Ultrasound-estimated hepatorenal index: diagnostic performance and interobserver agreement for pediatric liver fat quantification.

BACKGROUND: Semiquantitative and quantitative sonographic techniques have the potential for screening and surveillance of children at risk of nonalcoholic fatty liver disease. OBJECTIVE: To determine diagnostic performance and interobserver agreement of hepatorenal index (HRI) for pediatric ultrasound-based liver fat quantification. MATERIALS AND METHODS: In an institutional review board (IRB)-approved retrospective study (April 2014 to April 2023), children (< 18 years) with clinically performed magnetic resonance imaging (MRI) scans for liver fat quantification were assessed. Inclusion criteria required availability of abdominal ultrasound within 3 months of quantitative MRI. Three blinded readers subjectively assessed for sonographic hepatic steatosis and calculated HRI. MRI proton density fat fraction (PDFF) was the reference standard. Interobserver agreement, correlation with PDFF, and optimal HRI (using ROC analysis) values were analyzed. The significance level was set at p < 0.05. RESULTS: A total of 41 patients (25 male) with median (interquartile range (IQR)) age of 13 (10-15) years were included. Median (IQR) MRI PDFF was 11.30% (2.70-17.95%). Hepatic steatosis distribution by MRI PDFF included grade 0 (34%), grade 1 (15%), grade 2 (22%), and grade 3 (29%) patients. Intraclass correlation coefficient for HRI among the three readers was 0.61 (95% CI 0.43-0.75) (p < 0.001). Moderate correlation was observed between manually estimated HRI and PDFF for each reader (r = 0.62, 0.67, and 0.67; p < 0.001). Optimal HRI cutoff was found to be 1.99 to diagnose hepatic steatosis (sensitivity 89%, specificity 93%). Median (IQR) HRI for each MRI grade of hepatic steatosis (0-4) was as follows: 1.2 (1.1-1.5), 2.6 (1.1-3.3), 3.6 (2.6-5.4), 5.6 (2.6-10.9), respectively (p < 0.001). CONCLUSION: Ultrasound-estimated HRI has moderate interobserver agreement and moderate correlation with MRI-derived PDFF. HRI of 1.99 maximizes accuracy for identifying pediatric liver fat.

Decreased percent change in renal pelvis diameter on diuretic functional magnetic resonance urography following administration of furosemide may help characterize unilateral uretero-pelvic junction obstruction.

BACKGROUND: A well-established definition of obstruction in the setting of congenital hydronephrosis is lacking. Multiple imaging modalities and radiographic characteristics or parameters have been described to help confirm the diagnosis of ureteropelvic junction obstruction (UPJO). We sought to evaluate the change in anterior-posterior renal pelvic diameter (APRPD) following furosemide administration in patients with unilateral hydronephrosis and confirmed UPJO on functional magnetic resonance urography (fMRU) who underwent pyeloplasty. MATERIALS AND METHODS: There were 49 patients who met inclusion criteria (11 females, 38 males; average age 2.2 years, SD 3.4 years) from February 2006 to September 2020, diagnosed with unilateral hydronephrosis (SFU Grade 3-4) who underwent fMRU prior to pyeloplasty for confirmed UPJO. 29 of the included patients also underwent a post-pyeloplasty fMRU. A weight-adjusted dose of 1 mg/kg of furosemide (max 20 mg/kg) was administered intravenously. Two board-certified pediatric radiologists measured the APRPD of the obstructed and non-dilated kidneys prior to pyeloplasty and APRPD of the hydronephrotic kidneys on the post-pyeloplasty follow up fMRUs. Measurements were performed on images prior to and approximately 30 min following furosemide injection. RESULTS: The average APRPD before furosemide injection in the obstructed kidney prior to pyeloplasty was 26.3 mm (SD 9.0 mm) compared to the non-dilated (not obstructed) kidney measurement of 5.1 mm (SD 3.6 mm) (p < 0.001). Following administration of furosemide, the average APRPD was 31.4 mm (SD 8.8 mm) in the obstructed kidney, and 7.8 mm (SD 4.1 mm) in the non-dilated kidney (p < 0.001). After pyeloplasty, the pre-furosemide APRPD measurement was 17.8 mm (SD 11 mm), which was significantly less compared to the pre-pyeloplasty APRPD (p < 0.001). The post-pyeloplasty, post-furosemide APRPD measurement was 25.8 mm (SD 12 mm), also significantly less compared to the pre-pyeloplasty measurement (p = 0.02). The changes in APRPD in the obstructed kidney prior to pyeloplasty was 5.1 mm (SD 3.5 mm) and after pyeloplasty was 8 mm (SD 4.6 mm) (p = 0.002). Change in APRPD in the non-dilated kidney was 2.7 mm (SD 2.3 mm). Percent APRPD change in the obstructed kidney was 22.9% (SD 18.5%), which was significantly less than 33.3% (SD 22.1%) in the post-pyeloplasty kidney (p = 0.028) and 82.8% (SD 87.9%) in the non-dilated kidney (p < 0.001). CONCLUSIONS: A relatively smaller change in APRPD on fMRU following administration of furosemide in the setting of UPJO may serve as another predictive characteristic of obstructed kidneys.

Chest radiograph features of multisystem inflammatory syndrome in children (MIS-C) compared to pediatric COVID-19.

BACKGROUND: Although the radiographic features of coronavirus disease 2019 (COVID-19) in children have been described, the distinguishing features of multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 are not well characterized. OBJECTIVE: We compared the chest radiographic findings of MIS-C with those of COVID-19 and described other distinguishing imaging features of MIS-C. MATERIALS AND METHODS: We performed a retrospective case series review of children ages 0 to 18 years who were hospitalized at Children's Healthcare of Atlanta from March to May 2020 and who either met the Centers for Disease Control and Prevention (CDC) case definition for MIS-C (n=11) or who had symptomatic, laboratory-confirmed COVID-19 (n=16). Two radiologists reviewed the most severe chest radiographs for each patient. The type and distribution of pulmonary opacities and presence or absence of pleural effusions were recorded. The chest radiographs were categorized based on potential COVID-19 imaging findings as typical, indeterminate, atypical or negative. An imaging severity score was also assigned using a simplified version of the Radiographic Assessment of Lung Edema Score. Findings were statistically compared between patients with MIS-C and those with COVID-19. Additional imaging findings of MIS-C were also described. RESULTS: Radiographic features of MIS-C included pleural effusions (82% [9/11]), pulmonary consolidations (73% [8/11]) and ground glass opacities (91% [10/11]). All of the lung opacities (100% [10/10]) were bilateral, and the majority of the pleural effusions (67% [6/9]) were bilateral. Compared to children with COVID-19, children with MIS-C were significantly more likely to develop pleural effusions on chest radiograph (82% [9/11] vs. 0% [0/0], P-value <0.01) and a lower zone predominance of pulmonary opacifications (100% [10/10] vs. 38% [5/13], P-value <0.01). Children with MIS-C who also had abdominal imaging had intra-abdominal inflammatory changes. CONCLUSION: Key chest radiographic features of MIS-C versus those of COVID-19 were pleural effusions and lower zone pulmonary opacifications as well as intra-abdominal inflammation. Elucidating the distinguishing radiographic features of MIS-C may help refine the case definition and expedite diagnosis and treatment.

Imaging of Acute Abdominal Pain in the Pediatric Population.

Acute abdominal pain is a common complaint in pediatrics. Although age and location of pain can help focus differential diagnosis, imaging plays an essential role in clinical evaluation. In this review, we discuss the optimal imaging approach to pediatric patients with acute abdominal pain and important imaging findings in the most common causes of abdominal pain in the pediatric population. [Pediatr Ann. 2020;49(9):e380-e388.].

Incidence and importance of portal venous gas in children with hypertrophic pyloric stenosis.

BACKGROUND: Hypertrophic pyloric stenosis (HPS) is a common cause of gastric outlet obstruction in young infants. Infants with HPS present with projectile vomiting, sometimes have electrolyte abnormalities and typically undergo pyloromyotomy to alleviate the obstruction. Abdominal US is the gold standard imaging study for diagnosis. Case reports of incidental hepatic portal venous gas have been reported in infants with HPS; however, no large studies have been conducted to determine the incidence or possible clinical implications of this finding. OBJECTIVE: To assess the incidence of portal venous gas in infants with HPS and to determine whether the presence of this gas in infants with HPS indicates a more unstable patient, increased length of stay or worse outcome. MATERIALS AND METHODS: We conducted a retrospective review of sonographic reports containing "pyloric stenosis," excluding negative descriptor, at a tertiary-care children's hospital from November 2010 to September 2017. Data collected included pyloric thickness/length, liver evaluation, portal venous gas, any additional imaging, demographics, symptomatology days, electrolyte abnormality, and length of hospital stay. RESULTS: In a 7-year period, 545 US exams were positive for HPS. Of these, 334 exams included enough hepatic parenchyma to evaluate for portal venous gas. Infants in 6 of the 334 exams demonstrated portal venous gas (1.8%). Clinical presentation (length of symptoms and electrolyte abnormalities), demographics (male predominance and age at presentation) and imaging characteristics (pyloric thickness and length) were similar for the HPS groups with and without portal venous gas. There was no significant difference in outcome or length of hospital stay. CONCLUSION: Visualization of portal venous gas in infants with HPS is not rare and appears benign, without need for further imaging. Portal venous gas in infants with HPS does not portend a more severe patient presentation or outcome.

COL1A1 and COL1A2 sequencing results in cohort of patients undergoing evaluation for potential child abuse.

Child abuse is a major public health concern that can explain a proportion of fractures in children. Osteogenesis imperfecta (OI) is the most common inherited syndrome that predisposes to skeletal fractures. We conducted a retrospective analysis of data from clinical, laboratory, and radiographic information from children evaluated for child abuse in which molecular testing for COL1A1 and COL1A2 genes was conducted. A total of 43 patients underwent molecular testing for OI. Pathogenic variants predicted to result in a mild form of OI were found in two patients (5%), both clinically suspected to have this diagnosis. None of the cases in whom OI molecular testing was ordered when maltreatment concerns were thought to be more likely (0/35) were identified to have pathogenic variants. After reviewing each individual case, the final diagnosis was child abuse for 34 cases (77%), and additional radiographic and laboratory studies did not identify any with inherited metabolic predisposition to fracture or rickets. We conclude that routine testing for OI in the setting of child abuse when no other suggestive clinical findings are present has a low yield. A careful review of the medical history and a detailed clinical evaluation help identify those at risk for genetic alterations. © 2016 Wiley Periodicals, Inc.

Compared with feeding infants breast milk or cow-milk formula, soy formula feeding does not affect subsequent reproductive organ size at 5 years of age.

BACKGROUND: Literature reports suggest that phytochemicals, such as isoflavones found in soybeans, impair reproductive function in animals and raise the possibility that consuming soy infant formula could alter hormonally sensitive organ development in children. OBJECTIVE: This study compared reproductive organs volumes and structural characteristics in children at age 5 y who were enrolled in the Beginnings study long-term cohort. METHODS: Breast bud, uterus, ovaries, prostate, and testes volumes and characteristics were assessed by ultrasonography in 101 children (50 boys and 51 girls) aged 5 y who were breastfed (n = 35) or fed cow-milk formula (n = 32) or soy formula (n = 34) as infants. Analyses were adjusted for race, gestational age, and birth weight. RESULTS: Among girls, no significant differences were found in breast bud, ovarian, or uterine volumes; counts of ovaries with cysts; ovarian cysts numbers; ovarian cyst size; and uterine shape between the diet groups. Among boys, no significant differences were found in breast bud, testes, or prostate volumes or structural characteristics between the diet groups. CONCLUSIONS: In this cohort, no early infant feeding effects were found on reproductive organs volumes and structural characteristics in children age 5 y. The follow-up of these children through puberty is planned and should help delineate potential early infant feeding effect on reproductive function later in life.

Imaging in pediatric small bowel transplantation.

Small bowel transplantation, alone or with other organs as multivisceral transplantation, is performed for patients with chronic intestinal failure. With advancing surgical techniques and improved post-surgical management, survival of these patients has increased tremendously in the last two decades. The radiologist has an important role in the preoperative and postoperative management of these patients. Knowledge of surgical techniques and post-surgical complications seen in the transplant recipient is necessary for adequate management of these patients.

Congenital lung lesions: prenatal MRI and postnatal findings.

BACKGROUND: Congenital lung lesions refer to a spectrum of malformations and developmental abnormalities of the foregut, pulmonary airways and vasculature. These lesions range from small, asymptomatic to large space-occupying masses that can increase risk of fetal death and respiratory compromise after birth. Prenatal sonography has been used for routine screening in pregnancy. The advent of prenatal magnetic resonance imaging leads to complementary use in the diagnosis of fetal anomalies, including in fetuses with congenital lung lesions. OBJECTIVE: To determine whether fetal MRI can differentiate congenital lung lesions by comparing prenatal diagnosis with postnatal imaging and pathology. MATERIALS AND METHODS: In a 4-year period, 76 fetuses with suspected lung lesions were referred for fetal MRI. We retrospectively reviewed the MR exams and assigned a specific diagnosis based on predetermined criteria. We then compared the prenatal diagnosis to postnatal imaging and pathology. RESULTS: Of 76 cases, 7 were excluded because of an alternative diagnosis. Of the 69 remaining patients, 3 died and 13 were lost to follow-up. Among the 53 patients, there were 56 lung lesions. Four of these lesions were difficult to diagnose because of size and location. Based on imaging records we gave the remaining 52 lesions a specific prenatal diagnosis: 28 congenital pulmonary airway malformations (CPAM), 4 bronchopulmonary sequestrations (BPS), 9 cases of overinflation, 9 hybrid lesions and 2 bronchogenic cysts. The prenatal diagnosis was concordant with postnatal evaluation in 51 of the 52 lung lesions. One fetus given the diagnosis of CPAM prenatally was diagnosed with a hybrid lesion postnatally. CONCLUSION: Prenatal MRI is highly accurate in defining congenital lung anomalies. When fetal MRI findings suggest a specific diagnosis, postnatal findings confirmed the prenatal MRI diagnosis in 98% of cases.

Group A beta-hemolytic streptococcal colitis with secondary bacteremia.

We report a case of a 5-year-old girl with invasive colitis and secondary bacteremia caused by group A beta-hemolytic streptococcus. Although group A beta-hemolytic streptococcus is occasionally isolated from stool, it is a rare cause of colitis. This is the first report of group A beta-hemolytic streptococcus pancolitis with secondary bacteremia.

Fetal MRI clues to diagnose cloacal malformations.

BACKGROUND: Prenatal US detection of cloacal malformations is challenging and rarely confirms this diagnosis. OBJECTIVE: To define the prenatal MRI findings in cloacal malformations. MATERIALS AND METHODS: We performed a retrospective study of patients with cloacal malformations who had pre- and post-natal assessment at our institution. Fetal MRI was obtained in six singleton pregnancies between 26 and 32 weeks of gestation. Imaging analysis was focused on the distal bowel, the urinary system and the genital tract and compared with postnatal clinical, radiological and surgical diagnoses. RESULTS: The distal bowel was dilated and did not extend below the bladder in five fetuses. They had a long common cloacal channel (3.5-6 cm) and a rectum located over the bladder base. Only one fetus with a posterior cloacal variant had a normal rectum. Three fetuses had increased T2 signal in the bowel and two increased T1/decreased T2 signal bladder content. All had renal anomalies, four had abnormal bladders and two had hydrocolpos. CONCLUSION: Assessment of the anorectal signal and pelvic anatomy during the third trimester helps to detect cloacal malformations in the fetus. The specificity for this diagnosis was highly increased when bowel fluid or bladder meconium content was identified.

MRI findings in multifetal pregnancies complicated by twin reversed arterial perfusion sequence (TRAP).

BACKGROUND: Twin reversed arterial perfusion sequence (TRAP) is a rare complication in multifetal monochorionic pregnancies in which a normal "pump" twin provides circulation to an abnormal acardiac co-twin, resulting in high-output cardiac dysfunction in the pump twin. OBJECTIVE: To define fetal MRI findings of TRAP sequence. MATERIALS AND METHODS: Fetal MR images were retrospectively reviewed in 35 pregnancies complicated by TRAP sequence. Abnormalities of the pump twin, acardiac twin, umbilical cord, placenta and amniotic fluid were reviewed. RESULTS: Acardiac twins were classified as: acephalus (51%), anceps (40%), amorphus (9%), acormus (0%). Common findings in acardiac twins include subcutaneous edema (77%), absent cardiac structures (86%), absent or abnormal thoracic cavity (100%), abnormal abdominal organs (100%), superior limbs absent (46%) or abnormal (51%), and inferior limbs present but abnormal (83%). There were pump twin findings of cardiac dysfunction in 43% and intracranial ischemic changes in 3%. Umbilical cord anomalies were present in 97%. CONCLUSION: Acardiac twins present with a predictable pattern of malformation with poorly developed superior structures, more normally formed inferior structures and absent or rudimentary heart. Although usually absent, abnormal heart structures can be seen and do not exclude TRAP sequence. Pump twins are commonly normal with exception of findings of cardiac dysfunction and possible brain ischemia.

Sonography in the evaluation of acute appendicitis: are negative sonographic findings good enough?

OBJECTIVE: The purpose of this study was to evaluate the negative predictive value (NPV) of sonography in the diagnosis of acute appendicitis. METHODS: Right lower quadrant sonograms of 193 patients (158 female and 35 male; age range, 3-20 years) with suspected acute appendicitis over a 1-year period were retrospectively reviewed. Sonographic findings were graded on a 5-point scale, ranging from a normal appendix identified (grade 1) to frankly acute appendicitis (grade 5). Sonographic findings were compared with subsequent computed tomographic (CT), surgical, and pathologic findings. The diagnostic accuracy of sonography was assessed considering surgical findings and clinical follow-up as reference standards. RESULTS: Forty-nine patients (25.4%) had appendicitis on sonography, and 144 (74.6%) had negative sonographic findings. Computed tomographic scans were obtained in 51 patients (26.4%) within 4 days after sonography. These included 39 patients with negative and 12 with positive sonographic findings. Computed tomography changed the sonographic diagnosis in 10 patients: from negative to positive in 3 cases and positive to negative in 7. Forty-three patients (22.2%) underwent surgery. The surgical findings were positive for appendicitis in 37 (86%) of the 43 patients who had surgery. Patients with negative sonographic findings who, to our knowledge, did not have subsequent CT scans or surgery were considered to have negative findings for appendicitis. Seven patients with negative sonographic findings underwent surgery and had appendicitis; therefore, 137 of 144 patients with negative sonographic findings did not have appendicitis. On the basis of these numbers, the NPV was 95.1%. CONCLUSIONS: Sonography has a high NPV and should be considered as a reasonable screening tool in the evaluation of acute appendicitis. Further imaging could be performed if clinical signs and symptoms worsen.

Congenital dacryocystocele: prenatal MRI findings.

BACKGROUND: Congenital dacryocystocele can be diagnosed prenatally by imaging. Prenatal MRI is increasingly utilized for fetal diagnosis. OBJECTIVE: To present the radiological and clinical features of seven fetuses with congenital dacryocystocele diagnosed with prenatal MRI. MATERIALS AND METHODS: The institutional database of 1,028 consecutive prenatal MR examinations performed during a period of 4 years was reviewed retrospectively. The cases of congenital dacryocystocele were identified by reading the report of each MRI study. RESULTS: The incidence of dacryocystocele diagnosed with prenatal MRI was 0.7% (n = 7/1,028). The dacryocystocele was bilateral in three fetuses. Mean gestational age at the time of diagnosis was 31 weeks. The indication for prenatal MRI was the presence or the suspicion of central nervous system abnormality in six fetuses and diaphragmatic hernia in one. Dacryocystocele was associated with an intranasal cyst in six of ten eyes. Prenatal sonography revealed dacryocystocele in only two of seven fetuses. Of eight eyes with postnatal follow-up, four did not have any lacrimal symptoms. CONCLUSION: Prenatal MRI can delineate congenital dacryocystocele more clearly and in a more detailed fashion than ultrasonography. Presence of dacryocystocele was symptomatic in only 50% of our patients, supporting that prenatal diagnosis of dacryocystocele might follow a benign course.

Prenatal MRI findings of fetuses with congenital high airway obstruction sequence.

OBJECTIVE: To define the MRI findings of congenital high airway obstruction sequence (CHAOS) in a series of fetuses. MATERIALS AND METHODS: Prenatal fetal MR images were reviewed in seven fetuses with CHAOS at 21 to 27 weeks of gestation. The MRI findings were reviewed. The MRI parameters evaluated included the appearance of the lungs and diaphragm, presence or absence of hydrops, amount of amniotic fluid, airway appearance, predicted level of airway obstruction, and any additional findings or suspected genetic syndromes. RESULTS: All the fetuses viewed (7 of 7) demonstrated the following MRI findings: dilated airway below the level of obstruction, increased lung signal, markedly increased lung volumes with flattened or inverted hemidiaphragms, massive ascites, centrally positioned and compressed heart, as well as placentomegaly. Other frequent findings were anasarca (6 of 7) and polyhydramnios (3 of 7). MRI identified the level of obstruction as laryngeal in five cases and tracheal in two cases. In four of the patients, surgery or autopsy confirmed the MRI predicted level of obstruction. Associated abnormalities were found in 4 of 7 (genetic syndromes in 2). Postnatal radiography (n = 3) showed markedly hyperinflated lungs with inverted or flattened hemidiaphragms, strandy perihilar opacities, pneumothoraces and tracheotomy. Two fetuses were terminated and one fetus demised in utero. Four fetuses were delivered via ex utero intrapartum treatment procedure. CONCLUSION: MRI shows a consistent pattern of abnormalities in fetuses with CHAOS, accurately identifies the level of airway obstruction, and helps differentiate from other lung abnormalities such as bilateral congenital pulmonary airway malformation by demonstrating an abnormally dilated airway distal to the obstruction.

US findings of adnexal torsion in children and adolescents: size really does matter.

BACKGROUND: Adnexal torsion is rare, and symptoms are nonspecific. Clinicians often rely on US examinations to evaluate girls with abdominal or pelvic pain. OBJECTIVE: To determine which sonographic findings can predict adnexal torsion by comparing pediatric and adolescent patients with surgically confirmed torsion (cases) to those without torsion (controls). MATERIALS AND METHODS: Cases and controls were identified retrospectively by searching 7 years of medical record and radiology databases. An adnexal ratio was calculated as the volume of the affected adnexa divided by the volume of the unaffected adnexa. RESULTS: We identified 61 menarchal subjects: 33 cases and 28 controls. Adnexal volume was larger in cases than in controls (185 vs. 37.8 ml, P < 0.001). A volume of >75 ml was more common in cases than in controls (64 vs. 15%, P < 0.001). No cases had an adnexal volume of <20 ml (P < 0.001). The adnexal ratio was larger in cases than in controls (16.1 vs. 6.7, P < 0.001). An adnexal ratio of >15 was seen in 40% of cases and in no controls (P = 0.08). Doppler US results were not predictive of torsion. CONCLUSION: An adnexal volume of <20 ml is strong evidence against adnexal torsion in menarchal females. In this age group, the diagnosis of torsion cannot be established by US examination alone.