Unusual intramuscular locations as a first presentation of hydatid cyst disease in children: a report of two cases.

BACKGROUND: Hydatid disease is an endemic disease in many countries of the world including the Middle East. It mainly affects the liver and lungs. Intramuscular hydatid disease is rarely reported in children. Such uncommon localization of hydatid cyst may pose difficulties in the clinical and radiological diagnosis; hence affecting patient's management and outcome even in endemic areas. CASE PRESENTATION: We herein describe intramuscular hydatid cysts in 2 different children. The first case is a 5-year-old boy who presented with a painless palpable lump over the right lumbar paraspinal region. His history was remarkable for sheep contact. His laboratory results revealed a mild increase in white blood cell (WBC) count and C-reactive protein. The lesion showed typical features of a hydatid cyst on ultrasound. Further imaging including ultrasound of the abdomen and CT of the chest, abdomen, and pelvis showed infestation of the liver and lung as well. The lesions were resected surgically without complications. The patient received Albendazole preoperatively and after surgery for 3 months. No evidence of recurrence was seen during follow-up. The second case is a 6-year-old girl who presented with an incidental palpable lump in her left thigh during her hospital admission for recurrent meningitis. Ultrasound and MRI imaging were performed demonstrating a unilocular cystic lesion in the left proximal rectus femoris muscle. A provisional diagnosis of hematoma vs. myxoma was given. Biopsy was performed and yielded blood products only. The lesion was resected surgically with a postoperative diagnosis of hydatid cyst. Blood tests performed afterward showed a positive titer for Echinococcus. The patient received Albendazole for 3 months. No evidence of recurrence was seen during follow-up. CONCLUSIONS: Despite its rarity; skeletal muscle hydatid cyst should always be considered in the differential diagnosis of cystic muscle lesions in children in endemic areas even if imaging studies did not show any of the typical signs. This will improve patient outcome by preventing unnecessary cystic puncture which might lead to serious complications, such as anaphylaxis and local dissemination.

Vinblastine-induced posterior reversible encephalopathy syndrome.

Posterior reversible encephalopathy syndrome has recently been recognized as an entity characterized by central neurological and radiological manifestations. There are increasing reports of posterior reversible encephalopathy syndrome associated with the use of chemotherapeutic agents. We herein present a case of posterior reversible encephalopathy syndrome occurring in a patient with Hodgkin's lymphoma after taking two courses of adriamycin, bleomycin, vinblastine, dacarbazine chemotherapy. A prompt recognition of posterior reversible encephalopathy syndrome associated with vinblastine and discontinuation of this drug is paramount to prevent severe neurological damage.

CT findings in pediatric blunt intestinal injury.

Trauma is the leading cause of morbidity and mortality in children. Computed tomography examinations play an important role in the management of patients with major trauma. Though abdominal trauma is less common compared to head injuries, the associated morbidity and mortality are substantial. It is easier to diagnose solid abdominal injuries than intestinal or mesenteric injuries on CT examinations. However, recognition of bowel injury is very important as a delay in diagnosis increases the morbidity and mortality. Hence, with every CT of the abdomen and pelvis, the radiologist must look for signs of bowel and mesenteric injury. This pictorial review presents various CT findings of blunt intestinal injury in children.

Impact of the COVID-19 pandemic on imaging case volumes in King Abdullah University Hospitals (KAUH).

Objective: COVID-19 has an increased burden on the delivery of services because the measures taken by the governments forced hospitals to cancel most of their elective procedures and led to the shutting down of outpatient clinics. This study aimed to evaluate the impact COVID-19 pandemic on the volume of radiology exams based on patient service locations and imaging modality in the North of Jordan. Methods: The imaging case volumes that were performed at the King Abdullah University Hospital (KAUH), Jordan, from 1 January 2020 to 8 May 2020, were retrospectively collected and compared to those from 1 January 2019 to 28 May 2019, to determine the impact of the pandemic of COVID-19 on the volume of radiological examinations. The 2020 study period was chosen to cover the peak of COVID-19 cases and to record the effects on imaging case volumes. Results: A total of 46,194 imaging case volumes were performed at our tertiary center in 2020 compared to 65,441 imaging cases in 2019. Overall, the imaging case volume in 2020 decreased by 29.4% relative to the same period in 2019. The imaging case volumes decreased for all imaging modalities relative to 2019. The number of nuclear images showed the highest decline (41.0%) in 2020, followed by the number of ultrasounds (33.2%). Interventional radiology was the least affected imaging modality by this decline, with about a 22.9% decline. Conclusion: The number of imaging case volumes decreased significantly during the COVID-19 pandemic and its associated lockdown. The outpatient service location was the most affected by this decline. Effective strategies must be adopted to avoid the aforementioned effect on the healthcare system in future pandemics.

The ability of digital breast tomosynthesis to reduce additional examinations in older women.

Aims: To assess the diagnostic performance of digital breast tomosynthesis (DBT) in older women across varying breast densities and to compare its effectiveness for cancer detection with 2D mammography and ultrasound (U/S) for different breast density categories. Furthermore, our study aimed to predict the potential reduction in unnecessary additional examinations among older women due to DBT. Methods: This study encompassed a cohort of 224 older women. Each participant underwent both 2D mammography and digital breast tomosynthesis examinations. Supplementary views were conducted when necessary, including spot compression and magnification, ultrasound, and recommended biopsies. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve (AUC) were calculated for 2D mammography, DBT, and ultrasound. The impact of DBT on diminishing the need for supplementary imaging procedures was predicted through binary logistic regression. Results: In dense breast tissue, DBT exhibited notably heightened sensitivity and NPV for lesion detection compared to non-dense breasts (61.9% vs. 49.3%, p < 0.001) and (72.9% vs. 67.9%, p < 0.001), respectively. However, the AUC value of DBT in dense breasts was lower compared with non-dense breasts (0.425 vs. 0.670). Regarding the ability to detect calcifications, DBT demonstrated significantly improved sensitivity and NPV in dense breasts compared to non-dense breasts (100% vs. 99.2%, p < 0.001) and (100% vs. 94.7%, p < 0.001), respectively. On the other hand, the AUC value of DBT was slightly lower in dense breasts compared with non-dense (0.682 vs. 0.711). Regarding lesion detection for all cases between imaging examinations, the highest sensitivity was observed in 2D mammography (91.7%, p < 0.001), followed by DBT (83.7%, p < 0.001), and then ultrasound (60.6%, p < 0.001). In dense breasts, sensitivity for lesion detection was highest in 2D mammography (92.9%, p < 0.001), followed by ultrasound (76.2%, p < 0.001), and the last one was DBT. In non-dense breasts, sensitivities were 91% (p < 0.001) for 2D mammography, 50.7% (p < 0.001) for ultrasound, and 49.3% (p < 0.001) for DBT. In terms of calcification detection, DBT displayed significantly superior sensitivity compared to 2D mammography in both dense and non-dense breasts (100% vs. 91.4%, p < 0.001) and (99.2% vs. 78.5%, p < 0.001), respectively. However, the logistic regression model did not identify any statistically significant relationship (p > 0.05) between DBT and the four dependent variables. Conclusion: Our findings indicate that among older women, DBT does not significantly decrease the requirement for further medical examinations.

Subcutaneous panniculitis-like T-cell lymphoma: an unusual cause of right thigh hypertrophy.

A man in his mid-20s presented with a painless swelling over his right thigh, which had been progressively increasing over 3 years. He underwent an excisional biopsy for the same, which showed reactive lymphadenopathy. Since the last year and a half, he developed a lower abdominal wall swelling with mild redness over it. In addition, over the last few months before presentation to haematology outpatient clinic, he experienced bouts of fever, night sweats, anorexia, weight loss and right inguinal lymphadenopathy. On examination, splenomegaly was identified. In view of the patients' symptoms, he underwent a positron emission tomography scan, which showed hypermetabolic activity in the subcutaneous tissue sparing the lymph nodes and spleen. A deep skin punch biopsy taken from his right thigh was consistent with the diagnosis of subcutaneous panniculitis-like T-cell lymphoma αß T-cell phenotype. The patient was treated successfully with oral steroids and on routine follow-up, he is in remission for 5 years.

Chest Radiograph Severity Scores, Comorbidity Prevalence, and Outcomes of Patients with Coronavirus Disease Treated at the King Abdullah University Hospital in Jordan: A Retrospective Study.

Introduction: Hospitalized patients with coronavirus disease (COVID-19) often undergo chest x-ray (CXR). Utilizing CXR findings could reduce the cost of COVID-19 treatment and the resultant pressure on the Jordanian healthcare system. Methods: We evaluated the association between the CXR severity score, based on the Radiographic Assessment of Lung Edema (RALE) scoring system, and outcomes of patients with COVID-19. The main objective of this work is to assess the role of the RALE scoring system in predicting in-hospital mortality and clinical outcomes of patients with COVID-19. Adults with a positive severe acute respiratory syndrome COVID-19 two reverse-transcription polymerase chain reaction test results and a baseline CXR image, obtained in November 2020, were included. The RALE severity scores were calculated by expert radiologists and categorized as normal, mild, moderate, and severe. Chi-square tests and multivariable logistic regression were used to assess the association between the severity category and admission location and clinical characteristics. Results: Based on the multivariable regression analysis, it has been found that male sex, hypertension, and the RALE severity score were significantly associated with in-hospital mortality. The baseline RALE severity score was associated with the need for critical care (P<0.001), in-hospital mortality (P<0.001), and the admission location (P=0.002). Discussion: The utilization of RALE severity scores helps to predict clinical outcomes and promote prudent use of resources during the COVID-19 pandemic.

Successful management of dural venous sinus thrombosis secondary to ulcerative colitis in a pediatric patient: A case report.

Cerebral venous sinus thrombosis secondary to inflammatory bowel disease is a clinically rare and challenging entity with serious sequela. We preset a case of a 15-year-old female patient who was recently diagnosed with ulcerative colitis and had been suffering from headache for 4 days duration. During the diagnostic workup, computed tomography (CT) venography revealed Dural venous sinus thrombosis in the left transverse sinus extending into the left sigmoid sinus and the upper third of the left internal jugular vein as well as into the sinus confluence with non-occlusive filling defects in the superior sagittal sinus. Anticoagulant therapy with enoxaparin was initiated and the patient is being monitored in an outpatient setting regularly. Post-discharge disease course was uneventful. CT venography performed after 3 months illustrated partial recanalization of both left transverse and sigmoid sinuses. CVST is a rare extraintestinal manifestation of ulcerative colitis with significant morbidity and mortality which requires a high level of suspicion to establish a clear diagnosis. In spite the fact that CVST is rare, it should be ruled out in inflammatory bowel disease patients with new onset seizures, headache, along with focal, and non-focal neurologic symptoms.

Potential Composite Digenic Contribution of NPC1 and NOD2 Leading to Atypical Lethal Niemann-Pick Type C with Initial Crohn's Disease-like Presentation: Genotype-Phenotype Correlation Study.

Niemann-Pick disease type C (NPC) is an autosomal recessive neurovisceral disease characterized by progressive neurodegeneration with variable involvement of multisystemic abnormalities. Crohn's disease (CD) is an inflammatory bowel disease (IBD) with a multifactorial etiology influenced by variants in NOD2. Here, we investigated a patient with plausible multisystemic overlapping manifestations of both NPC and CD. Her initial hospitalization was due to a prolonged fever and non-bloody diarrhea. A few months later, she presented with recurrent skin tags and anal fissures. Later, her neurological and pulmonary systems progressively deteriorated, leading to her death at the age of three and a half years. Differential diagnosis of her disease encompassed a battery of clinical testing and genetic investigations. The patient's clinical diagnosis was inconclusive. Specifically, the histopathological findings were directed towards an IBD disease. Nevertheless, the diagnosis of IBD was not consistent with the patient's subsequent neurological and pulmonary deterioration. Consequently, we utilized a genetic analysis approach to guide the diagnosis of this vague condition. Our phenotype-genotype association attempts led to the identification of candidate disease-causing variants in both NOD2 and NPC1. In this study, we propose a potential composite digenic impact of these two genes as the underlying molecular etiology. This work lays the foundation for future functional and mechanistic studies to unravel the digenic role of NOD2 and NPC1.

Post-Traumatic Hemosiderotic Synovitis of the Knee Mimicking Pigmented Villonodular Synovitis on Magnetic Resonance Imaging (MRI) in a Child: A Case Report.

BACKGROUND Hemosiderotic synovitis (HS) is a rare proliferative synovial disorder with incompletely understood pathophysiology. It mainly affects the knee joint. It can be confused with pigmented villonodular synovitis (PVNS), both clinically and radiologically. HS has not been previously reported in children, and this rare incidence may lead to difficulties in early clinical and radiological diagnosis, possibly affecting the patient's outcome. CASE REPORT A 13-year-old boy presented with progressive right knee pain, swelling, and limitation of movement 2 months after a traumatic injury in a soccer game. His past medical and family history was unremarkable. His physical exam showed right knee effusion, fullness in the popliteal fossa, and painful restriction in active and passive knee motion. Laboratory tests showed a mildly elevated erythrocyte sedimentation rate. Knee X-rays showed joint effusion. Knee MRI showed large knee joint effusion with diffuse low signal intensity villous synovial hypertrophy in all sequences in addition to a large popliteal cyst with the same imaging characteristics, consistent with diffuse-form PVNS. Total arthroscopic synovectomy was performed without complications. Intraoperatively, there was a large effusion containing yellow clots. The histopathological diagnosis was post-traumatic HS with no evidence of PVNS or malignancy. The patient showed significant clinical and radiological improvement postoperatively with no evidence of recurrence. CONCLUSIONS Post-traumatic HS is a very rare entity that should always be considered in the differential diagnosis of synovitis in active, non-hemophilic children. Radiologists' familiarity with this rare condition is important to guide correct and early diagnosis, and to avoid unnecessary invasive intervention.

Extraspinal findings prevalence and clinical significance in 4250 lumbar spine MRI exams.

To assess extraspinal findings (ESFs) prevalence in lumbar spine MRI, including clinically significant findings using a systematic approach, and to determine their reporting rate. Lumbar spine MRI scans were retrospectively reviewed over 18 months by two radiologists. Reading discrepancies were resolved by consensus. ESFs were classified according to the involved system, clinical diagnosis, and clinical significance. The reporting rate was estimated by referring to the original report. There were 1509 ESFs in 1322/4250 patients with a substantial agreement between the two radiologists (kappa = 0.8). Almost half (621/1322) were in the 45-60 age group. Females represented 56.6% (748/1322). 74.2% (1120/1509) of the ESFs involved the urinary system among which 79.6% (892/1120) were renal cysts. Clinically significant findings represented 8.7% (131/1509) among which hydronephrosis represented 23% (30/131). First time detected malignant lesions represented 4.6% (6/131). ESFs reporting rate was 47.3%. 58.8% of the clinically significant ESFs were not reported. ESFs prevalence was 31.1%. The Urinary system was the most commonly involved. Most ESFs were benign warranting no further workup. However, clinically significant ESF were not infrequently detected. More than half of the clinically significant findings were not reported. A systematic review of MRI images is highly recommended to improve patient's outcome.

The radiological characteristics of childhood intussusception including unusual features and rare pathological lead points.

PURPOSE: To describe the radiological characteristics for childhood intussusceptions including unusual radiological features and rare pathological lead points (PLP). MATERIAL AND METHODS: The medical records of all childhood intussusceptions between 1/1/2010 -1/10/2020 were retrospectively reviewed. 95 cases were identified in 82 patients. The demographic data, presenting symptoms, diagnostic and treatment methods, radiological features, and PLPs among the different types of intussusception were analyzed. RESULTS: Ileocolic intussusception (ICI) represented 53.7% (51/95). The average age for ICI was 1.87 years. Males constituted 72.1% (31/43). 29.4% (15/51) were treated primarily surgically due to peritonitis. Small bowel intussusception (SBI) represented 40% (38/95) in which females constituted 51.5% (17/33). Ileo-ileal represented 63.2% (24/38). 81.8% (27/33) were transient. On ultrasound; There was a statistically significant difference in the size of the outer diameter of ICI compared to SBI (P-value 0.00012). Ileo-ileocolic and colo-colic intussusceptions constituted 3.2% (3/95); each and were more common in females. Vomiting was the most common symptom for intussusception and ultrasound was diagnostic in the majority of cases. PLPs were seen in 36.6% (30/82) of the patients of which the average age was 7 years. PLPs/risk factors were benign in 80% (24/30). A case of colo-colic intussusception was seen in a 16-year-old female due to clear cell sarcoma which was not reported before. 12.2% patients (10/82) had recurrent intussusception. CONCLUSION: Our study showed that ICI is the most commonly encountered type. SBIs are mostly transient. It is important to radiologically determine the type of intussusception and to identify PLPs or unusual radiological features to avoid unnecessary intervention and significant patient morbidity.

Bronchiolitis clinical practice guidelines implementation: surveillance study of hospitalized children in Jordan.

INTRODUCTION: Bronchiolitis is a leading cause of hospital admissions and death in young children. Clinical practice guidelines (CPG) to diagnose and manage bronchiolitis have helped healthcare providers to avoid unnecessary investigations and interventions and to provide evidence-based treatment. Aim of this study is to determine the effect of implementing CPG for the diagnosis and management of bronchiolitis in a tertiary hospital in Jordan. METHODS: The study compared children (age <24 months) diagnosed with bronchiolitis and who required admission to King Abdullah University Hospital in Irbid during the winter of 2017 (after CPG implementation) and age-matched children admitted in the winter of 2016. The proportion of patients receiving diagnostic tests and treatments in the two groups were compared. RESULTS: Eighty-eight and 91 patients were diagnosed with bronchiolitis before and after CPG implementation, respectively. Respiratory syncytial virus rapid antigen detection testing decreased after CPG implementation [n=64 (72.7%) vs n=46 (50.5%), p=0.002]. However, there was no significant change in terms of other diagnostic tests. The use of nebulized salbutamol [n=44 (50%) vs n=29 (31.9%), p=0.01], hypertonic saline [n=39 (44.3%) vs n=8 (8.8%), p<0.001], and inappropriate antibiotics [n=31 (35.2%) vs n=15 (16.5%), p=0.004] decreased after CPG implementation. There was no difference in mean LOS (standard deviation; SD) between the pre- and post-CPG groups [3.5(2) vs 4 (3.4) days, p=0.19]. The mean cost of stay (SD) was 449.4 (329.1) US dollars for pre-CPG compared to 507.3 (286.1) US dollars for the post-CPG group (p=0.24). CONCLUSION: We observed that the implementation of CPG for bronchiolitis diagnosis and management helped change physicians' behavior toward evidence-based practices. However, adherence to guidelines must be emphasized to improve practices in developing countries, focusing on the rational use of diagnostic testing, and avoiding use of unnecessary medications when managing children with a diagnosis of bronchiolitis.

Viral Surveillance of Children with Acute Respiratory Infection in Two Main Hospitals in Northern Jordan, Irbid, during Winter of 2016.

Acute lower respiratory infection (ALRI) is a major cause of morbidity and mortality worldwide. Data regarding the etiology of acute respiratory infection (ARI) is scarce in developing countries. The aim of this study was to identify the viral etiology of ARI/ALRI in hospitalized children and factors associated with increased length of stay (LoS) and severe disease presentation in Northern Jordan. This was a prospective viral surveillance study using real-time reverse transcriptase-polymerase chain reaction in children younger than 5 years admitted with ARI to two main hospitals in Northern Jordan during the winter of 2016. Nasopharyngeal swabs were obtained and tested for respiratory syncytial virus (RSV) and other viruses. Demographic and clinical characteristics of RSV-positive patients were compared with those of RSV-negative patients. There were 479 patients hospitalized with ARI. Their mean age (standard deviation) was 10.4 (11.6) months. 53.9% tested positive for at least one virus, with RSV being the most commonly detected virus (34%). Compared with RSV-negative patients, RSV-positive patients were younger, more likely to have chronic lung disease, and more likely to present with cough, rhinorrhea, difficulty in breathing, retraction, flaring, grunting, wheezing, and a higher respiratory rate. Prematurity, presence of a chronic illness, oxygen saturation < 90%, and atelectasis and consolidation on chest X-rays were significantly associated with an increased mean LoS. Patients with a history of prematurity had higher risk of severe disease (odds ratio = 2.6; 95% confidence interval: 1.5, 4.7; p = 0.001). Compared with patients 6 months old and younger, patients aged 6.1 to 12 months were less likely to have severe disease. Human metapneumovirus (HMPV)-positive ALRI was associated with increased odds of severe disease. Viruses are recognized as etiological agent of ARI/ALRI-associated morbidity in developing countries that need more attention and implementation of targeted strategies for prevention and detection. HMPV can be a cause of severe ALRI.

Ingested sharp foreign body presented as chronic esophageal stricture and inflammatory mediastinal mass for 113 weeks: Case report.

INTRODUCTION: Impacted foreign bodies in the esophagus have the potential to cause serious complications. Ingested sharp objects carry the risk of acute complications as: perforation, acute mediastinitis, and acute bleeding. Rarely, such foreign bodies might migrate through the esophageal wall and present as chronic esophageal foreign body. CASE PRESENTATION: We present a case of a 36-month-old girl presented with solid food dysphagia and regurgitation proved to be secondary to esophageal stricture after 26 months of accidental ingestion of aluminum can tab which has migrated through the wall of the upper esophagus into the mediastinum. After two trials of endoscopic treatment; she underwent thoracotomy and partial esophagectomy. Multiple trials of dilation and Mitomycin C injection were followed because of re-stricture. CONCLUSION: Foreign body impaction or secondary stricture needs to be considered in the differential diagnosis of children presenting with new onset dysphagia and regurgitation. Metallic Foreign body might be even radiolucent. Practitioners should keep a high index of suspicion for a retained esophageal FB in the child with gastrointestinal or respiratory symptoms that do not respond to standard therapy.

Factors Affecting Pregnancy Rate Following Fallopian Tube Recanalization in Women with Proximal Fallopian Tube Obstruction.

Fallopian tube obstruction is a major cause of female infertility. We aimed to evaluate the factors potentially affecting pregnancy rate following fallopian tube recanalization (FTR) in infertile women with proximal fallopian tube obstruction. Data was retrospectively collected for 61 women (25, primary infertility; 36, secondary infertility) who underwent FTR at our institution. Bivariable and multivariable analyses of clinical pregnancy rates in relation to the following factors were performed: primary vs. secondary infertility, duration of infertility, age at the time of FTR, unilateral vs. bilateral obstruction, and previous pelvic interventions. All women who underwent fluoroscopically guided transcervical FTR of one or both proximally obstructed tubes were successfully recanalized (technical success rate, 100%). Within a year after FTR, 41% of women had conceived. None of the studied variables was significantly associated with pregnancy rate on bivariable analysis. Nevertheless, on multivariable analysis, the type and duration of infertility were significantly associated with pregnancy among women aged <35 years at the time of FTR. Our findings regarding pregnancy rates following FTR reflect the diversity of the patient population and suggest the presence of multiple contributing factors. Younger women with secondary infertility for <5 years are highly likely to achieve conception following FTR.