Patterns of Sonographically Detectable Echogenic Foci in Pediatric Thyroid Carcinoma with Corresponding Histopathology: An Observational Study.

BACKGROUND AND PURPOSE: Small echogenic foci within pediatric thyroid nodules are commonly seen by ultrasound and are one of the features used to determine the level of suspicion for malignancy. These are sometimes termed "microcalcifications," but their relation with malignancy is controversial due to the lack of standard terminology. Our aim was to evaluate sonographic patterns of echogenic foci in malignant pediatric thyroid nodules and describe the distribution of corresponding psammoma bodies and other histopathologic findings in thyroidectomy specimens. MATERIALS AND METHODS: Ultrasounds of 15 pathologically proved malignant thyroid nodules in children were retrospectively reviewed by 2 radiologists who separately classified echogenic foci into the 4 morphologic patterns described in the American College of Radiology Thyroid Imaging, Reporting and Data System and noted their presence and distribution. Interobserver agreement was assessed, and consensus was reached for nodules for which there was disagreement. Surgical pathology findings from thyroidectomy specimens were retrospectively reviewed for the presence and distribution of psammomatous and dystrophic/stromal calcifications and eosinophilic/sticky colloid. Ultrasound and histopathologic ratings were compared, and frequencies and percentages corresponding to observed agreement levels were calculated. RESULTS: Interobserver agreement between radiologists' sonographic assessments for the presence and distribution of echogenic foci ranged from 53% to 100% for all categories. Punctate echogenic foci were present in all nodules, and macrocalcifications, in 27%. Histopathology of the 15 nodules revealed that only 4 (27%) had psammomatous calcifications, while 9 (60%) had stromal calcifications and 8 (53%) had sticky colloid. CONCLUSIONS: Sonographically detectable echogenic foci in malignant pediatric thyroid nodules can be reliably classified on the basis of American College of Radiology Thyroid Imaging, Reporting and Data System, with punctate echogenic foci composing the most common subtype. These echogenic foci do not represent psammomatous calcifications most of the time; instead, more than half of the malignant thyroid nodules with echogenic foci contained stromal calcifications or sticky colloid.

Retroperitoneal abscess and mycotic aortic aneurysm: unusual septic complications of central vascular line placement in premature infants.

OBJECTIVE: To describe the sonographic appearance of unusual septic complications after central vascular line placement in premature infants. METHODS: Two case reports are presented. RESULTS: The first patient had a retroperitoneal abscess after percutaneous central venous catheter placement. The second patient had a ruptured mycotic aneurysm of the abdominal aorta after umbilical arterial catheter placement. CONCLUSIONS: Retroperitoneal abscess and aortic aneurysm should be considered in patients with histories of long-standing catheters or line sepsis. Both of these complications are readily diagnosed on the basis of sonography.

Abdominal sonography in examination of children with blunt abdominal trauma.

OBJECTIVE: The objective of our study was to evaluate abdominal sonography for the detection of fluid and organ injury in children with blunt abdominal trauma. SUBJECTS AND METHODS: Fifty-one consecutive children with blunt abdominal trauma requiring abdominal CT were prospectively examined with sonography. Sonograms and CTs were independently evaluated by two radiologists for fluid and organ injury; CT examinations were considered abnormal if either was identified. Differences in CT interpretation were settled by a third observer. Using CT as the truth standard, we calculated the sensitivity, specificity, and negative predictive value of sonography for both observers. Agreement of the sonographic interpretations was evaluated using kappa statistic. RESULTS: In 33.3% of patients, CT revealed fluid, organ injury, or both. The sensitivity and specificity of sonography when detection of fluid was the sole parameter evaluated was 58.8% and 79.4%, respectively, for observer 1 and 47.1% and 79.4%, respectively, for observer 2. In contrast, the sensitivity and specificity of sonography when detection of both fluid and organ injury was evaluated was 64.7% and 79.4%, respectively, for observer 1 and 70.6% and 70.6%, respectively, for observer 2. The negative predictive value of sonography was 79.4% and 75.0% with evaluation limited to detection of fluid and 81.8% and 82.8% with evaluation of fluid and organ abnormality for observers 1 and 2 , respectively. Agreement was excellent for sonographic identification of fluid (kappa = 0.82) but poor for detection of organ injury (kappa = 0.34). CONCLUSION: The low sensitivity and negative predictive value of sonography when assessing for either fluid alone or fluid and organ injury suggest that a normal screening sonography alone in the setting of blunt abdominal trauma fails to confidently exclude the presence of an intraabdominal injury.

The interrupted bronchus: a fluoroscopic sign of bronchial foreign body in infants and children.

OBJECTIVE: The objective is to describe the characteristic features of the interrupted bronchus sign and to determine the value of this sign in detection of bronchial foreign bodies. The interrupted bronchus sign refers to disruption of the air column in the main bronchi seen by fluoroscopy. CONCLUSION: The interrupted bronchus sign has a sensitivity of 100% for detection of foreign bodies in the main bronchi. This sign is particularly helpful when chest radiography shows atelectasis or pneumonia. The specificity of this sign for foreign bodies is only 71% because other endobronchial lesions can disrupt the air column. Nevertheless, the interrupted bronchus sign indicates the presence of bronchial occlusion and signifies the need for bronchoscopy. This sign is not sensitive for detection of foreign bodies in lobar or segmental bronchi.

Manual epigastric compression during upper gastrointestinal examination of neonates: value in diagnosis of intestinal malrotation and volvulus.

OBJECTIVE: This paper describes the value of manual epigastric compression during upper gastrointestinal examination in establishing the diagnosis of intestinal malrotation and volvulus in five neonates. CONCLUSION: In two patients, the location of the duodenojejunal junction was near normal. Manual compression revealed abnormal mobility of the duodenojejunal junction, indicating malrotation. In three other patients, the duodenum was completely obstructed. Manual compression unequivocally displayed the anatomy of midgut volvulus by allowing contrast material to pass beyond the point of obstruction.

Aspiration after administration of oral contrast material in children undergoing abdominal CT for trauma.

OBJECTIVE: The practice of routinely administering oral contrast material to children undergoing abdominal CT for blunt trauma is controversial, primarily because of the increased risk of aspiration. The purpose of this study was to determine how often aspiration occurs in this population of children. MATERIALS AND METHODS: We retrospectively studied 50 children who underwent abdominal CT scans after blunt trauma. All children received diluted 3% water-soluble oral contrast material. The medical record of each child was reviewed for evidence of aspiration pneumonia as many as 48 hr after the CT. In each patient, sections of the CT scan through the lung bases were examined for opacities. When lung opacities were identified, they were classified as atelectasis, confusion, laceration, or nonspecific. We made attenuation measurements of lung opacities larger than 1 cm, and each measurement was compared with the attenuation measurement of contrast material in that patient's stomach. Student's two-tailed t test was used to compare the two measurements. RESULTS: Four patients were febrile after the CT scan, but in none was aspiration pneumonia suspected to be the cause. The remaining 46 patients did not have any clinical evidence of aspiration. Twelve of the 50 patients had pulmonary opacities revealed by CT that were sufficiently large that attenuation measurements could be obtained. The opacity in one of these patients was classified as nonspecific, and the attenuation was as high as that of contrast material in the stomach. CONCLUSION: No clinically symptomatic episodes of aspiration pneumonia were found in 50 pediatric patients with blunt trauma who were given oral contrast material for abdominal CT. Although one of the children had CT findings that suggested clinically silent aspiration of oral contrast material, no evidence was found that administration of oral contrast material was harmful.

Unusual features of osteoarticular tuberculosis in children.

Three children with tuberculous arthritis, two of whom also had tuberculous otitis media, are described. Two of the children were atypical at presentation, with an acute onset of arthritis, an elevated erythrocyte sedimentation rate, and a predominance of polymorphonuclear cells in the joint fluid. Both had histories of recurrent otitis media with perforations. Recognition that Mycobacterium tuberculosis could be the cause of disease in all three cases was delayed. Placement of a tuberculin skin test ultimately led to the correct diagnosis. These cases Illustrate that tuberculous arthritis is not always insidious in onset and underscore the need to maintain a high index of suspicion for tuberculosis infection in high-risk patient populations. Our experiences suggest that Mantoux skin tests might be considered part of the "routine" diagnostic study of children with arthritis or recurrent otitis media, especially in communities with high tuberculosis case rates.

Sonographic demonstration of a normal thyroid gland excludes ectopic thyroid in patients with thyroglossal duct cyst.

OBJECTIVE: Preoperative thyroid scintigraphy has been performed in patients with presumed thyroglossal duct cyst to document a normal thyroid and to exclude the possibility of an ectopic thyroid mimicking a thyroglossal duct cyst. Often, an ectopic thyroid is the patient's only functioning thyroid tissue, and its removal will result in hypothyroidism. The purpose of this study was to determine whether demonstration of a normal thyroid gland by sonography in children with thyroglossal duct cyst can exclude ectopic thyroid and thereby obviate routine preoperative thyroid scintigraphy. MATERIALS AND METHODS: We studied 30 patients with pathologically proved thyroglossal duct cysts who had neck sonograms. The sonograms were evaluated for the presence or absence of a normal thyroid gland. The medical records of these children were also reviewed. Three children had normal preoperative radionuclide thyroid scans. All the children were clinically euthyroid preoperatively. Follow-up was available in 15 of the 30 patients, and all of these patients were clinically euthyroid postoperatively. RESULTS: A sonographically normal thyroid gland was detected in all patients. CONCLUSION: Preoperative sonographic identification of a normal thyroid gland in patients with thyroglossal duct cyst confirms a source of thyroid hormone separate from the thyroglossal duct cyst and thus excludes ectopic thyroid. Routine thyroid scintigraphy is not necessary.

Septic arthritis of the elbow in children: the role of sonography.

Twelve children with suspected septic arthritis of the elbow were prospectively studied with plain-film radiography and ultrasound. Imaging data were correlated with clinical history and final diagnosis. Joint effusion was seen by sonography in six patients, four of whom underwent ultrasound-guided joint aspiration, confirming the diagnosis of septic arthritis in two patients and excluding it in two. Of nine patients whose plain films showed only soft tissue swelling, seven had one or more significant findings with sonography: joint effusion (without fat pad elevation on lateral plain films) in three patients, periosteal reaction in two, and epitrochlear mass in three. Sonography confirmed soft tissue swelling alone in two patients, thus excluding the diagnosis of septic arthritis and obviating unnecessary attempts at joint aspiration. Sonography of the elbow is an informative, easily performed examination, which is capable of showing both intra- and extra-articular abnormalities not apparent by plain radiography. Both the demonstration of pathologic changes and the failure to show joint fluid may affect clinical management.