Successful treatment of a complete Susac syndrome in a 16-year-old boy: A case report.

Key Clinical Message: We reported a pediatric case of SuS with a complete diagnosis triad. Although the optimal treatment of SS is unclear, prompt diagnosis and treatment can result in almost a complete recovery. Abstract: Susac's syndrome (SuS) is a rare, autoimmune disorder known as a typical triad of sensorineural hearing impairment, central nervous system involvement, and multiple branch retinal artery occlusions (BRAOs). It is usually misdiagnosed or underdiagnosed because its symptoms may vary at the presentation time. Diagnosis can be established based on neuroimaging, ophthalmic examination, and audiometry, which match the clinical symptoms. SuS is very limited and rare in childhood and can be easily misdiagnosed with multiple sclerosis or acute disseminated encephalomyelitis. We report a 16-year-old boy patient with a completed SuS triad including BRAO in fluorescent angiography (FA), mild to moderate sensory neural hearing loss (SNHL), "Snowball lesions," and "pearl of string" signs in magnetic resonance imaging (MRI). Successful treatment was achieved with methylprednisolone, rituximab, azathioprine, cyclophosphamide, and plasmapheresis. SuS is a rare disorder, which rarely presents with a full triad and all the manifestations may not be present at the onset of the disease, leading to misdiagnosis or underdiagnosis. Our case is exceptional because he was in a pediatric age and presented with a complete triad of SuS which adds to the rarity of this disease. Although optimal treatment of SuS is unclear, our treatment regimen resulted in almost a complete recovery.

Quantitative analysis of lung lesions using unenhanced chest computed tomography images.

INTRODUCTION: Chest radiograph and computed tomography (CT) scans can accidentally reveal pulmonary nodules. Malignant and benign pulmonary nodules can be difficult to distinguish without specific imaging features, such as calcification, necrosis, and contrast enhancement. However, these lesions may exhibit different image texture characteristics which cannot be assessed visually. Thus, a computer-assisted quantitative method like histogram analysis (HA) of Hounsfield unit (HU) values can improve diagnostic accuracy, reducing the need for invasive biopsy. METHODS: In this exploratory control study, nonenhanced chest CT images of 20 patients with benign (10) and cancerous (10) lesion were selected retrospectively. The appearances of benign and malignant lesions were very similar in chest CT images, and only pathology report was used to discriminate them. Free hand region of interest (ROI) was inserted inside the lesion for all slices of each lesion. Mean, minimum, maximum, and standard deviations of HU values were recorded and used to make HA. RESULTS: HA showed that the most malignant lesions have a mean HU value between 30 and 50, a maximum HU less than 150, and a minimum HU between -30 and 20. Lesions outside these ranges were mostly benign. CONCLUSION: Quantitative CT analysis may differentiate malignant from benign lesions without specific malignancy patterns on unenhanced chest CT image.

Surgical Interventions in Coronavirus Disease 2019 Pleural and Pulmonary Complications: A Case Series of the Tertiary Thoracic Surgery Center Experience.

Background: In most cases of pulmonary or pleural post-coronavirus disease 2019 (COVID-19) complications, surgical interventions are performed to treat these complications, but the method of the surgery and its outcome in these patients is not clearly defined. We present 40 patients with pulmonary and pleural complications after COVID-19 who required surgical intervention. Patients and Methods: In this case series, patients' data were prospectively collected from April to August 2022 at Masih Daneshvari Hospital. Inclusion criteria were patients with COVID-19 who were referred to the thoracic surgery department because of pleural effusion, pneumothorax, empyema, infected or non-infected pneumatocele, and lung cavity with suspected fungal infections. The required intervention for each patient was assessed. Results: Patients' mean age was 49.21 ± 11.5 (30-69 years). Nine patients (22.5%) were female. Pure pleural effusion was reported in five (12.5 %), pneumothorax in eight (20%), empyema in 29 (72.5%), and infected pneumatocele in two patients (5%). Twelve patients had bronchial fistulas that were clarified at the time of surgery that needed repair after resection. In 13 patients (32.5%) because of pleural effusion or pneumothorax, a chest tube was inserted and after two weeks lungs were fully expanded. All patients with pneumothorax were managed by chest tube initially but in the presence of continuous air leakage and non-expanding lungs surgical thoracotomy or video-assisted thoracoscopic surgery (VATS) were considered for correction. In 10 patients who required thoracotomy, the chest tube was necessary for more than one month. In most of the patients, there were small cystic lesions or peripheral bronchopleural fistula. In 17 (42.5%) cases of empyema, necrotic pneumonia was documented and eight patients (20%) had aspergillus infection in the pathology report and two patients had a pulmonary abscess. Conclusions: Pleural COVID-19 complications can be treated with conventional surgical methods such as chest tube insertion, and debridement of infected tissue with no mortality and further complications.

Role of abbreviated non-contrast-enhanced MR-enterography in the evaluation of Crohn's disease activity and complications as an alternative for full protocol contrast-enhanced study: A systematic review and meta-analysis.

Background: Crohn's disease (CD) is a chronic disorder that often starts at a young age and involves periods of remission and relapse. Prompt diagnosis of relapses through screening is crucial due to the potential morbid complications of untreated active inflammation. Magnetic resonance enterography (MRE) is a noninvasive technique to screen for active inflammation. The standard protocol involves intravenous injection of contrast agents with potential side effects. Some abbreviated non-contrast-enhanced MRE protocols are proposed as alternatives for conventional MRE to identify active inflammation. Currently, there is controversy regarding the applicability and accuracy of these protocols. This study aims to describe and compare these protocols and evaluate their accuracy in detecting active inflammation and CD complications. Methods: Results from a systematic search of three databases in August 2022 were queried and screened by abstract and full text. Eligible studies were qualitatively and quantitatively analyzed by diagnostic test accuracy meta-analysis. Results: 59 studies entered the systematic review, and 37 were eligible for meta-analysis. Diffusion-weighted imaging (DWI) and fast T2-weighted (T2w) sequences were most frequently used in abbreviated protocols and showed non-inferior accuracy compared to the full protocol in detecting active inflammation. ADC and qualitative DWI had pooled sensitivity of 90% (CI: 82-95%) and 89% (CI:82-93%) and pooled specificity of 94% (CI: 88-97%) and 89% (CI: 79-94%), respectively for detecting active inflammation. Moreover, T2w and combined T2w+DWI sequences had pooled sensitivity of 80% (CI: 64-90%) and 76% (CI: 61-86%) and pooled specificity of 90% (CI: 80-95%) and 87% (CI: 74 - 94%), respectively. Unenhanced protocols show relatively poor diagnostic accuracy in detecting penetrating complications of CD. Magnetization transfer imaging (MTI) has demonstrated excellent accuracy in detecting fibrosis. High heterogeneity was observed in all subgroups, and accuracy was reported to be highly operator dependent in most studies. Conclusion: An abbreviated protocol consisting of DWI and fast T2w imaging can potentially replace the full protocol MRE. Full protocol MRE will still have its role in identifying penetrating complications. MTI should be indicated in case of suspected fibrostenotic disease.