < 0.05). In conclusion, clinical, serological, and epidemiological evidences for larval Toxocara infection were found in the studied population.

Normal thickness and appearance of the prevertebral soft tissues on multidetector CT

BACKGROUND AND PURPOSE

Analysis of the prevertebral soft tissue (PVST) is helpful in detecting osseous and ligamentous injuries of the cervical spine. Because the standard of care has shifted from radiographs to multidetector CT (MDCT), a re-examination of the PVST on MDCT images is needed to establish normal values for thickness appropriate for this imaging technique.

MATERIALS AND METHODS

Thickness of the PVST was measured in 192 patients undergoing screening cervical spine MDCT with multiplanar reconstructions as part of a trauma protocol. Patients included in the study were not intubated, had an immobilized cervical spine, had normal findings on cervical spine CT, and did not have a diagnosis of osseous or soft-tissue cervical injury. Exclusion criteria included patients with a congenital or acquired (nondegenerative) abnormality of the cervical spine or PVST.

RESULTS

The upper limits of normal for the thickness of the PVST were 8.5 mm at C1, 6 mm at C2, 7 mm at C3, 18 mm at C6, and 18 mm at C7. The upper limit of normal was not determined for C4 and C5 levels due to variable position of the esophagus and larynx. The smallest variability and calculated SDs were found at C2 and C3.

CONCLUSIONS

The thickness of the PVST is important in the detection of underlying injuries to the cervical spine. We propose the obtained values as the upper limits of normal for PVST thickness on MDCT images in the adult population.

Cardiovascular complications of cocaine: imaging findings

Cocaine is the second most commonly abused illicit drug in the US and the most common one involved in emergency department visits, the majority of which are related to the cardiovascular system. Cardiovascular complications related with cocaine abuse include myocardial ischemia and infarction, myocarditis, hypertrophic cardiomyopathy, dilated cardiomyopathy, aortic dissection, thrombosis, stroke and cerebral hemorrhage, and different forms of visceral ischemia, among others. In an era where cocaine use has reached epidemic proportions, it is necessary for the radiologist to understand the pathophysiology, clinical presentation, and imaging characteristics of its cardiovascular complications.

Reassessment of the craniocervical junction: normal values on CT

BACKGROUND AND PURPOSE

As the standard of care for the evaluation of the cervical spine shifts from plain radiographs to multidetector row CT (MDCT), a re-examination of the normal anatomic relationships of the occipitovertebral articulations is needed. We aimed to define the normal anatomic relationships of craniocervical articulations on MDCT and address any discrepancies with currently accepted ranges of normal on plain radiographs.

MATERIALS AND METHODS

A total of 200 patients underwent an MDCT scan of the cervical spine with multiplanar reconstructions (MPR). We measured the basion-axial interval (BAI), basion-dens interval (BDI), Powers ratio, atlantodental interval (ADI), and atlanto-occipital interval (AOI) in each patient. After statistical analysis, we compared these values to previously accepted data on plain radiographs.

RESULTS

Ninety-five percent of the population was found to have a BDI less than 8.5 mm compared with 12 mm on data from plain radiographs. The Powers ratio demonstrated no significant difference compared with data obtained by plain radiographs. Ninety-five percent of the population was found to have an ADI less than 2 mm, compared with 3 mm previously accepted. The AOI demonstrated 95% of the population ranged between 0.5 mm and 1.4 mm. The BAI was difficult to reproduce on CT images.

CONCLUSION

Normal values for the craniocervical relationships on MDCT are significantly different from the accepted ranges of normal on plain radiographs. We propose these values as normal for the adult population.

A multifaceted intervention to prevent American cutaneous leishmaniasis in Colombia: results of a group-randomized trial

INTRODUCTION

American cutaneous leishmaniasis is endemic in Colombia, where approximately 6.000 new cases are reported every year. Current prevention and control measures are restricted to the diagnosis and treatment of cases.

OBJECTIVE

To evaluate the efficacy of a multifaceted intervention to prevent the transmission of Leishmania in the endemic focus of Tumaco, on the Pacific Coast of Colombia.

MATERIALS AND METHODS

A group-randomized trial was conducted. Twenty villages were matched according to prevalence of Leishmania infection, number of inhabitants and level of community participation, and then randomly assigned to intervention or control. The intervention included deltamethrin-impregnated bednets, repellent (20% diethyltoluamide and 0.5% permethrin), modification of sand fly resting sites, and health education. Villages were under surveillance for one year and the use of the intervention measures monitored. The incidence of American cutaneous leishmaniasis and Leishmania infection in the two groups were compared, adherence to the intervention and adverse events were monitored, and the results were adjusted for village intraclass correlation.

RESULTS

Ten cases of American cutaneous leishmaniasis were confirmed in the intervention and 23 in the control group, OR = 0.42, 95% CI 0.14-1.26. The intervention had a greater effect in children < 10 years old, in people living on the periphery of the village and in villages with a prevalence of infection in small children > 1%. Adverse events associated with the use of the bednets and the repellent were reported in 2% of the participants and were always mild.

CONCLUSION

Incident cases of American cutaneous leishmaniasis were reduced by 58% in the intervention group. However, the small number of cases renders the effect estimate imprecise and precludes us to claim a protective effect for the intervention. Specific populations could be the targets of simpler and more cost-effective interventions in the future.

Failure of a killed Leishmania amazonensis vaccine against American cutaneous leishmaniasis in Colombia

We report the results of a double-blind, randomized, placebo-controlled clinical trial of a killed whole-cell Leishmania amazonensis candidate vaccine against American cutaneous leishmaniasis (CL) in Colombia. The trial subjects were 2597 healthy volunteers with negative leishmanin skin test (LST) selected from rural Colombian soldiers who were going to patrol endemic areas. They were randomized to receive either three doses of vaccine (n=1295) or placebo (n=1302) given at 20-day intervals. An active and passive case detection system was established to follow-up volunteers for 1 year after vaccination. Safety and efficacy of the vaccine were determined by comparing local and systemic adverse reactions after each dose and the incidence of parasitologically confirmed CL. In the vaccine and placebo groups 101 (7.7%) and 88 (6.8%) volunteers developed CL respectively. The vaccine was shown to be safe but offered no protection against CL caused by L. panamensis in the proposed vaccination schedule.

Surveillance and screening of American cutaneous leishmaniasis by Colombian primary health care workers using a clinical prediction rule

Confirmed cases of American cutaneous leishmaniasis (ACL) and other dermatological diseases were evaluated in Colombia with a clinical prediction rule independently by 3 types of evaluators: community health volunteer (CHV), practical nurse (PN) and programme physician (PP). The adapted prediction rule included 6 variables based upon clinical-historical information. The screening instrument was a rotating tower of coloured squares, one colour for each variable. A score ranging from 0 to 7, and a cutoff point of > or = 4 was selected for ACL classification (sensitivity 94.3%, specificity 53.3% and efficiency 80.3%). Disease classification, total score, and variable-specific score obtained by CHVs and PNs were compared to those obtained by a PP. The impact on case detection in the study area was assessed. Both types of primary health worker had a high agreement with the PP (sensitivity) on the classification of patients with ACL by score, CHV (92.3%) and PN (93.3%). Case detection of ACL increased 3-fold over that observed one year earlier. This screening instrument and prediction rule, when incorporated into a community surveillance programme for ACL, can facilitate greater case detection and appropriate referral for more-specific diagnostic procedures.

An ecosystem approach to human health and the prevention of cutaneous leishmaniasis in Tumaco, Colombia

A study was conducted during 1996-1997 in 20 villages of Tumaco, Colombia, to evaluate the effectiveness of personal protective measures against cutaneous leishmaniasis (CL). The intervention was effective, but the high costs of the preventive measures and the lack of a more holistic approach hampered the intervention's sustainability. This paper analyzes the results using an ecosystem approach to human health. Using this approach, we found that CL has been present in the study area for a long time and affects farmers and those living closest to the forest. The forest constitutes the habitat for insect vectors (sandflies) and parasite reservoirs (wild mammals). Four spatial scales were identified in this ecosystem: residential, village, regional, and global. From the ecosystem perspective, three interventions are proposed to prevent CL in the 20 villages: improve housing construction, organize village housing in clusters, and make diagnosis and treatment of CL more accessible. The design and implementation of these interventions require active involvement by people with the disease (village inhabitants) and decision-makers (local authorities).

Laboratory and field evaluations of a repellent soap containing diethyl toluamide (DEET) and permethrin against phlebotomine sand flies (Diptera: Psychodidae) in Valle del Cauca, Colombia

The repellency and insecticidal efficacy of Nopikex, a soap formulation containing 20% diethyl toluamide and 0.5% permethrin, was evaluated against a laboratory colony of phlebotomine sand flies (Lutzomyia longipalpis). The repellency of Nopikex soap was also compared with that of a placebo soap against another species (Lu. youngi) in a forest near Tulua, Valle del Cauca, Colombia. In laboratory trials of the soap, no reduction in repellency was seen 4 hr after application, but within 8 hr, repellency decreased significantly to 67.0% of the initial value (P < 0.05) based on calculations of the coefficient of protection (CP). Under field conditions, the soap gave up to 100% protection immediately after application, but within 4 hours its CP value had decreased to a median value of only 44.3%. The placebo soap was also found to be somewhat repellent when compared with no treatment, giving a median CP value of 67.7 immediately after application. No significant mortality was seen in sand flies within 24 hr of exposure to the soap in the laboratory, even in those that had fed on protected volunteers.