Imaging of Kingella kingae musculoskeletal infections in children: a series of 5 cases.

PURPOSE: Kingella kingae musculoskeletal infections continue to be under-diagnosed and there remains a paucity of literature on its imaging features. The purpose of this manuscript is to review the imaging, clinical, and laboratory findings of microbiology-proven K. kingae infections. MATERIALS AND METHODS: A retrospective review of musculoskeletal infections between January 1, 2013 and Dec 31, 2016 yielded 134 patients from whom 5 patients had confirmed K. kingae infections (3 boys and 2 girls, mean age of 16 months, range 9-38 months). Picture archiving and communication system and electronic medical records were reviewed. RESULTS: At presentation, none of the patients had a fever and not all patients had abnormal inflammatory markers. Three patients had septic arthritis (2 knee and 1 sternomanubrial joints), one had epiphyseal osteomyelitis, and one had lumbar spondylodiscitis. The case of epiphyseal osteomyelitis of the distal humerus also had elbow joint involvement. A combination of radiography (n = 4), ultrasound (n = 2), and magnetic resonance (MR) imaging (n = 5) were performed. Prominent synovial thickening was observed for both knee and elbow joints and extensive regional myositis for all except for the patient with sternomanubrial joint infection. The diagnosis of K. kingae infection resulted in a change in the antibiotic regimen in 80% of the patients. CONCLUSION: Disproportionate synovial thickening, prominent peri-articular myositis, and/or characteristic sites of involvement demonstrating imaging features of infection or inflammation in a young child with mild infectious symptoms and elevated inflammatory markers should invoke the possibility of an underlying K. kingae infection.

Cornelia de Lange syndrome: Correlation of brain MRI findings with behavioral assessment.

Neurobehavioral and developmental issues with a broad range of deficits are prominent features of Cornelia de Lange syndrome (CdLS), a disorder due to disruption of the cohesin protein complex. The etiologic relationship of these clinical findings to anatomic abnormalities on neuro-imaging studies has not, however, been established. Anatomic abnormalities in the brain and central nervous system specific to CdLS have been observed, including changes in the white matter, brainstem, and cerebellum. We hypothesize that location and severity of brain abnormalities correlate with clinical phenotype in CdLS, as seen in other developmental disorders. In this study, we retrospectively evaluated brain MRI studies of 15 individuals with CdLS and compared these findings to behavior at the time of the scan. Behavior was assessed using the Aberrant Behavior Checklist (ABC), a validated behavioral assessment tool with several clinical features. Ten of fifteen (67%) of CdLS patients had abnormal findings on brain MRI, including cerebral atrophy, white matter changes, cerebellar hypoplasia, and enlarged ventricles. Other findings included pituitary tumors or cysts, Chiari I malformation and gliosis. Abnormal behavioral scores in more than one behavioral area were seen in all but one patient. All 5 of the 15 (33%) patients with normal structural MRI studies had abnormal ABC scores. All normal ABC scores were noted in only one patient and this was correlated with moderately abnormal MRI changes. Although our cohort is small, our results suggest that abnormal behaviors can exist in individuals with CdLS in the setting of relatively normal structural brain findings. © 2016 Wiley Periodicals, Inc.

MR Imaging of Pediatric Bone Marrow.

The bone marrow is one of the largest organs in the body and is visible in every magnetic resonance (MR) imaging study. It is composed of a combination of hematopoietic red marrow and fatty yellow marrow, and its composition changes throughout life in response to normal maturation (red to yellow conversion) and stress (yellow to red reconversion). MR imaging is highly sensitive for detection of altered marrow signal intensity, and the T1-weighted spin-echo sequence provides the most robust contrast between yellow marrow and disease. Heterogeneous red marrow and red marrow hyperplasia can mimic marrow disease, but should be distinguished from neoplastic replacement (leukemia, lymphoma, primary bone sarcomas, hematogenous metastases) and expected posttreatment changes (radiation therapy, chemotherapy, colony-stimulating factor, bone marrow transplant). Nonneoplastic edema-like processes can also alter marrow signal intensity, including trauma, infection, inflammation (chronic recurrent multifocal osteomyelitis, juvenile inflammatory arthritis), altered biomechanics, and chronic regional pain syndrome. Unfortunately, MR imaging findings are often nonspecific and overlap among many of these vastly different causes. Therefore, a definitive diagnosis is reliant on a combination of imaging findings, clinical evaluation, laboratory assessment, and occasionally tissue analysis. ©RSNA, 2016.

Epidural Fibrin Sealant Injection for the Management of Cerebrospinal Fluid Leak Following Dural Puncture in Children.

Cerebrospinal fluid (CSF) leak, intracranial hypotension, and postdural puncture headaches are common following dural punctures. Management usually consists of conservative treatments with medications (e.g. caffeine, nonsteroidal anti-inflammatory drugs, steroids, opioids), increased fluid intake, and bed rest. In more severe and persistent cases, epidural blood patches (EBPs) are indicated. When multiple EBPs fail, epidural injection of fibrin sealant has been successful in a few reported adult cases. The authors describe the first reported clinical experiences of epidural fibrin patch in children for repair of CSF leak and resolution of intracranial hypotension. This technique was used in three cases where serial EBPs failed to resolve symptoms related to intracranial hypotension following dural puncture. Following the procedure, each patient had resolution of their presenting clinical symptoms and radiographic abnormalities, and there were no noted complications. Epidural fibrin sealant injection is a reasonable option for relieving intracranial hypotension due to CSF leak following dural puncture in children.