Comparison of plain radiographs, coronal CT, and intraoperative findings in children with chronic sinusitis.

Evaluating the extent of chronic sinusitis in children is critical in management of the disease and determination of the need for surgery. High-resolution computed tomography can demonstrate disease that is not shown on routine x-ray films. It can also delineate pathologic variations and demonstrate inaccessible anatomic structures. We compared plain radiographs, CT scans, and intraoperative findings for 300 pediatric patients with chronic or recurrent sinusitis. Despite an imperfect record in demonstration of sinus disease in all of our patients, computed tomography was unquestionably better than plain radiography in diagnosis of chronic sinusitis and evaluation of the need for surgery. Despite its superior performance, CT should not be used exclusively to diagnose disease or propose surgery. These determinations must be made on the basis of a combination of the patient's symptoms, physical examination findings, and CT results.

Childhood multifocal osteosarcoma. Clinicopathologic and radiologic correlates.

The authors reviewed the clinical charts and pathologic and radiographic materials of nine pediatric patients (mean age, 11.0 years) presenting with multiple skeletal foci of osteosarcoma. Four patients presented with pulmonary metastases, and five had osseous disease only. All had densely sclerotic, predominantly osteoblastic tumors, usually in metaphyseal locations. Evidence of aggressive tumor cell behavior--such as vascular, articular, epiphyseal, or soft-tissue invasion--was usually present in surgical specimens. Despite intensive chemotherapy, all patients died from 6 to 37 months after diagnosis (median survival, 12 months). Comparison of clinical and pathologic features for patients presenting with or without pulmonary metastases failed to disclose any notable differences between the two groups, indicating a common pathogenesis and evolution for their multifocal disease. The authors conclude that this variant of osteosarcoma is a highly aggressive form of the disease that may be accompanied by pulmonary metastases.

Developmental cystic renal neoplasms in children. Diagnostic imaging characteristics.

We report diagnostic imaging and histopathologic findings in four children with different cystic renal neoplasms. The features discerned with computed tomography (CT), as well as ultrasound, correlated well with gross histologic findings, although a definitive diagnosis could not be made on the basis of CT and ultrasound alone. Because the most malignant variants of these lesions cannot be excluded preoperatively, we advocate complete diagnostic imaging studies, followed by nephrectomy, for all cases of cystic renal neoplasms in infants and children.

Pseudoreduction of intussusception: is ileal reflux the end point?

Two cases of unsuccessful hydrostatic reduction of intussusception are reported. Both were associated with barium filling multiple loops of distal ileum, despite lack of complete reduction of the intussusception. The presence of free ileal reflux does not guarantee successful reduction. Careful examination of the cecum for residual intussusceptum and of non-contrast-filled small-bowel loops for evidence of remaining small-bowel obstruction is essential to recognize unsuccessful reduction.

Serial cranial computed-tomography scans in children with leukemia given two different forms of central nervous system therapy.

Cranial computed tomography (CT) was used to estimate the frequency and permanence of brain abnormalities in 108 consecutive children with acute lymphoblastic leukemia (ALL). Fifty-five patients received cranial irradiation (1,800 rad) with intrathecal methotrexate (RT group) and 53 patients received intravenous and intrathecal methotrexate without irradiation (IVIT group). Continuation treatment included sequential drug pairs for the RT group and periodic IVIT methotrexate for the other group. After 12 to 24 months of serial evaluation, five (9%) of the 55 patients in the RT group have had CT scan abnormalities, compared to 10 (19%) of 52 in the IVIT group (p = 0.171). Fourteen of the 15 patients with CT scan abnormalities had focal or diffuse white-matter hypodensity; these have reverted to normal in most cases, reflecting a dynamic process. While such CT findings are of concern and may be an early indicator of central nervous system toxicity, this remains to be proven. Therapy should not be altered on the basis of abnormal CT scans alone but in the context of the entire clinical situation.

Use of infusion pump for intravenous enhanced computed tomography.

For enhanced computed tomography, rapid injections through small bore needles can be easily accomplished utilizing an infusion pump. A reduction in radiation exposure to medical personnel is an associated benefit.

Computed tomography of hepatic and splenic fungal abscesses in leukemic children.

Six hundred fifty-eight abdominal computed tomography scans of 275 children with cancer were retrospectively studied for evidence of multiple hepatic or splenic "abscess-like" lesions. Seven patients, all with subsequently confirmed fungal disease, were found to have such lesions. In addition to acute leukemia, all patients had prolonged fever not responsive to antibiotics, had neutropenia (less than 500 neutrophils per mm3) and had received anticancer chemotherapy for up to 4 weeks before the positive computed tomography scans. We conclude that the presence of multiple well-circumscribed hepatic or splenic lesions on the abdominal computed tomography scan of a febrile, neutropenic, immunosuppressed patient not responding to antibiotics and with no other source of infection is strong evidence for systemic fungal infection. However, the absence of such lesions may not exclude the diagnosis of systemic mycosis.

Wilms' tumor metastatic to the mediastinum.

We report two children with mediastinal metastasis of Wilm's tumor. One case presented with a right hilar mass and the other with a posterior mediastina mass. In each instance, no additional radiologic evidence of metastasis was found. Metastasis of Wilms' tumor to the mediastinum is uncommon, usually occurring with radiologic evidence of either additional metastases or direct cephalad growth of the primary tumor.

CT demonstration of fat tissue in malignant renal neoplasms: atypical Wilms' tumors.

It has been implied that the recognition of fat in a renal tumor suggests that the lesion is benign. Several authors have suggested tht angiomyolipoma is the only common renal tumor containing mature adipose tissue. Other neoplasms may contain mature fat that can be identified with current diagnostic imaging techniques. Under discussion is our experience with Wilms' tumor containing a predominance of adipose tissue.

Course of pulmonary dysfunction in children surviving Pneumocystis carinii pneumonitis. A prospective study.

Pulmonary function studies were done serially in 23 children 7 to 18 yrs of age who had survived the acute stage of Pneumocystis carinii pneumonitis. Each child was asymptomatic. Spirometric indices, expiratory flows, pulmonary gas transfer factor, arterial blood gases, and other clinical variables were assessed a few days before patients were discharged from the hospital and at 1-, 3-, 6-, and 12-month intervals thereafter; two patients developed recurrent pneumonitis during follow-up and were studied twice. All but five subjects had pulmonary dysfunction when tested initially. A decrease in pulmonary gas transfer factor, observed in 17 studies, was the most common abnormality. Restrictive pulmonary disease was seen in 11 studies; an obstructive component, in one. Arterial hypoxemia at rest, while patients were breathing room air, was noted in nine cases. Roentgenographic evidence of bilateral diffuse lung opacities was seen in 11 patients and was positively correlated with decreases in pulmonary gas transfer factor (p less than 0.001). Arterial hypoxemia was significantly related to intrapulmonary right-to-left shunt (p less than 0.001) but not to decreases in pulmonary gas transfer factor, indicating the importance of ventilation-perfusion abnormalities in these patients. Serial follow-up studies disclosed significant improvement in pulmonary function deficits within 1 month and complete resolution by 6 months in all survivors. Recovery was not related to the amount of duration of O2 therapy, to the need for ventilatory support, or to chest roentgenographic abnormalities. Histopathologic findings in nine patients who died during follow-up did not indicate any residual interstitial fibrosis, collagen deposits, or alveolopathy. We conclude that Pneumocystis carinii pneumonitis during childhood does not typically produce long-lasting pulmonary sequelae.

Neonatal herpes simplex virus infection introduced by fetal-monitor scalp electrodes.

An infant was severely infected with herpes simplex virus as a result of fetal monitoring with scalp electrodes on the buttocks. The first vesicles appeared at the site where the electrodes had been placed and, by day 9 after birth, additional lesions covered the entire perineum and lower extremities. The child developed acute meningoencephalitis and pneumatosis intestinalis. Herpes simplex virus was isolated from cultures of skin vesicle fluid, cornea, saliva, blood, and spinal fluid. The infection resolved after treatment with adenosine arabinoside, administered intravenously for 11 days and applied topically for another 15 days. A follow-up examination when the child was 2 years old disclosed no physical or neurologic abnormalities. This case illustrates the risk of introducing herpes simplex infection by internal fetal monitoring.

The telltale triangle: use of the supine cross table lateral radiograph of the abdomen in early detection of pneumoperitoneum.

The most sensitive method for detecting a small pneumoperitoneum depends upon directing a horizontal x-ray beam tangential to the collection of free air. We have observed in the detection of small amounts of free intraabdominal air that the supine cross table lateral abdominal view is most valuable. Such small amounts of free intraperitoneal air collect between loops of bowel at the highest points in the peritoneal space forming typical small triangular lucencies with their bases at the peritoneal reflection.

Perforated appendix presenting with disproportionate jejunal distention.

Six cases of perforated appendix are presented in whom there was disproportionate gas distention of the jejunum without other radiographic signs of appendicitis. This appearance tended to divert one's attention from the offending cause in the right lower abdomen.

Arteriographic diagnosis of brain death in children.

Transfemoral cerebral angiography was performed in four children with brain death secondary to increased intracranial pressure. Findings not previously described are filling of the cavernous, petrous and cervical portions of the contralateral internal carotid artery via the anterior communicating artery, filling of the basilar and vertebral arteries via the posterior communicating artery and anterior displacement of the basilar artery.

Roentgenology-pathology correlative study of neovascularity.

In an attempt to evaluate the histologic picture of what is shown on angiograms as neovascularity, several benign and malignant tumors were examined. New vessels (neovascularity) are large capillaries or sinusoids, and neither contain smooth muscle in their walls. The walls may contain some fibrous connective tissue. Puddling, laking, and staining represent the collection of contrast medium in small capillaries or sinusoids. Some tumors, such as hemangioma of the liver, cystadenoma of the pancreas, and angiomyolipoma of the kidney contained abnormal vascularity, but this was not composed of vessels which had arisen or developed anew, as there was smooth muscle in their walls, and this indicates that those vessels had been there from birth. In xanthogranulomatous pyelonephritis and chronic renal disease, the appearance of increased vascularity is the result of rearrangement of the normal vascular structures.