Megaconial congenital muscular dystrophy: Same novel homozygous mutation in CHKB gene in two unrelated Chinese patients

Megaconial congenital muscular dystrophy (CMD) is a rare form of congenital muscular dystrophy attributed to an autosomal recessive CHKB mutation. We report two unrelated Chinese girls with Megaconial CMD who harbored the same novel homozygous CHKB mutation but exhibited different phenotypes. Patient 1, who is now 8 years old, has autism, intellectual disabilities, mild girdle weakness, and characteristic muscle biopsy with COX-negative fibers. Patient 2, now 12 years old, has limited intelligence and marked weakness, with scoliosis, hip subluxation and early loss of ambulation. Both exhibited mildly elevated creatine kinase levels, have relative sparing of adductor longus and extensor digitorum longus on MRI leg muscles, and a c.598del (p.Gln200Argfs*11) homozygous CHKB loss-of-function mutation. Their parents are heterozygous carriers. This is the first report of Megaconial CMD in Chinese patients demonstrating the pathogenicity of the identified homozygous CHKB variant. A case review of all previously reported patients of different ethnicities is also included.

Interstitial lung disease in systemic sclerosis: An HRCT-clinical correlative study

Purpose: To evaluate high-resolution CT (HRCT) parameters of inflammation and fibrosis in systemic sclerosis (SSc), for correlation with lung function, skin scores and exercise tolerance.

Material and Methods: 45 SSc patients (40 women, 48.5±13.4 years), underwent thoracic HRCT, lung function assessment, and modified Rodnan skin scores. Exercise tolerance was also graded. HRCT were scored for extent of 4 HRCT patterns of interstitial lung disease (ILD): ground glass opacification (GGO), reticular, mixed and honeycomb pattern in each lobe. Total HRCT score, inflammation index (GGO and mixed score) and fibrosis index (reticular and honeycomb scores) were correlated with lung function and clinical parameters.

Results: ILD was present in 39/45 (86.7%) patients. Abnormal (<80% predicted) forced vital capacity (FVC), total lung capacity (TLC) and carbon monoxide diffusion factor (DLco) were detected in 30%, 22% and 46% of patients. Total HRCT score correlated with FVC ( r=−0.43, p=0.008), FEV1 (forced expiratory volume) ( r=–0.37, p=0.03), TLC ( r=–0.47, p=0.003), and DLCO ( r=–0.43, p=0.008); inflammatory index with DLCO ( r=–0.43, p=0.008) and exercise tolerance ( r=–0.39, p < 0.05); and fibrosis index with FVC ( r=–0.31, p=0.05) and TLC ( r=–0.38, p=0.02). Higher total HRCT score, and inflammation and fibrosis indices were found in patients with abnormal lung function.

Conclusion: Qualitative HRCT is able to evaluate inflammation and fibrosis, showing important relationships with diffusion capacity and lung volume, respectively.

Aerobic exercise and yoga improve neurocognitive function in women with early psychosis

Impairments of attention and memory are evident in early psychosis, and are associated with functional disability. In a group of stable, medicated women patients, we aimed to determine whether participating in aerobic exercise or yoga improved cognitive impairments and clinical symptoms. A total of 140 female patients were recruited, and 124 received the allocated intervention in a randomized controlled study of 12 weeks of yoga or aerobic exercise compared with a waitlist group. The primary outcomes were cognitive functions including memory and attention. Secondary outcome measures were the severity of psychotic and depressive symptoms, and hippocampal volume. Data from 124 patients were included in the final analysis based on the intention-to-treat principle. Both yoga and aerobic exercise groups demonstrated significant improvements in working memory (P<0.01) with moderate to large effect sizes compared with the waitlist control group. The yoga group showed additional benefits in verbal acquisition (P<0.01) and attention (P=0.01). Both types of exercise improved overall and depressive symptoms (all P⩽0.01) after 12 weeks. Small increases in hippocampal volume were observed in the aerobic exercise group compared with waitlist (P=0.01). Both types of exercise improved working memory in early psychosis patients, with yoga having a larger effect on verbal acquisition and attention than aerobic exercise. The application of yoga and aerobic exercise as adjunctive treatments for early psychosis merits serious consideration. This study was supported by the Small Research Funding of the University of Hong Kong (201007176229), and RGC funding (C00240/762412) by the Authority of Research, Hong Kong.

Prognostic role of coronary calcification in patients with rheumatoid arthritis and systemic lupus erythematosus

OBJECTIVES

To study the predictive value of coronary calcification score (CCS) for future cardiovascular (CVS) events as detected by multi-detector computed tomography (MDCT) in patients with rheumatoid arthritis(RA) and systemic lupus erythematosus (SLE).

METHODS

A total of 152 patients with RA and SLE, and 106 healthy controls underwent MDCT to measure CCS. All patients were prospectively followed up for major CVS events.

RESULTS

Compared with controls, patients with RA and SLE had a significantly higher mean CCS (42.2±154.3 vs. 1.4±13.0, p<0.01) and prevalence of CCS 1-10, CCS 11-100 and CCS>100 (all p<0.05). After a mean period of 4.3±0.6 years, major CVS events occurred in 10 patients with RA and SLE. In patients with RA and SLE, a higher major CVS events rate occurred in patients with CCS 1-10 (5.0%), CCS 11-100 (14.3%) and CCS >100 (40.0%) than those with CCS=0 (1.0%, p<0.01). Multivariate Cox regression analysis revealed that hypercholesterolemia (hazard ratio (HR) 11.2, confidence interval (CI 1.4-89.3, p=0.02) and CCS>100 (HR 11.1, CI 1.31-95.0, p=0.03) were independent predictors of combined events.

CONCLUSIONS

Coronary calcification detected by MDCT independently predicts CVS events in patients with RA and SLE. Risk stratification by assessment of CCS may have an important role in patients with systemic inflammatory disease.

18F-FDG-PET-CT imaging findings of recurrent intracranial haemangiopericytoma with distant metastases

A 42-year-old woman presented with local recurrence and distant lung and liver metastases 7 years after resection of a primary intracranial haemangiopericytoma. Whole-body (18)F-fluoro-2-deoxy-d-glucose (FDG)-positron emission tomography (PET)-CT scan showed no increased uptake in local recurrence or distant metastases except for a focus of increased FDG uptake within a hepatic metastasis. The hypermetabolic area correlated with an intratumoral hypoenhancing area on the CT scan. PET-CT scan may be useful to allow further understanding of the tumour.

Radiation dose and cancer risk in retrospectively and prospectively ECG-gated coronary angiography using 64-slice multidetector CT

This study aimed to estimate the radiation dose and cancer risk to adults in England, the USA and Hong Kong associated with retrospectively and prospectively electrocardiogram (ECG)-gated coronary computed tomography angiography (CTA) using currently practised protocols in Hong Kong. The doses were simulated using the ImPACT spreadsheet. For retrospectively ECG-gated CTA with pitches of 0.2, 0.22 and 0.24, the effective doses were 27.7, 23.6 and 20.7 mSv, respectively, for males and 23.6, 20.0 and 18.8 mSv, respectively, for females. For prospectively ECG-gated CTA, the effective dose was 3.7 mSv for both males and females. A table of lifetime attributable risks (LAR) of cancer incidence was set up for the English population for the purpose of estimating cancer risk induced by low-dose radiation exposure, as previously reported for US and Hong Kong populations. From the tables, the LAR of cancer incidence for a representative 50-year-old subject was calculated for retrospectively ECG-gated CTA to be 0.112% and 0.227% for English males and females, respectively, 0.103% and 0.228% for US males and females, respectively, and was comparatively higher at 0.137% and 0.370% for Hong Kong males and females, respectively; for prospectively ECG-gated CTA, the corresponding values were calculated to be 0.014% and 0.035% for English males and females, respectively, and 0.013% and 0.036% for US males and females, respectively, and again were higher at 0.017% and 0.060% for Hong Kong males and females, respectively. Our study shows that prospectively ECG-gated CTA reduces radiation dose and cancer risks by up to 87% compared with retrospectively ECG-gated CTA.

Coronary atherosclerosis using computed tomography coronary angiography in patients with systemic sclerosis

BACKGROUND

Impaired coronary artery reserve has previously been demonstrated in patients with systemic sclerosis (SSc). Both micro- and macrovascular factors are probably contributory to the underlying pathogenesis.

OBJECTIVES

To examine the frequency of coronary atherosclerosis in a series of SSc patients by computed tomography coronary angiography (CTCA), a less invasive method than conventional coronary angiography, the current gold standard in the detection of coronary atherosclerosis, and to explore its clinical associations.

METHODS

Nineteen consecutive SSc patients [six with diffuse (dSSc) and 13 with limited disease (lSSc)] with disease duration of >or= 3 years were recruited. Coronary calcium score and contrast angiography were examined by CT scan. Conventional cardiovascular factors and inflammatory markers were measured and correlated with CT findings.

RESULTS

The mean+/-SD age of these patients was 52.5+/-12.5 years with median disease duration of 12.5 years. Six (31.6%) patients were found to have coronary artery calcification (calcium score 13-2008). Coronary calcium was detected in one dSSc patient but contrast angiography was not performed because of interference from an in situ implantable cardiac device. Some parts of the coronary arteries were not assessable in two patients who had ectopic cardiac rhythm. Five lSSc patients had calcified plaques causing variable coronary luminal stenosis. All patients were asymptomatic. Patients with abnormal CTCA findings were more likely to be older (p < 0.001) and were less likely to have serum anti-Scl70 antibodies (p = 0.003) than those without, after Bonferroni correction.

CONCLUSIONS

Coronary atherosclerosis is not uncommon in asymptomatic SSc patients. CTCA is a convenient and non-invasive method for studying coronary atherosclerosis.

White matter fractional anisotrophy differences and correlates of diagnostic symptoms in autism

BACKGROUND

Individuals with autism have impairments in 3 domains: communication, social interaction and repetitive behaviours. Our previous work suggested early structural and connectivity abnormalities in prefrontal-striato-temporal-cerebellar networks but it is not clear how these are linked to diagnostic indices.

METHOD

Children with autism (IQ > 70) aged 6 to 14 years old and matched typically developing controls were studied using diffusion tensor imaging. Voxel-based methods were used to compare fractional anisotrophy (FA) measures in each group and to correlate FA measures in the autism group with the diagnostic phenotype described by the Autism Diagnostic Interview - Revised (ADI-R) algorithm for ICD-10.

RESULTS

After controlling for the effects of age and white matter volume, we found that FA in the autism group was significantly lower than controls in bilateral prefrontal and temporal regions, especially in the right ventral temporal lobe adjacent to the fusiform gyrus. FA was greater in autism in the right inferior frontal gyrus and left occipital lobe. We observed a tight correlation between lower FA and higher ADI-R diagnostic algorithm scores across white matter tracts extending from these focal regions of group difference. Communication and social reciprocity impairments correlated with lower FA throughout fronto-striato-temporal pathways. Repetitive behaviours correlated with white matter indices in more posterior brain pathways, including splenium of the corpus callosum and cerebellum.

CONCLUSIONS

Our data support the position that diagnostic symptoms of autism are associated with a core disruption of white matter development.

A diffusion tensor imaging study of structural dysconnectivity in never-medicated, first-episode schizophrenia

BACKGROUND

Diffusion tensor imaging (DTI) can be used to investigate cerebral structural connectivity in never-medicated individuals with first-episode schizophrenia.

METHOD

Subjects with first-episode schizophrenia according to DSM-IV-R who had never been exposed to antipsychotic medication (n=25) and healthy controls (n=26) were recruited. Groups were matched for age, gender, best parental socio-economic status and ethnicity. All subjects underwent DTI and structural magnetic resonance imaging (MRI) scans. Voxel-based analysis was performed to investigate brain regions where fractional anisotropy (FA) values differed significantly between groups. A confirmatory region-of-interest (ROI) analysis of FA scores was performed in which regions were placed blind to group membership.

RESULTS

In patients, FA values significantly lower than those in healthy controls were located in the left fronto-occipital fasciculus, left inferior longitudinal fasciculus, white matter adjacent to right precuneus, splenium of corpus callosum, right posterior limb of internal capsule, white matter adjacent to right substantia nigra, and left cerebral peduncle. ROI analysis of the corpus callosum confirmed that the patient group had significantly lower mean FA values than the controls in the splenium but not in the genu. The intra-class correlation coefficient (ICC) for independent ROI measurements was 0.90 (genu) and 0.90 (splenium). There were no regions where FA values were significantly higher in the patients than in the healthy controls.

CONCLUSIONS

Widespread structural dysconnectivity, including the subcortical region, is already present in neuroleptic-naive patients in their first episode of illness.

A prediction rule for clinical diagnosis of severe acute respiratory syndrome

A prospective study was undertaken to identify clinical, radiographical, haematological and biochemical profiles of severe acute respiratory syndrome (SARS) patients. A prediction rule, which demarcates low from high risk patients for SARS in an outbreak situation was developed. A total of 295 patients with unexplained respiratory illnesses, admitted to Queen Mary Hospital, Hong Kong SAR, China, in March to July 2003, were evaluated for clinical, radiological, haematological and alanine transaminase (ALT) data daily for 3 days after hospitalisation. In total, 44 cases were subsequently confirmed to have SARS by RT-PCR (68.2%) and serology (100%). The scoring system of attributing 11, 10, 3, 3 and 3 points to the presence of independent risk factors, namely: epidemiological link, radiographical deterioration, myalgia, lymphopenia and elevated ALT respectively, generated high and low-risk (total score 11-30 and 0-10, respectively) groups for SARS. The sensitivity and specificity of this prediction rule in positively identifying a SARS patient were 97.7 and 81.3%, respectively. The positive and negative predictive values were 47.8 and 99.5%, respectively. The prediction rule appears to be helpful in assessing suspected patients with severe acute respiratory syndrome at the bedside, and should be further validated in other severe acute respiratory syndrome cohorts.

Partial rhombencephalosynapsis and Chiari II malformation

We report a rare case of partial rhombencephalosynapsis coexistent with Chiari II malformation in a 6-year-old girl and discuss the features of these entities on magnetic resonance imaging.

Hyperbilirubinemia and cholelithiasis in Chinese patients with hemoglobin H disease

Hemoglobin H disease (HbH) is a hemoglobinopathy peculiar to parts of the world with high incidence alpha-thalassemia mutations. Among 90 HbH cases, 50 cases suffered from clinically significant jaundice (bilirubin >30 mmol/l), including 14 with severe jaundice (bilirubin >60 mmol/l). Cholelithiasis was found in 38 cases. The incidence is roughly eight times higher than that in background control population but 50% lower than that in beta-thalassemia. The risk of gallstones was related to higher bilirubin levels but not alpha-globin genotype, sex, ferritin, and hemoglobin levels. Homozygotes or double heterozygotes for Gilbert alleles (17.2%), but not heterozgyotes (42.2%), were found to have a significantly increased risk of gallstones and jaundice. However, common Chinese Gilbert syndrome alleles do not completely explain the variable risks.

Post-operative magnetic resonance evaluation of children after laparoscopic anorectoplasty for imperforate anus

BACKGROUND AND AIMS

Laparoscopic anorectoplasty (LAR) is a relatively new procedure in the treatment of imperforate anus. Using magnetic resonance imaging (MRI), we evaluated the anatomical features of the anorectal region of children treated with LAR and compared this with conventional posterior sagittal anorectoplasty (PSARP). The findings were correlated with functional outcome.

PATIENT/METHODS

A retrospective review of ten children with the high/intermediate types of imperforate anus underwent LAR between May 2000 and December 2002. MRI of the pelvis was performed post-operatively and a semi-quantitative score was used to assess the degree of sphincter symmetry, peri-rectal fibrosis, and the position of the pull-through rectum. The defecation status of these patients was also recorded. Eight historical patients who had undergone PSARP served as a control group.

RESULTS/FINDINGS

When compared with PSARP patients, a significantly lower proportion of LAR patients had sphincter asymmetry (40 vs. 100%, p < 0.05) and peri-rectal fibrosis (40 vs. 87.5%, p < 0.05). The positioning of the rectum was, however, central for both groups (90 vs. 87.5%). No statistical correlation was found between defecation status and the degree of sphincter asymmetry or peri-rectal fibrosis.

INTERPRETATION/CONCLUSION

LAR allows more optimal anatomical reconstruction for patients with the high/intermediate types of imperforate anus. However, additional factors that are not correctable by surgery, such as intrinsic innervation deficiency, also influence the clinical outcome.

Exhaled nitric oxide in bronchiectasis: the effects of inhaled corticosteroid therapy

SETTING

While exhaled nitric oxide (eNO) levels are reduced by inhaled corticosteroid therapy in asthma, such treatment effect is unclear in bronchiectasis.

DESIGN

Stable non-smoking bronchiectasis patients were randomised to receive either fluticasone (1 mg/daily) or identical placebo via the Accuhaler device.

RESULTS

Sixty non-smoking patients (38 women; mean age 56.4 +/- 12.7 years) were recruited. Of these, half received inhaled fluticasone and half placebo therapy. eNO was measured using a chemiluminescence analyser at 0, 4, 12, 24, 36 and 52 weeks. There was no significant difference in eNO levels between fluticasone and placebo patients over the study period. There was no correlation between baseline eNO with age, FEV1, FVC, 24 h sputum volume or number of bronchiectatic segments. Patients with Pseudomonas aeruginosa (PA) infection, but not their counterparts, displayed a correlation between 0- and 52-week eNO levels. PA infection was associated with significantly lower eNO levels among the patients.

CONCLUSIONS

Inhaled fluticasone therapy, despite being an effective anti-inflammatory agent, has no significant effect on eNO production, either at individual time points or over the entire 52-week profile, in bronchiectasis. It appears that eNO might not reflect the extent of airway inflammation in bronchiectasis.

Pentaglobin in steroid-resistant severe acute respiratory syndrome

SETTING

The treatment of severe acute respiratory syndrome (SARS) is at best controversial, although there is considerable anecdotal experience to show the benefits of corticosteroid therapy for selected patients. Some patients deteriorate relentlessly despite treatment with antibiotic, corticosteroid and mechanical ventilation.

OBJECTIVE

To attempt to determine the clinical efficacy of pentaglobin, an IgM-enriched immunoglobulin preparation, on 12 severe SARS patients who continued to deteriorate despite corticosteroid and ribavirin therapy.

DESIGN

Retrospective analysis of daily quantitative and radiographic data on the cohort in a regional teaching hospital.

RESULTS AND CONCLUSION

There was significant improvement in radiographic scores, when compared with day 1, on days 5, 6 and 7 (P < 0.05) after commencement of pentaglobin treatment. Similarly, there was significant improvement in oxygen requirement, when compared with day 1, on days 6 and 7 (P < 0.05) after commencement of pentaglobin treatment. There were no reported adverse events attributable to pentaglobin administration. Ten patients made an uneventful recovery after treatment. One elderly man died from cardiorespiratory arrest despite clinical and radiological improvement, and another patient is making good progress. Pentaglobin is safe and probably effective in the treatment of steroid-resistant SARS. A double-blind placebo-controlled study should therefore be considered.

A case of cerebellar hypoplasia in a Chinese infant with osteogenesis imperfecta

We report a unique case of unilateral cerebellar hypoplasia in a young Chinese girl with osteogenesis imperfecta type IV. Magnetic resonance imaging showed mild basilar invagination and impression. Although unilateral cerebellar hypoplasia and osteogenesis imperfecta may have been coincidental diagnoses, we propose possible mechanisms for unilateral cerebellar hypoplasia secondary to osteogenesis imperfecta. For example, cerebellar hypoplasia may have been because of vascular disruption or direct compression to the posterior circulation in utero. Foetuses with osteogenesis imperfecta are more susceptible to the above risks compared to the normal foetus because of associated craniocervical anomalies and a poorly ossified skull.

Advances in imaging of the solitary pulmonary nodule

OBJECTIVE

To review the radiological management of a solitary pulmonary nodule.

DATA SOURCES

MEDLINE literature search (1958-2002).

STUDY SELECTION

All review articles and original articles. Key words for the literature search were 'solitary pulmonary nodule' and 'imaging'.

DATA EXTRACTION

All relevant information and data.

DATA SYNTHESIS

The solitary pulmonary nodule remains a perennial problem in radiological practice, particularly with current trends using low-dose computed tomography to screen for lung cancer. Determining the likelihood of malignancy forms the basis of the radiological approach of a solitary pulmonary nodule. Several factors that influence risk analysis include morphological and enhancement characteristics of the solitary pulmonary nodule on imaging, stability of the nodule, age of patient, smoking history, and history of malignant disease. Other ancillary procedures and imaging techniques that assist in the evaluation of a solitary pulmonary nodule include fluorodeoxyglucose positron-emission tomography, technetium Tc 99m depreotide imaging, bronchoscopy with bronchioloalveolar lavage and biopsy, image-guided transthoracic needle aspiration biopsy, video-assisted thorascopic surgery, and thoracotomy.

CONCLUSIONS

The success of any radiological management of a solitary pulmonary nodule rests on careful clinical evaluation and risk stratification for malignancy before the implementation of appropriate imaging techniques.

Magnetic resonance screening of iron status in transfusion-dependent β-thalassaemia patients

The clinical utility of dual sequence (T1- and T2-weighted) magnetic resonance (MR) imaging in estimating liver iron concentration (LIC) in 32 transfusion-dependent beta-thalassaemia major (24 females; age 18.5+/-5.9 years) patients on desferrioxamine was evaluated. Signal intensity ratios (SIR) between liver, spleen and pancreas to psoas muscle were determined on both sequences. Relationships between clinical and MR parameters, and accuracy of SIR thresholds in determining adequacy of chelation from LIC were analysed. Liver T1- and T2-SIR were related to LIC (P < 0.001). T1-SIR < 0.60 predicted severe iron overload (LIC > 15 mg/g) with sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 100%, 87%, 33% and 100% respectively. T2-SIR < 0.1 yielded 100% sensitivity, 93% specificity, 50% PPV and 100% NPV. T1-SIR > or = 1.1 predicted LIC < 7 mg/g with 69% sensitivity, 88% specificity, 85% PPV and 74% NPV. T2-SIR > or = 0.20 yielded 56.5% sensitivity, 94% specificity, 90% PPV and 71% NPV. LIC correlated with liver T1-SIR, liver T2-SIR and serum ferritin (r = -0.76, -0.65, 0.47, respectively; P < 0.01). Serum ferritin was inversely related to liver T1-SIR, liver T2-SIR and spleen T2-SIR (r = -0.35, -0.43, -0.40, respectively; P < 0.05). Mean total transfusion burden was not related to any MR parameter. Although neither MR sequence was a highly accurate predictor of LIC, SIR thresholds are useful to determine presence of iron overload and adequacy of chelation treatment.

The relationship between mediastinal lymph node attenuation with parenchymal lung parameters in silicosis

OBJECTIVE

Attenuation changes on computed tomography (CT) in mediastinal lymph nodes (LN) may be related to lung alterations and functional impairment in silicosis.

DESIGN

CT and clinical data of 41 (64.2 +/- 8.3 years) males with silicosis were retrieved. Attenuation type (calcified, hyperdense, normodense) and calcification pattern (central, eccentric, dense, eggshell, speckled) of mediastinal LN were evaluated; LN attenuation of uncalcified LNs quantified on CT in six LN stations. Nodular profusion (CT-NP) and progressive massive fibrosis (CT-PMF) were graded. Relationships between LN, CT, lung function and clinical parameters were determined.

RESULTS

LN sites were paratracheal (n = 39), subcarinal (n = 39), tracheobronchial (n = 37), aortopulmonary (n = 37), hilar (n = 27), and peri-oesophageal (n = 21). LNs were calcified, hyperdense and normodense in 107, 85 and 54 LN stations, respectively. Uniformly calcified LN was most common, followed by speckled calcification. Central, eccentric and eggshell calcification was rare. CT-NP scores > or = 16 were associated with higher LN attenuation and number of calcified LN stations than CT-NP scores < 16. PMF had no influence over LN morphology or calcification pattern. LN attenuation correlated with CT-PMF (r = 0.36, P = 0.01), CT-NP (r = 0.54, P < 0.001) and DLCO/VA (r = -0.33, P = 0.02).

CONCLUSION

Uniformly calcified and hyperdense LNs are common in silicosis, and eggshell LN calcification is rare. There are associations between LN attenuation and lung function impairment, and CT grades of nodular profusion and PMF.

MRI of Neonatal Encephalopathy

We present the magnetic resonance imaging (MRI) findings in neonatal encephalopathy, including hypoxic-ischaemic encephalopathy, perinatal/neonatal stroke, metabolic encephalopathy from inborn errors of metabolism, congenital central nervous system infections and birth trauma. The applications of advanced MRI techniques, such as diffusion-weighted imaging and magnetic resonance spectroscopy are emphasized.

Ultrasonography of intra-abdominal cystic lesions in the newborn

Intra-abdominal cystic lesions are increasingly recognized in the newborn because of the advent of routine antenatal ultrasonography. As these lesions are often asymptomatic or non-specific in clinical presentation in the newborn, imaging by ultrasonography has an important role in diagnosis. We present a pictorial review of the commonly encountered intra-abdominal cystic lesions in the newborn, with emphasis on ultrasonographic features that can aid differentiation between the various lesions.

Interstitial lung disease in systemic sclerosis

PURPOSE

To evaluate high-resolution CT (HRCT) parameters of inflammation and fibrosis in systemic sclerosis (SSc), for correlation with lung function, skin scores and exercise tolerance.

MATERIAL AND METHODS

45 SSc patients (40 women, 48.5+/-13.4 years), underwent thoracic HRCT, lung function assessment, and modified Rodnan skin scores. Exercise tolerance was also graded. HRCT were scored for extent of 4 HRCT patterns of interstitial lung disease (ILD): ground glass opacification (GGO), reticular, mixed and honeycomb pattern in each lobe. Total HRCT score, inflammation index (GGO and mixed score) and fibrosis index (reticular and honeycomb scores) were correlated with lung function and clinical parameters.

RESULTS

ILD was present in 39/45 (86.7%) patients. Abnormal (<80% predicted) forced vital capacity (FVC), total lung capacity (TLC) and carbon monoxide diffusion factor (DLco) were detected in 30%, 22% and 46% of patients. Total HRCT score correlated with FVC (r=-0.43, p=0.008), FEV1 (forced expiratory volume) (r=-0.37, p=0.03), TLC (r=-0.47, p=0.003), and DLCO (r=-0.43, p=0.008); inflammatory index with DLCO (r=-0.43, p=0.008) and exercise tolerance (r=-0.39, p < 0.05); and fibrosis index with FVC (r=-0.31, p=0.05) and TLC (r=-0.38, p=0.02). Higher total HRCT score, and inflammation and fibrosis indices were found in patients with abnormal lung function.

CONCLUSION

Qualitative HRCT is able to evaluate inflammation and fibrosis, showing important relationships with diffusion capacity and lung volume, respectively.

Computed tomography characteristics of advanced primary pulmonary lymphoepithelioma-like carcinoma

Our objectives were to document CT features of advanced primary pulmonary lymphoepithelioma-like carcinoma (LELC) and to determine features that may assist differentiation from other non-small cell lung cancers (NSCLC). Imaging and clinical data of all patients with biopsy-proven pulmonary LELC ( n=12) were retrieved from a database of all NSCLC patients over a 2-year period. Twenty-five controls were recruited from other inoperable non-LELC NSCLC patients from the database. Pre-treatment CT scans of the thorax of both study and control patients were reviewed for lobe involved; tumour site, borders and size; and pleural, vascular or pulmonary involvement. Presence of lymphangitis carcinomatosis was noted. Lymph node metastasis was characterised as ipsilateral or contralateral enlarged (>1 cm) mediastinal or hilar nodes, or as peribronchovascular nodal spread. Differences between the two groups were tested using Mann-Whitney rank-sum test. The LELC tumours were significantly larger (45.67 vs 17.71 cm(2)) than controls and were closely associated with the mediastinum. There were more LELC tumours with well-defined borders ( p<0.001) and fewer with spiculated borders ( p<0001) than non-LELC tumours. There was increased peribronchovascular nodal spread ( p=0.01) and vascular encasement ( p=0.02) in LELC compared with non-LELC tumours. Advanced primary pulmonary LELC has distinct radiological features, and can appear as well-defined tumour closely associated with the mediastinum, with peribronchovascular spread and vascular encasement.

Pulmonary iron overload in thalassemia major presenting as small airway disease

Lung function abnormalities that are associated with thalassemia major are variable with etiology that is yet undetermined. Some studies have suggested that pulmonary iron deposition is a probable cause for these lung defects although there has been no antemortem histopathological and radiological evidence for this. We report a case of thalassemia major with biopsy-proven pulmonary iron overload, in which thoracic high-resolution computed tomography revealed a morphological-functional correlation consistent with small airway disease.

Portal venous velocity in the follow-up of patients with biliary atresia after Kasai portoenterostomy

BACKGROUND/PURPOSE

Liver transplantation is the only therapeutic option for biliary atresia (BA) patients with failed Kasai portoenterostomy (PE). The indication for and timing of liver transplantation in these patients are important management issues. The aims of this study are to evaluate the relationship between portal venous velocity (PVV) and clinical and biochemical indicators of liver function in BA, and to examine the role of PVV in the postoperative surveillance of these patients.

METHODS

Twenty-nine children (mean age, 8 years 4 months) who had PE for BA underwent Doppler ultrasonography to evaluate PVV. Using regression analysis, these findings were correlated with biochemical indicators of liver function. The Mann-Whitney test was used to detect any significant differences in PVV between the Child-Pugh A group and combined Child-Pugh B and C group patients.

RESULTS

The mean +/- SD PVV for the Child-Pugh A group and the combined Child-Pugh B and C group was 17.1 cm/s +/- 8.9 cm/s and 10.2 cm/s +/- 3.3 cm/s, respectively, and this difference was statistically significant (P =.037).

CONCLUSIONS

Doppler ultrasonography measurement of PVV provides adjunctive information to the clinical and biochemical assessment of the liver function status in BA. Its use in the postoperative surveillance of these patients is helpful in identifying the need for and in timing of liver transplantation.

Mature teratomas of the adrenal gland: imaging features

BACKGROUND

We describe the imaging features of three, histologically confirmed, mature teratomas of the adrenal gland not described previously in the radiologic literature and discuss the differential diagnosis of lipomatous tumors of the adrenal gland.

METHODS

Computed tomographic (n = 3), magnetic resonance imaging (n = 1), and sonographic (n = 1) features were reviewed retrospectively and the findings correlated with gross pathology and histology.

RESULTS

There were two females (age 8 and 18 years) and one male (age 17 years). Tumor size ranged from 5 to 11 cm (mean = 7.3 cm). All tumors were well circumscribed and contained fat components. Calcification was demonstrated in two tumors and was the predominant component in one. Only one was cystic.

CONCLUSION

The radiologic features of these tumors were typical of mature teratomas occurring elsewhere in the body. This should be considered in the differential diagnosis of lipomatous tumors of the adrenal gland, especially in children and adolescents.

Imaging of peripheral PNET: common and uncommon locations

AIM

We present the imaging features of peripheral primitive neuroectodermal tumour (PNET) in eight children, highlighting the unusual locations of this tumour in three children.

MATERIALS AND METHODS

At presentation, the tumours were studied with magnetic resonance imaging (MRI; n = 6), computed tomography (CT; n = 7) and ultrasound (US; n = 1). The diagnoses were confirmed histologically (n = 8), immunohistochemically (n = 8), by cytogenetics (n = 3) and electron microscopy (n = 1). Correlation with gross pathology, histology, treatment and outcome were obtained.

RESULTS

The tumours were located in the chest wall (n = 2), shoulder, pelvis, small bowel mesentery, adrenal gland, dura mater and skin and subcutaneous tissue of the abdominal wall (n = 1 each). Peripheral PNET arising from the small bowel mesentery, adrenal gland and dura mater have not been previously reported in the English literature. The tumours were mainly large (mean size: 10.6 cm) and infiltrative. All tumours were heterogeneously hyperintense on T2-weighted MRI, heterogeneously iso/hypodense on CT and had variable contrast enhancement. Most tumours were heterogeneously hypointense to muscle on T1-weighted MRI. US showed a hypoechoic mass with a cystic component.

CONCLUSION

Peripheral PNET can occur in unusual locations. The clinical and imaging features of peripheral PNET are non-specific, making tissue diagnosis essential. PNET should be included in the differential diagnosis of aggressive soft tissue tumours in children.

Solid-cystic papillary tumor of the pancreas in children

Solid-cystic papillary tumor (SCPT) of the pancreas is a rare neoplasm in children. The current study attempted to estimate the incidence and possible pathological origin of the tumor. Clinicopathologic features of the children under the age of 16 years with pancreatic tumors managed in a single institution between January 1993 and November 1999 were reviewed. Representative blocks of SCPT specimens were immunostained for neuron-specific enolase (NSE) chromogrannin, synaptophysin, insulin, glucagon, somatostatin, and gastrin. There were three SCPTs, two pancreatic endocrine tumors, and one acinar cell carcinoma during the study period. The estimated yearly incidence in the referral area of 2 million population is about 0.01 pediatric SCPT per year per 100,000 population. The children underwent surgical removal of the tumors. Postoperatively, they were followed up for 6 months to 4 years and were well. Immunostaining for NSE, chromogranin, synaptophysin, insulin, somatostatin, and gastrin was negative in all cases. SCPT may thus be the most common pancreatic tumor in the Asian pediatric population. The pathological origin of the tumor remains unclear and requires further investigations.

Varicocele: Laparoscopic clipping and color Doppler follow-up

PURPOSE

The aim of this study was to evaluate the results of laparoscopic treatment of varicocele and findings of testicular volume and blood supply using color Doppler ultrasound scan on follow-up.

METHODS

Fourteen patients aged 7 to 15 years old (median, 12.3 years) with left varicocele (grade II, n = 4; grade III, n = 10) underwent laparoscopic clipping of internal testicular vein and artery. At follow-up, both testes were scanned by ultrasonography in axial and longitudinal planes, and at least 3 measurements-length, width, and thickness-were taken to calculate testicular volumes. Arterial perfusion of the testes also was assessed.

RESULTS

Operating time ranged from 25 to 80 minutes (mean, 60 minutes). There was no perioperative complication. At a mean follow-up of 14 months (range, 2 to 39 months) all children were asymptomatic with disappearance of varicocele. The volumes of bilateral testes were equal (difference in volumes less than 10%) in 9 children. Ipsilateral testicular hypertrophy was found in 3 children. There was no difference in arterial perfusion between the testes in each patient. Small transient ipsilateral hydrocele was observed in 2 patients.

CONCLUSION

Laparoscopic clipping of testicular vein and artery was simple and effective for varicocele treatment and did not compromise testicular blood supply.

Ewing sarcoma of the small intestine

This report describes a rare case of Ewing sarcoma (ES) of the small intestine. The patient was a 9-year-old girl with progressive abdominal distension. Computed tomography showed a large mass in the small bowel. Histopathologic examination of the resected tumor showed ES with typical histologic, immunohistochemical, and ultrastructural features. The tumor recurred in the pelvic cavity 18 months after the original surgery. Molecular study of the recurrent tumor confirmed a diagnostic EWS-FLI1 gene fusion. This patient illustrates the unique occurrence of ES in the small intestine.

Radiologic manifestations of granulocytic sarcoma in adult leukemia

OBJECTIVE

This study was conducted to summarize the clinical and radiologic presentations including pertinent imaging features of granulocytic sarcoma, a rare extramedullary tumor of acute myeloid leukemia, in 11 adult patients.

CONCLUSION

In patients in our study, the clinical and radiologic manifestations of granulocytic sarcoma were variable and occurred most commonly as disease progression in acute myeloid leukemia (73% of the patients). Granulocytic sarcoma lesions were multiple soft-tissue masses with variable enhancement, recurring in nearly 50% of patients at different sites and points of time during the course of the disease. Lesions in the central nervous system, subcutaneous tissues, and genitourinary system accounted for nearly 52% of all lesions. In general, granulocytic sarcoma masses were isodense to muscle on CT scans, and isointense and hyperintense (mild to moderate) on T1- and T2-weighted MR images, respectively. The presence of peripheral rim enhancement with hypodense or hypointense centers on T1-weighted images may, however, mimic an abscess.

Ultrasound-guided hydrostatic reduction of childhood intussusception: technique and demonstration

The authors review the technique of ultrasound-guided hydrostatic reduction of childhood intussusception and illustrate, in real-time fashion, the treatment of three cases with this technique. Two cases of successful reduction of ileocolic intussusception are demonstrated. The third case is an example of the complex fronded appearance of ileo-ileocolic intussusception and failed reduction. This technique is recommended as an alternative method for the treatment of childhood intussusception, as it does not involve ionizing radiation and is a simple and safe procedure.

MR imaging of breast paraffinomas

OBJECTIVE

Our objective is to present the MR appearance of breast paraffinoma, a late complication of breast augmentation by liquid paraffin wax, and to correlate this appearance with the histopathologic findings that were available for three of the 11 breasts we studied.

CONCLUSION

Breast paraffinomas have a characteristic MR appearance that correlates well with histopathologic findings. With MR imaging, we were able to visualize the location and extent of the paraffinoma, best seen on the fat-suppression sequence, and to evaluate the surrounding fibroglandular breast tissue.

Ultrasound contrast agent Levovist in colour Doppler sonography of hepatocellular carcinoma in Chinese patients

In a phase IIIb clinical trial of the ultrasound contrast agent Levovist (Schering AG, Berlin, Germany), the role of Levovist in the management of patients with clinically suspected hepatocellular carcinoma (HCC) was evaluated and its efficacy was assessed. The assessment included the duration of diagnostically usable Doppler signal enhancement, and safety and tolerance of intravenous administration. All patients with clinically suspected hepatocellular carcinoma were referred for Doppler sonographic examination over a 5-month period and lesions with absent or suboptimal Doppler signals were included in the trial. A total of 300 mg/mL in concentration (8.5 mL) of Levovist was administered through a peripheral vein while Doppler signal intensity in the lesion, based on a visual score, was recorded. Blood pressure and pulse were recorded before and after injection. Thirty-eight patients were examined, of which 29 were included in the trial. The lesions were subsequently proven histologically to be 19 HCC, one cholangiocarcinoma, two regeneration nodules and one colonic metastasis. For six patients in whom histological proof was not available, the diagnosis of HCC was suggested based on markedly elevated serum alpha-fetoprotein levels. All but one (96%) of the 25 HCC demonstrated increased Doppler signal after Levovist. There were no Doppler signals before and after Levovist injection in three non-HCC lesions (two regeneration nodules and one colonic metastasis). Two patients (6.9%) suffered minor adverse reactions of nausea and vomiting. The results show that Levovist is safe and is able to improve lesion characterization and increase diagnostic confidence of hepatocellular carcinoma by enhancing tumour vascularization Doppler signal intensity.

Ileoileocolic intussusception in children: diagnosis and significance

The ileoileocolic type of childhood intussusception is difficult to diagnose pre-operatively and is associated with increased morbidity. This study describes the clinical and imaging features of 10 consecutive ileoileocolic intussusceptions diagnosed ultrasonically in 10 patients over a 36 month period. Ultrasound-guided hydrostatic reduction using Hartmann's solution was attempted in all 10 patients. Clinical and imaging features were compared with those of 28 ileocolic intussusceptions in 25 patients diagnosed and treated using the same methods during the same period. Most of the clinical and plain radiographic features of the patients with the ileoileocolic and ileocolic types of intussusception were similar. The two types of intussusception had the classical doughnut or pseudokidney, or both, signs on pre-reduction ultrasound scans. During the reduction process, when surrounded by fluid within the caecal lumen, the ileoileocolic type of intussusception had a typical complex appearance due to frond-like loops of intussuscepted small bowel. This finding was present in all cases. The hydrostatic reduction rate was only 10% (1/10) for ileoileocolic intussusception, compared with 92.9% (26/28) for the ileocolic type. All unsuccessfully-reduced cases underwent surgery, with surgical confirmation of the intussusception type in all cases. Only one patient was found to have a lead point, caused by a Meckel's diverticulum. In conclusion, the diagnosis of ileoileocolic intussusception can be made pre-operatively and these patients require surgical management.

Technical aspects of insertion and removal of an inferior vena cava IVC filter for prophylactic treatment of pulmonary embolus

We report the successful insertion and subsequent retrieval of a Gunther-Tulip vena cava filter in a patient with an anomalous left-sided inferior vena cava, who developed a right ilio-femoral venous thrombosis prior to planned surgical resection of a right femoral osteosarcoma. The indication was for short-term prophylaxis against pulmonary embolism during manipulative leg surgery.

Percutaneous retrieval of a fractured biliary guidewire from a reduced liver graft

We describe a unique case of percutaneous retrieval of a broken guidewire in the biliary tree of a patient with a biliary stricture following liver transplantation with a reduced segment 2,3 graft using an Amplatz "goose-neck" snare.

Childhood intussusception: ultrasound-guided Hartmann's solution hydrostatic reduction or barium enema reduction?

A comparison was made of the efficacy of ultrasound guided Hartmann's solution hydrostatic reduction on 23 patients (US group) with the same number of consecutive patients in whom hydrostatic reduction was done by barium enema (BE group) under fluoroscopy for childhood intussusception. The US group was diagnosed by ultrasound scan and reduction was attempted under the guidance of ultrasonography with Hartmann's solution at 100 mm Hg pressure. Excluded were patients older than 12 years, patients in shock, patients with peritonitis, bowel perforation, and gross abdominal distension as well as recurrent intussusception of more than three episodes. There were three patients excluded in this group. The diagnosis of intussusception and complete reduction were confirmed by gastrografin enema. This US group had three recurrences (3 of 26, 11.5%), one lead point (1 of 23, 4.4%), and 19 successful reductions (19 of 26, 73%). Incidentally, there were also three patients excluded in this period of barium enema reduction. There was only one recurrence (1 of 24, 4.2%), one leadpoint (1 of 23, 4.4%), and 12 successful reductions (12 of 24, 50%) in these 23 BE patients. The success rates for the ileo-colic intussusceptions with Hartmann's solution reduction and barium enema reduction were 91% (19 of 21) and 55% (12 of 22), respectively (P = .00865). There was no complication in either group, and the accuracy of diagnosing a complete reduction was 100% in both forms of reduction. Hence, ultrasound-guided hydrostatic reduction for childhood ileocolic intussusception is preferred because it is safe, accurate, has a higher success rate, and can avoid radiation exposure risk.

Metallic stenting of the biliary tree following liver transplant hepatic artery thrombosis in an infant

We report the placement of intrahepatic metallic, balloon-expandable stents in the biliary tree following liver transplantation in a 12-month-old infant who developed biliary strictures secondary to hepatic artery thrombosis. The use of such stents has not previously been reported following transplantation in an infant. Re-transplantation was undertaken 5 months after stenting because of chronic rejection and progressive obstructive jaundice.

Horseshoe kidney with bilateral single system ectopic ureters

A horseshoe kidney, associated with bilateral single system ectopic ureters in a 9-month-old boy, is reported. The right ureteric orifice was located near the midline of a deformed trigone while the grossly dilated left ureter inserted into the posterior urethra. Imaging defined this rare combination of urological anomalies prior to surgical treatment.