Splenic abscesses in childhood brucellosis: a case-based review.

OBJECTIVE: Human brucellosis is a zoonosis with an extremely wide spectrum of clinical manifestations. Focal splenic involvement is very uncommon, particularly in the pediatric age group, during the illness' acute phase. CASE REPORT: A 4-year-old boy, already receiving third-generation cephalosporin treatment, was transferred from a local hospital to the University Pediatric Department for fever, anemia, increased inflammation index, and multiple, hyper-echogenic splenic lesions on abdominal ultrasound. Initial diagnostic laboratory investigations for Brucella infection, including the Widal-Wright test, were found to be negative. However, further diagnostic laboratory analysis using the chemiluminescent immunoassay was positive for Brucella IgM antibodies. Treatment with rifampicin at a dose of 150 mg/Kg/twice daily and co-trimethoprim at a dose of 80 mg/Kg/twice daily was started and continued for 7 weeks. IgM antibodies were undetectable after 2 weeks of treatment, and after 6 weeks of treatment, abdominal ultrasound documented a reduction of the diameter of the major splenic infiltrate from 1 to 0.5 cm. At 3 and 5 months of follow-up, re-evaluation of the abdominal lesions displayed complete resolution of the splenic lesions and a complete clinical recovery. CONCLUSIONS: The present case and a literature review are presented in this study since a standard diagnostic laboratory evaluation for brucellosis may miss the diagnosis, and in suspected cases, the laboratory analysis should be extended. Splenic abscesses are known to be rare in brucellosis, but the diagnosis should be considered in children with severe focal lesions, as specific antibiotic treatment may result in complete clinical recovery.

Diffusion MRI for rectal cancer staging: ADC measurements before and after ultrasonographic gel lumen distension.

OBJECTIVES: To compare Apparent Diffusion Coefficient (ADC) measurements in rectal neoplastic lesions before and after lumen distension obtained with sonography transmission gel. METHODS: From January 2014 to July 2016, 25 patients (average age 63.7, range 41-85, 18 males) were studied for pre-treatment rectal cancer staging using a 1.5T MRI. Diffusion MRI was obtained using echo-planar imaging with b=800 value; all patients were studied acquiring diffusion sequences with and without rectal lumen distension obtained using sonography transmission gel. In both diffusion sequences, two blinded readers calculated border ADC values and small ADC values, drawing regions of interest respectively along tumour borders and far from tumour borders. Mean ADC values among readers - for each type of ADC measurement - were compared using Wilcoxon matched pairs signed rank test. Correlation was assessed using Pearson analysis. RESULTS: Border ADC mean value for diffusion MR sequences without endorectal contrast was 1.122mm2/sec, with 95% Confidence Interval (CI)=1.02-1.22; using gel lumen distension, higher border ADC mean value of 1.269mm2/s (95% CI=1.16-1.38) was obtained. Wilcoxon matched pairs signed rank test revealed statistical difference (p<0.01); a strong Pearson correlation was reported, with r value of 0.69. Small-ADC mean value was 1.038mm2/s (95% CI=0.91-1.16) for diffusion sequences acquired without endorectal distension and 1.127mm2/s (95% CI=0.98-1.27) for diffusion sequences obtained after endorectal gel lumen distension. Wilcoxon analysis did not show statistical difference (p=0.13). A very strong positive correlation was observed, with r value of 0.81. CONCLUSIONS: ADC measurements are slightly higher using endorectal sonographic transmission gel; ROI should be traced far from tumour borders, to minimize gel filled-pixel along the interface between lumen and lesion. Further studies are needed to investigate better reliability of ADC in rectal cancer MRI using sonographic gel intraluminal distension.

Cystic pancreatic neoplasms: diagnosis and management emphasizing their imaging features.

The incidence of cystic pancreatic neoplasms increased in the past decade, due to the recent advances in multidetector computed tomography and magnetic resonance imaging; several pancreatic cysts are incidentally encountered during diagnostic exams performed for non-pancreatic diseases. Indeed, cystic pancreatic tumors are currently considered relatively rare, accounting for approximately 10% of all pancreatic neoplasms. Serous cystadenoma, mucinous cystadenoma, intraductal papillary mucinous neoplasms and solid-pseudopapillary tumor represent about 90% of all pancreatic primary cystic tumours. The non-optimal diagnostic preoperative accuracy in distinguishing benign from malignant cystic lesions ensures that up till now there are no well-defined guidelines regarding the management of cystic pancreatic neoplasms. Imaging findings often do not allow the diagnosis, because there is a considerable overlap among the cystic lesions; the best pre-operative characterization is obtained by the association of all diagnostic procedures available. For their different histology and behavior, cystic pancreatic neoplasms need to be managed according to various factors. In this review, the main elements necessary for their management are assessed--radiological features, tumour dimensions, patients' characteristics, the mode of clinical presentation and the associated oncologic markers. A multidisciplinary approach--including gastroenterologists, radiologists and surgeons--should be adopted in order to perform a differential diagnosis and a correct management.

Multidetector CT Dentascan evaluation of bone regeneration obtained with deproteinised bovine graft in residual cavity after mandibular cyst enucleation.

PURPOSE: This study compared spontaneous bone healing and regeneration obtained with deproteinised bovine graft in residual cavities after mandibular cyst enucleation using computed tomography (CT) Dentascan. MATERIALS AND METHODS: Eighty patients with a radiological diagnosis of mandibular cyst underwent surgical enucleation. Patients were divided into a control group (spontaneous healing, 40 patients) and a test group (deproteinised bovine graft, 40 patients). All patients underwent follow-up CT Dentascan 12 months after the procedure. For each residual cavity, apical-coronal and mesial-distal distance, average pixel intensity and volume were calculated and results compared between two groups using the t test. RESULTS: The control group showed mean volume, apical-coronal and mesial-distal distance of 703.2 ± 185.3 mm(3), 28.6 ± 9.4 mm and 25 ± 2.84 mm, respectively. In the test group, values were 738.2 ± 189.2 mm(3), 27.5 ± 3.6 mm and 25.3 ± 2.97 mm, respectively. There was no statistically significant difference between groups. Average pixel intensity was 1,102.8 ± 124.3 in the test group and 624.9 ± 133.3 in the control group, with a significant difference between groups (p<0.0001). CONCLUSIONS: The significantly higher average pixel intensity observed in the test group demonstrates the cavalue of treatment with biomaterials to obtain earlier bone regeneration.

Endometrial carcinoma: MR staging and causes of error.

PURPOSE: This study was undertaken to prospectively determine the diagnostic capabilities of magnetic resonance (MR) imaging in detecting myometrial and cervical invasion and lymph node involvement in endometrial carcinoma and to identify the causes of errors in staging endometrial carcinoma. MATERIALS AND METHODS: Twenty consecutive patients with a histological diagnosis of endometrial carcinoma underwent preoperative MR imaging. MR findings were compared with surgical staging, considered as the standard of reference. RESULTS: In assessing myometrial invasion, MR imaging showed 70% accuracy, 80% sensitivity, 40% specificity, 80% positive predictive value (PPV), and 40% negative predictive value (NPV). In detecting cervical invasion, MR imaging had 95% accuracy, 100% sensitivity, 94.4% specificity, 66.7% PPV, and 100% NPV. In evaluating lymph node involvement, MR imaging showed 100% accuracy, sensitivity, specificity, PPV and NPV. Errors in evaluating myometrial invasion were caused by polypoid tumour, adenomyosis and leiomyomas, whereas those in evaluating cervical invasion were caused by dilatation and curettage. CONCLUSIONS: MR imaging is a reliable technique for preoperative evaluation of endometrial carcinoma. Its main limitation is differentiating between stage IA and IB carcinomas, which is not highly important for surgical planning. Cooperation between the gynaecologist and radiologist is mandatory to avoid staging errors.

Pelvic floor imaging: comparison between magnetic resonance imaging and conventional defecography in studying outlet obstruction syndrome.

PURPOSE: This study prospectively compared the diagnostic capabilities of magnetic resonance (MR) imaging with conventional defecography (CD) in outlet obstruction syndrome. MATERIALS AND METHODS: Nineteen consecutive patients with clinical symptoms of outlet obstruction underwent pelvic MR examination. The MR imaging protocol included static T2-weighted fast spin-echo (FSE) images in the sagittal, axial and coronal planes; dynamic midsagittal T2-weighted single-shot (SS)-FSE and fast imaging employing steady-state acquisition (FIESTA) cine images during contraction, rest, straining and defecation. MR images (including and then excluding the evacuation phase) were compared with CD, which is considered the reference standard. RESULTS: Comparison between CD and MR with evacuation phase (MRWEP) showed no significant differences in sphincter hypotonia, dyssynergia, rectocele or rectal prolapse and significant differences in descending perineum. Comparison between CD and MR without evacuation phase (MRWOEP) showed no significant differences in sphincter hypotonia, dyssynergia or enterocele but significant differences in rectocele, rectal prolapse and descending perineum. Comparison between MRWEP and MRWOEP showed no significant differences in sphincter hypotonia, dyssynergia, enterocele or descending perineum but significant differences in rectocele, rectal prolapse, peritoneocele, cervical cystoptosis and hysteroptosis. CONCLUSIONS: MR imaging provides morphological and functional study of pelvic floor structures and may offer an imaging tool complementary to CD in multicompartment evaluation of the pelvis. An evacuation phase is mandatory.

Magnetic resonance with diffusion-weighted imaging in the evaluation of transplanted kidneys: updating results in 35 patients.

BACKGROUND: We compared values of apparent diffusion coefficient (ADC) with renal function indices among a population of kidney transplant recipients who underwent magnetic resonance with diffusion-weighted imaging (DWI) of their grafts. MATERIALS AND METHODS: Thirty-five patients with right iliac transplanted kidneys were studied using 1.5-T magnetic resonance. Diffusion echo-planar sequences with several b-values were acquired to investigate transplanted grafts. Patients were divided into 3 groups according to their creatinine clearances; Group A, clearance >60 mL/min; Group B, clearance >30 and ≤60 mL/min; and Group C, clearance ≤30 mL/min. ADC values between groups were compared using Mann-Whitney U test. Receiver operating characteristic (ROC) curves were used to predict the normal function (Group A) versus renal failure cohorts (Group C). RESULTS: Comparing mean values of ADC between Group A and Group C patients, we observed a significant difference (P = .0003) with higher ADC values among patients with a normal creatinine clearance (>60 mL/min). Comparing Groups B and C did not show a significant difference (P = .05); nor did Group A and Group B reveal a significant difference (P = .38). To predict normal clearance values, the Group A ROC curve showed an area under curve (AUC) of 0.780 with a sensitivity of 92.3% and a specificity of 68.2% at a threshold ADC value of ≥2.08 × 10(-3) mm(2)/sec. In the prediction of low clearance values, the Group C ROC curve showed an AUC of 0.846 with a sensitivity of 83.3% and a specificity of 82.6% using a threshold ADC value of ≤2.07 × 10(-3) mm(2)/sec. CONCLUSIONS: Updating our experience among 35 patients, DWI was confirmed to be a promising noninvasive tool to assess renal function; an ADC ≥2.08 × 10(-3) mm(2)/sec may be used as a threshold to predict a normal clearance. However, an overlap of ADC values between groups is a limit.

Hemoperitoneum as severe and unusual complication in the stapler recto-anopexy for hemorrhoidal prolapse. Case report.

We report unusual but severe complication after Longo recto-anopexy for hemorrhoidal prolapse, i.e. large intramural hematoma of the rectum and subsequent hemoperitoneum. We make some assessment about the technique.

Evaluation of the biliary and pancreatic system with 2D SSFSE, breathhold 3D FRFSE and respiratory-triggered 3D FRFSE sequences.

PURPOSE: The authors compared biliary and pancreatic imaging obtained through 2D single-shot fast spin-echo (SSFSE), breath-hold 3D fast recovery fast spin-echo (FRFSE) and respiratory-triggered 3D FRFSE sequences. MATERIALS AND METHODS: A total of 106 magnetic resonance cholangiopancreatography (MRCP) examinations performed between December 2007 and September 2008 were evaluated with a comparison of 2D SSFSE (thin section and thick slab), breath-hold 3D FRFSE and respiratory-triggered 3D FRFSE sequences. The biliary tract was divided into seven segments: right hepatic duct, left hepatic duct, common hepatic duct, cystic duct, common bile duct, cystic duct junction and biliary-pancreatic confluence. The main pancreatic duct was divided into three segments (head, body and tail). Visualisation of biliary variants was also compared. Two blinded radiologists evaluated segment visibility using a quantitative scale. The Student's t test for paired samples was used for statistical analysis. RESULTS: Compared with 2D SSFSE, respiratory-triggered 3D FRFSE sequences showed better visibility of the right hepatic duct (p=0.0277), the cystic duct (p=0.0081), the cystic duct junction (p=0.0010), the biliary-pancreatic confluence (p=0.0334) and biliary variants (p=0.0198). In the comparison between breath-hold 3D FRFSE and 2D SSFSE, a significant statistical difference was found in visualisation of the cystic duct (p=0.027), the cystic duct junction (p=0.020), the biliary-pancreatic confluence (p=0.0338) and biliary variants (p=0.0311). CONCLUSIONS: Three-dimensional FRFSE offers a significant benefit over conventional 2D imaging.

Power Doppler ultrasonography with time-signal intensity curves in monitoring hepatocellular carcinoma and liver metastases after intralesional therapy.

PURPOSE: Analysis of time-intensity curves allows evaluation of the patterns of lesion enhancement before and after treatment. The aim of this study was to evaluate the diagnostic accuracy of time-intensity curves in monitoring intralesional therapy of focal hepatic lesions. MATERIALS AND METHODS: Twenty patients underwent intralesional therapy with either radiofrequency thermal ablation or percutaneous ethanol injection. Contrast-enhanced power Doppler ultrasound with analysis of time-intensity curves was performed one day before and one day after treatment. Targeted biopsy was then obtained to confirm the imaging findings. RESULTS: Before treatment, all lesions showed time-intensity curves characterised by high peaks of signal intensity and plateaus. Complete tumour necrosis, confirmed by targeted biopsy, was observed in patients showing no intralesional flow signals and time-intensity curves with low peak of signal intensity and absence of plateau after treatment. Biopsy confirmed the presence of residual neoplastic tissue in one patient exhibiting perilesional vascularity, absence of intralesional flow signals, and a time-intensity curve with high peak of signal intensity and plateau. CONCLUSIONS: According to our findings, time-intensity curves characterised by high peak of signal intensity and plateau might reflect the presence of perilesional or intralesional neoplastic tissue and provide important information on the effectiveness of the treatment.

Contrast-enhanced colour-Doppler sonography versus pH-metry in the diagnosis of gastro-oesophageal reflux in children.

PURPOSE: The aim of this study was to evaluate the accuracy of contrast-enhanced colour-Doppler ultrasound (CDUS) in the diagnosis of gastro-oesophageal reflux in children. MATERIALS AND METHODS: One hundred and twenty children (68 boys and 52 girls aged between 1 month and two years) with a clinical suspicion of gastro-oesophageal reflux (postprandial vomiting, weight loss, failure to thrive, anaemia, night-time coughing and crying, regurgitation, etc.) were studied by contrast-enhanced CDUS and subsequently by 24-hour pH-metry. Results of the two techniques were compared using the McNemar test. RESULTS: Gastro-oesophageal reflux was detected on CDUS in 84 patients and with 24-h pH-metry in 86. In all cases of reflux, CDUS visualised the passage of contrast material from the stomach into the abdominal and middle and distal third of the thoracic oesophagus, enabling assessment of the segment of oesophagus involved by the reflux. Compared with pH-metry, CDUS had a sensitivity of 98% (p<0.0001 with McNemar's test). CONCLUSIONS: In consideration of the results obtained and particularly of the low level of invasiveness, contrast-enhanced CDUS could be used to monitor children undergoing medical or surgical treatment for the complications of gastro-oesophageal reflux disease.