[Pancreatoblastoma in a pediatric patient: a case report]. / Pancreatoblastoma en paciente pediátrico: reporte de caso.

Pancreoblastoma is a very rare tumor that originates from the exocrine epithelial cells of the pancreas. However, it is the most frequent pancreatic tumor in children. It usually appears in the first decade of life with an average of 5 years old. The clinical manifestations are usually unspecific, being the abdominal pain and the abdominal mass the most frequent. The radiological signs are not very well described in medical literature. The definite diagnosis should always be established with biopsia and histological examination. Here it is presented a clinical case of pancreoblastoma with unusual involvement of a major duodenal papilla in a pediatric patient.

Pancreatoblastoma en paciente pediátrico: reporte de caso

El pancreatoblastoma es un tumor muy raro que se origina de las células epiteliales exocrinas del páncreas. Sin embargo, es el tumor pancreático más frecuente en niños. Suele presentarse en la primera década de vida con una edad media de 5 años. Las manifestaciones clínicas son inespecíficas, siendo el dolor abdominal y la masa palpable las más frecuentes.Los signos radiológicos no están muy bien descritos en la literatura. El diagnóstico definitivo siempre debe establecerse con biopsia y examen histológico. Se presenta un caso clínico de pancreatoblastoma con afectación inusual de papila duodenal mayor en un paciente pediátrico.

Pancreoblastoma is a very rare tumor that originates from the exocrine epithelial cells of the pancreas. However, it is the most frequent pancreatic tumor in children. It usually appears in the first decade of life with an average of 5 years old. The clinical manifestations are usually unspecific, being the abdominal pain and the abdominal mass the most frequent. The radiological signs are not very well described in medical literature. The definite diagnosis should always be established with biopsia and histological examination. Here it is presented a clinical case of pancreoblastoma with unusual involvement of a major duodenal papilla in a pediatric patient.

Building a Prediction Model for Radiographically Confirmed Pneumonia in Peruvian Children: From Symptoms to Imaging.

BACKGROUND: Community-acquired pneumonia remains the leading cause of death in children worldwide, and current diagnostic guidelines in resource-poor settings are neither sensitive nor specific. We sought to determine the ability to correctly diagnose radiographically confirmed clinical pneumonia when diagnostics tools were added to clinical signs and symptoms in a cohort of children with acute respiratory illnesses in Peru. METHODS: Children < 5 years of age with an acute respiratory illness presenting to a tertiary hospital in Lima, Peru, were enrolled. The ability to predict radiographically confirmed clinical pneumonia was assessed using logistic regression under four additive scenarios: clinical signs and symptoms only, addition of lung auscultation, addition of oxyhemoglobin saturation (Spo2), and addition of lung ultrasound. RESULTS: Of 832 children (mean age, 21.3 months; 59% boys), 453 (54.6%) had clinical pneumonia and 221 (26.6%) were radiographically confirmed. Children with radiographically confirmed clinical pneumonia had lower average Spo2 than those without (95.9% vs 96.6%, respectively; P < .01). The ability to correctly identify radiographically confirmed clinical pneumonia using clinical signs and symptoms was limited (area under the curve [AUC] = 0.62; 95% CI, 0.58-0.67) with a sensitivity of 66% (95% CI, 59%-73%) and specificity of 53% (95% CI, 49%-57%). The addition of lung auscultation improved classification (AUC = 0.73; 95% CI, 0.69-0.77) with a sensitivity of 75% (95% CI, 69%-81%) and specificity of 53% (95% CI, 49%-57%) for the presence of crackles. In contrast, the addition of Spo2 did not improve classification (AUC = 0.73; 95% CI, 0.69-0.77) with a sensitivity of 40% (95% CI, 33%-47%) and specificity of 72% (95% CI, 68%-75%) for an Spo2 ≤ 92%. Adding consolidation on lung ultrasound was associated with the largest improvement in classification (AUC = 0.85; 95% CI, 0.82-0.89) with a sensitivity of 55% (95% CI, 48%-63%) and specificity of 95% (95% CI, 93%-97%). CONCLUSIONS: The addition of lung ultrasound and auscultation to clinical signs and symptoms improved the ability to correctly classify radiographically confirmed clinical pneumonia. Implementation of auscultation- and ultrasound-based diagnostic tools can be considered to improve diagnostic yield of pneumonia in resource-poor settings.

"Deceiving appearances": intrapulmonary teratoma-a diagnostic challenge.

Intrapulmonary teratoma is a rare and little-known disease. The present case was that of an adolescent with recurrent cough and haemoptysis. Chest radiography revealed a mass on the left lung base, and computed tomography (CT) indicated a heterogeneous tumour with a fluid component, soft parts, fat, and calcifications in the left upper lobe. Upper left lobectomy was performed; histopathological findings confirmed a mature pulmonary teratoma.

Lung ultrasound as a diagnostic tool for radiographically-confirmed pneumonia in low resource settings.

BACKGROUND: Pneumonia is a leading cause of morbidity and mortality in children worldwide; however, its diagnosis can be challenging, especially in settings where skilled clinicians or standard imaging are unavailable. We sought to determine the diagnostic accuracy of lung ultrasound when compared to radiographically-confirmed clinical pediatric pneumonia. METHODS: Between January 2012 and September 2013, we consecutively enrolled children aged 2-59 months with primary respiratory complaints at the outpatient clinics, emergency department, and inpatient wards of the Instituto Nacional de Salud del Niño in Lima, Peru. All participants underwent clinical evaluation by a pediatrician and lung ultrasonography by one of three general practitioners. We also consecutively enrolled children without respiratory symptoms. Children with respiratory symptoms had a chest radiograph. We obtained ancillary laboratory testing in a subset. RESULTS: Final clinical diagnoses included 453 children with pneumonia, 133 with asthma, 103 with bronchiolitis, and 143 with upper respiratory infections. In total, CXR confirmed the diagnosis in 191 (42%) of 453 children with clinical pneumonia. A consolidation on lung ultrasound, which is our primary endpoint for pneumonia, had a sensitivity of 88.5%, specificity of 100%, and an area under-the-curve of 0.94 (95% CI 0.92-0.97) when compared to radiographically-confirmed clinical pneumonia. When any abnormality on lung ultrasound was compared to radiographically-confirmed clinical pneumonia the sensitivity increased to 92.2% and the specificity decreased to 95.2%, with an area under-the-curve of 0.94 (95% CI 0.91-0.96). CONCLUSIONS: Lung ultrasound had high diagnostic accuracy for the diagnosis of radiographically-confirmed pneumonia. Added benefits of lung ultrasound include rapid testing and high inter-rater agreement. Lung ultrasound may serve as an alternative tool for the diagnosis of pediatric pneumonia.

Evaluación de la capacidad discriminativa diagnóstica de la ultrasonografía en apendicitis aguda en el Instituto Nacional de Salud del Niño (2010-2011) / Evaluation of Diagnostic Discriminative Capacity of Ultrasonography in Acute Appendicitis at the Instituto Nacional de Salud del Niño (2010-2011)

Objetivo: Evaluar la capacidad discriminativa diagnóstica de la ultrasonografía en apendicitis aguda (AA) en el Instituto Nacional de Salud del Niño (INSN). Metodología: Estudio observacional para validación de prueba diagnóstica. Se realizó ecografía abdominal con compresión gradual en 235 pacientes menores de 18 años, con clínica sugestiva de AA, entre noviembre del 2010 y diciembre del 2011. Se excluyeron pacientes con enfermedades concomitantes. El criterio de AA por ecografía fue un apéndice no compresible, con diámetro transverso mayor a 6 mm y grosor de pared mayor a 1,5 mm o visualización de plastrón o absceso apendicular. La prueba estándar fue el hallazgo anatomopatológico (AP) o seguimiento clínico. Resultados: La ecografía fue positiva para AA en 58,30 % (137/235); fueron operados el 62,55 % (147/235), de los cuales el 89,12 % tuvo diagnóstico definitivo de AA. La ecografía mostró una sensibilidad de 93,13 %, especificidad de 85,58 %, valor predictivo positivo de 89,05 % y negativo de 90,82 %, y un cociente de probabilidad positivo de 6,46 y negativo de 0,08. Conclusiones: La ecografía con técnica de compresión gradual es muy sensible, específica y fiable para el diagnóstico de AA. La utilidad fue mayor en casos de sospecha clínica media o baja.

Objective: To evaluate the discriminative ability of ultrasonography in diagnosis of acute appendicitis (AA) at the Instituto Nacional de Salud del Niño (National Institute of Child Healthcare) (INSN). Methodology: Observational validation of a diagnostic test. Gradual compression ultrasound was performed in 235 patients younger than 18 years with symptoms suggestive of AA, between November 2010 and December 2011. Patients with underlying diseases were excluded. Appendicitis was considered to be present when the appendix was non-compressible and measured more than 6 mm in transversal diameter and had a wall thickness greater than 1.5 mm or when the patient presented an appendicular plastron or abscess in right abdominal lower quadrant. The findings were confirmed by pathology or clinical follow up. Results: The ultrasound was positive in 58.30% of cases (137/235); 62.55% underwent surgery (147/235), out of which 89.12% had a definitive diagnosis of AA according to pathological report. Ultrasonography had a sensitivity of 93.13%, specificity of 85.58%, positive predictive value of 89.05%, negative predictive value of 90.82%, positive likelihood ratio of 6.46 and negative likelihood ratio of 0.08. Conclusions: Ultrasound with gradual compression technique is very sensitive, specific and reliable for the diagnosis of AA. The utility was higher in cases of medium or low clinical suspicion.

Hallazgos ultrasonográficos del riñón y las vías urinarias en niños con reflujo vesicouteral / Ultrasonographic findings of the kidney and urinary tract in children with reflux vesicouteral

Objetivos: Identificar las principales características epidemiológicas y ultrasonográficas de los diferentes grados del reflujo vésicoureteral (RVU) detectados por cistouretrografía miccional seriada (CUMS) en niños. Material y métodos: Se realizó un estudio descriptivo retrospectivo donde se analizaron las US y las CUMS de 279 niños (554 riñones) menores de 18 años con sospecha de RVU en el Instituto Nacional de Salud del Niño, entre julio a diciembre del 2009. Los hallazgos de US para RVU considerados fueron la dilatación del sistema pielocalicilial y del uréter, el engrosamiento del urotelio y de la pared vesical; mientras que para daño renal fueron la disminución del tamaño renal y del grosor del parénquima renal, el incremento de la ecogenicidad del parénquima renal y la desdiferenciación córtico medular. El RVU se clasificó según el Sistema Internacional de Gradación del RVU en cinco grados. Los datos se analizaron en base a frecuencias y porcentajes. Resultados: Predominó el sexo femenino (54.05 por ciento) y la edad entre los 6 meses y 6 años (64.86 por ciento). Sólo 27 niños (51 riñones) presentaron RVU. La dilatación del sistema pielocalicilial fue el criterio ultrasonográfico más frecuente (52.94 por ciento) para RVU, mientras que la disminución del tamaño renal lo fue para daño renal (52.94 por ciento). Todos los hallazgos por US evaluados predominaron en los grados severos de RVU (IV y V). Sin embargo, existieron pacientes con US normal a pesar de presentar grados severos de reflujo. La poliquistosis renal (21.43 por ciento) fue la anomalía congénita más frecuente. El 17.64 por ciento de pacientes con RVU se asoció con otra anomalía. Conclusiones: El RVU es más frecuente en el sexo femenino. La ultrasonografía permite detectar los grados más severos de RVU y la presencia de daño renal, sin embargo, una ecografía normal no la excluye. Además la ultrasonografía ayuda a determinar otras anomalías que pueden estar o no asociadas al RVU

Objectives: To identify the epidemiological and ultrasonographic characteristics of different degrees of vesicoureteral reflux (VUR) detected by voiding cystourethrography (VCUO). Material and methods: We performed a retrospective study which evaluated the US and VCUO in 279 children (554 kidneys) under 18 years with suspected VUR at the National Institute of Child Health from July to December 2009. The US findings to VUR were considered the pelvic and ureteral dilatation, the thickening of the urothelium and bladder wall, while for kidney darnage were decreased renal size and thickness of the renal parenchyma, increased echogenicity renal parenchyma and corticomedullary dedifferentiation. VUR was classified according to the lnternational System of Grading of VUR into five grades. The data were analyzed based on frequencies and percentages. Results: The VUR predominance in females (54.05 per cent) and age between 6 months and 6 years (64.86 per cent). Only 27 children (51 kidneys) had VUR. The pelvic dilatation was more frequent uItrasonographic criteria (52.94 per cent) for VUR, while the decrease in kidney size was for kidney damage (52.94 per cent). AlI of US findings evaluated were predominant in severe grades of VUR (IV and V). However, there were patients with normal US despite having severe grades of reflux. Polycystic kidney disease (21.43 per cent) was the most common congenital anomaly. The 17.64 per cent of the patients with VUR is associated with other abnormalities. Conclusions: VUR is more common in females. The ultrasound can detect the most severe degrees of VUR and the presence of kidney darnage, however, a normal ultrasound does not excIude it. In addition ultrasound helps identify other abnorrnalities that may or may not be associated with VUR