CT-guided hook-wire localization of pulmonary nodules in children prior to atypical resection by thoracoscopy: Practical aspects.

In the multidisciplinary treatment of pediatric oncologic patients, multiple imaging tests, biopsies, and resections are required for diagnosis, initial staging, and posterior restaging. In these patients, pulmonary nodules are not always metastases, so the correct diagnosis of these lesions affects their treatment and the patient's survival. Percutaneous localization of pulmonary nodules is key for two reasons: it enables the surgeon to resect the smallest amount of lung tissue possible and it guarantees that the nodule will be included in the resected specimen. Without percutaneous localization, it can be impossible to accomplish these two objectives in patients with very small nodules that are separated from the pleural surface and therefore impossible to see by thoracoscopy. This article reviews the technique for hook-wire localization of pulmonary nodules and the keys to ensuring the best results.

Self-limiting sternal tumors of childhood (SELSTOC): A diagnostic challenge.

INTRODUCTION: Self-limiting sternal tumors of childhood (SELSTOC) are rapidly growing sternal lesions that tend to resolve spontaneously. Patients have no history of infection, trauma, or neoplasms, and the most likely etiologyis an aseptic inflammatory reaction of unknown origin. The differential diagnosis includes a wide spectrum of lesions such as tumors, infections, malformations, or anatomic variants. MATERIAL AND METHODS: We analyzed all cases of sternal masses in pediatric patients seen between 2012 and 2019; five of these had findings compatible with SELSTOC. We retrospectively recorded patients' race, sex, age, clinical presentation, laboratory findings, imaging tests, treatment, and follow-up. RESULTS: We present five cases of rapidly growing sternal lesions whose clinical and radiological features are compatible with SELSTOC. In the absence of alarming symptoms and laboratory markers, watchful waiting could be an appropriate therapeutic approach. However, patients with some findings such as fever, elevated acute phase reactants, and/or comorbidities could require therapeutic interventions such as antibiotics or percutaneous drainage. In our series, depending on the clinical presentation and the patient's comorbidities, different therapeutic approaches were adopted (a conservative approach in two patients, antibiotics in three patients, and percutaneous drainage in one patient). In all cases, the sternal lesion was absent at discharge and/or at later follow-up visits. CONCLUSION: Radiologists and pediatricians must be aware of this entity and the different diagnostic and therapeutic approaches to rapidly growing sternal lesions in pediatricpatients because recognizing SELSTOC can avoid unnecessary diagnostic tests and/or disproportionate therapeutic strategies.

Pediatric chest X-rays during the COVID-19 pandemic. / Radiografía de tórax pediátrica en la era COVID.

BACKGROUND: An infectious disease caused by a new type of coronavirus that can manifest as an acute respiratory infection was discovered in China in mid-December 2019 and soon spread throughout the country and to the rest of the world. Although chest X-rays are the initial imaging technique of choice for low respiratory infections with or without dyspnea, few articles have reported the radiologic findings in children with COVID-19. OBJECTIVE: To describe the clinical, laboratory, and chest X-ray findings in pediatric patients with signs and symptoms of respiratory infection attended at our hospital in March 2020. To analyze the frequency of COVID-19 compared to other respiratory infections, and to describe the radiologic manifestations of COVID-19 in pediatric patients. MATERIAL AND METHODS: This cross-sectional observational study included all children with clinical manifestations of respiratory infection (fever, rhinorrhea, cough, and/or dyspnea) that required chest X-rays in our hospital between March 1 and March 31. RESULTS: A total of 231 pediatric patients (90 (39%) girls and 141 (61%) boys; mean age, 4 y, range 1 month - 16 years) underwent chest X-rays for suspected respiratory infections. Most (88.4%) had mild symptoms; 29.9% had a family member positive for COVID-19 with symptoms similar to those of the patient. Nasal and/or throat swabs were analyzed for SARS-CoV-2 with PCR in the 47 (20.3%) children who presented at the emergency department; 3 (6.3%) of these were positive. Microbiological analyses were done in 85 (36.8%) of all patients, finding infections due to pathogens other than SARS-CoV-2 in 30 (35.3%). One of the patients with a PCR positive for SARS-CoV-2 had urine infection due to E. coli and blood culture positive for S. viridans. Abnormalities were observed on X-rays in 73.2% of the patients. Peribronchial thickening was the most common abnormal finding, observed in 57% of patients. Parenchymal consolidations were observed in 38.5%, being bilateral in 29.2% and associated with pleural effusion in 3.3%. The interstitial lines were thickened in 7.3%, and 7.3% had ground-glass opacities. CONCLUSION: During March 2020, COVID-19 and other symptomatic respiratory infections were observed. The radiologic pattern of these infections is nonspecific, and chest X-rays alone are insufficient for the diagnosis. Children with clinical manifestations compatible with COVID-19 (with or without PCR confirmation of infection by SARS-CoV-2) had mild symptoms and most did not require admission or invasive mechanical ventilation. In a context of community transmission, the absence of a known epidemiological antecedent should not be a contraindication for PCR to detect SARS-CoV-2.

Radiografía de tórax pediátrica en la era COVID / Pediatric chest X-rays during the COVID-19 pandemic

INTRODUCCIÓN: A mediados de diciembre de 2019 se describió en China una enfermedad infecciosa causada por un nuevo tipo de coronavirus que provocaba infección respiratoria aguda y pronto se extendió por el país y por el resto del mundo. A pesar de que la radiografía de tórax es la prueba de elección inicial ante infecciones respiratorias bajas con o sin disnea, hay pocos artículos que describan los hallazgos radiológicos del niño con COVID-19. OBJETIVO: Describir las características clínicas, analíticas y los hallazgos en la radiografía de tórax de la población pediátrica atendida con clínica de infección respiratoria en nuestro hospital durante el mes de marzo. Analizar la frecuencia de COVID-19 frente a otras infecciones respiratorias y sus manifestaciones radiológicas. MATERIAL Y MÉTODOS: Estudio observacional transversal desde el 1 de marzo al 31 de marzo del 2020 de todos los niños con clínica de infección respiratoria (fiebre, rinorrea, tos y/o disnea) que han precisado radiografía de tórax en nuestro hospital. RESULTADOS: 231 niños precisaron radiografía de tórax por clínica de infección respiratoria, 90 (38,9%) niñas y 141 (61%) niños; rango de edad 1 mes-16 años, con una mediana de 4 años. La mayoría de los niños presentaron síntomas leves (88,4%). Un 29,9% de los niños presentaba ambiente epidémico familiar positivo con clínica respiratoria similar a la que presentaba el paciente. Se realizó test PCR SARS-CoV-2 a 47 de los niños que acudieron a la urgencia (20,3%), que fue positivo en 3 (6,3% de los testados). Se realizaron determinaciones microbiológicas al 36,8% (85/231), demostraron otros agentes infecciosos diferentes al SARS-CoV-2 en el 35,3% de los pacientes (30/85). Únicamente uno de los pacientes PCR positivo para SARS-CoV-2 presentó infección de orina por Escherichia coli y hemocultivo positivo para Streptococcus viridans. El 73,2% de los pacientes presentó algún tipo de alteración en la radiografía de tórax. Los engrosamientos peribronquiales fueron el hallazgo más común en el 57%. El 38,5% presentó consolidación parenquimatosa, que en un 29,2% fue bilateral y en un 3,3% asoció derrame pleural. Se demostró aumento de la trama intersticial en el 7,3%. El 7,3% se manifestó con opacidades en vidrio deslustrado. CONCLUSIÓN: Durante el mes de marzo coexistieron infecciones respiratorias sintomáticas COVID-19 y no COVID-19. El patrón radiológico de las infecciones respiratorias, incluida la COVID-19, no es específico y la radiografía en ningún caso fue suficiente para establecer el diagnóstico. Los niños con clínica respiratoria compatible con COVID-19, con o sin PCR confirmatoria, presentaron síntomas leves y en su mayoría no requirieron ingreso ni ventilación invasiva. En un entorno de transmisión comunitaria, la ausencia de antecedente epidemiológico conocido no debería ser una contraindicación para realizar estudio de PCR para SARS-CoV-2

BACKGROUND: An infectious disease caused by a new type of coronavirus that can manifest as an acute respiratory infection was discovered in China in mid-December 2019 and soon spread throughout the country and to the rest of the world. Although chest X-rays are the initial imaging technique of choice for low respiratory infections with or without dyspnea, few articles have reported the radiologic findings in children with COVID-19. OBJECTIVE: To describe the clinical, laboratory, and chest X-ray findings in pediatric patients with signs and symptoms of respiratory infection attended at our hospital in March 2020. To analyze the frequency of COVID-19 compared to other respiratory infections, and to describe the radiologic manifestations of COVID-19 in pediatric patients. MATERIAL AND METHODS: This cross-sectional observational study included all children with clinical manifestations of respiratory infection (fever, rhinorrhea, cough, and/or dyspnea) that required chest X-rays in our hospital between March 1 and March 31. RESULTS: A total of 231 pediatric patients (90 (39%) girls and 141 (61%) boys; mean age, 4 y, range 1 month - 16 years) underwent chest X-rays for suspected respiratory infections. Most (88.4%) had mild symptoms; 29.9% had a family member positive for COVID-19 with symptoms similar to those of the patient. Nasal and/or throat swabs were analyzed for SARS-CoV-2 with PCR in the 47 (20.3%) children who presented at the emergency department; 3 (6.3%) of these were positive. Microbiological analyses were done in 85 (36.8%) of all patients, finding infections due to pathogens other than SARS-CoV-2 in 30 (35.3%). One of the patients with a PCR positive for SARS-CoV-2 had urine infection due to E. coli and blood culture positive for S. viridans. Abnormalities were observed on X-rays in 73.2% of the patients. Peribronchial thickening was the most common abnormal finding, observed in 57% of patients. Parenchymal consolidations were observed in 38.5%, being bilateral in 29.2% and associated with pleural effusion in 3.3%. The interstitial lines were thickened in 7.3%, and 7.3% had ground-glass opacities. CONCLUSION: During March 2020, COVID-19 and other symptomatic respiratory infections were observed. The radiologic pattern of these infections is nonspecific, and chest X-rays alone are insufficient for the diagnosis. Children with clinical manifestations compatible with COVID-19 (with or without PCR confirmation of infection by SARS-CoV-2) had mild symptoms and most did not require admission or invasive mechanical ventilation. In a context of community transmission, the absence of a known epidemiological antecedent should not be a contraindication for PCR to detect SARS-CoV-2

Dolor en la fosa iliaca derecha: ¿apendicitis?... No, «Ascaris lumbricoides» / Pain in right lower quadrant: appendicitis? No, Ascaris lumbricoides

El dolor abdominal es un cuadro de consulta muy frecuente en la edad pediátrica, tanto en atención primaria como en atención especializada, e incluye los servicios de urgencias. En los casos en que el dolor se focaliza en la fosa iliaca derecha, el primer diagnóstico que hay que descartar es la apendicitis aguda. Además, destacamos la importancia de la ecografía para el diagnóstico de dolor abdominal. Presentamos un caso de dolor abdominal localizado en la fosa iliaca derecha en el que, tras descartar una apendicitis aguda mediante ecografía, se descubrió una infestación por Ascaris lumbricoides, entidad de dolor abdominal infrecuente en nuestro medio (AU)

Abdominal pain is a usual reason for consultation in pediatric, both in primary care and hospital, including emergency service. When the pain is located in right lower quadrant, the first diagnosis to discard is acute appendicitis. Besides, the relevance of ultrasonography for diagnosis of abdominal pain is emphasized. We report a case of abdominal pain located in right lower quadrant, where, after discarding acute appendicitis with an abdominal ultrasonography, we discover an Ascaris lumbricoides infestation, which is an unusual cause of abdominal pain in our country (AU)

Urgencias abdominales en pediatría / Abdominal emergencies in pediatrics

La sintomatología abdominal es uno de los motivos de consulta más frecuente en la urgencia pediátrica, siendo el dolor abdominal el síntoma más referido. Habitualmente, para el diagnóstico es suficiente con una anamnesis y exploración física precisas. Para el radiólogo es útil conocer cuáles son las patologías abdominales más frecuentes por franjas de edad, lo cual permite acotar el diagnóstico diferencial. Cuando esté indicado realizar alguna prueba de imagen, la ecografía es la técnica inicial en la mayoría de los casos; permite realizar el diagnóstico o añadir información relevante, con las ventajas conocidas de esta técnica. La radiografía simple hoy en día queda reservada cuando existe sospecha de perforación, obstrucción intestinal o ingesta de cuerpo extraño. Conviene recordar, que el dolor abdominal puede ser secundario a una neumonía basal. La TC queda reservada para indicaciones concretas y en casos individualizados. Por ejemplo, en pacientes con alta sospecha clínica de patología abdominal y con hallazgos ecográficos no concluyentes. Se revisan algunas de las patologías más frecuentes en la urgencia pediátrica, las diferentes pruebas de imagen indicadas y la semiología radiológica en las patologías abordadas (AU)

Abdominal symptoms are among the most common reasons for pediatric emergency department visits, and abdominal pain is the most frequently reported symptom. Thorough history taking and physical examination can often reach the correct diagnosis. Knowing the abdominal conditions that are most common in each age group can help radiologists narrow the differential diagnosis. When imaging tests are indicated, ultrasonography is usually the first-line technique, enabling the diagnosis or adding relevant information with the well-known advantages of this technique. Nowadays, plain-film X-ray studies are reserved for cases in which perforation, bowel obstruction, or foreign body ingestion is suspected. It is also important to remember that abdominal pain can also occur secondary to basal pneumonia. CT is reserved for specific indications and in individual cases, for example, in patients with high clinical suspicion of abdominal disease and inconclusive findings at ultrasonography. We review some of the most common conditions in pediatric emergencies, the different imaging tests indicated in each case, and the imaging signs in each condition (AU)

Abdominal emergencies in pediatrics. / Urgencias abdominales en pediatría.

Abdominal symptoms are among the most common reasons for pediatric emergency department visits, and abdominal pain is the most frequently reported symptom. Thorough history taking and physical examination can often reach the correct diagnosis. Knowing the abdominal conditions that are most common in each age group can help radiologists narrow the differential diagnosis. When imaging tests are indicated, ultrasonography is usually the first-line technique, enabling the diagnosis or adding relevant information with the well-known advantages of this technique. Nowadays, plain-film X-ray studies are reserved for cases in which perforation, bowel obstruction, or foreign body ingestion is suspected. It is also important to remember that abdominal pain can also occur secondary to basal pneumonia. CT is reserved for specific indications and in individual cases, for example, in patients with high clinical suspicion of abdominal disease and inconclusive findings at ultrasonography. We review some of the most common conditions in pediatric emergencies, the different imaging tests indicated in each case, and the imaging signs in each condition.

Pitfalls en el diagnóstico de la subluxación rotatoria atlantoaxial postraumática tipo II: a propósito de dos casos / Pitfalls in diagnosis of posttraumatic type II atlantoaxial rotatory subluxation: report of two cases

La subluxación rotatoria atlantoaxial es una entidad poco frecuente que puede causar dolor cervical y limitación funcional para girar la cabeza. Exponemos los casos de dos niños con sospecha clínica y pruebas de imagen iniciales compatibles con una subluxación rotatoria atlantoaxial, cuyo diagnóstico final fue de tortícolis postural. Resaltamos la utilidad de las técnicas de imagen para el manejo adecuado de estas situaciones (AU)

The atlantoaxial rotatory subluxation is a rare entity, which can cause cervical pain and functional limitation to turn the head. We show the cases of two children with a clinical suspicion and initial test images compatible with atlantoaxial rotator subluxation and with final diagnosis of postural torticollis, as well as the usefulness of the image techniques for the adequate management of these situations (AU)

Trombosis venosa renal neonatal: diagnóstico precoz con ecografía Doppler y secuelas a largo plazo / Neonatal renal vein thrombosis: early diagnosis using Doppler ultrasonography and long-term sequelae

Objetivo: Describir los mecanismos fisiopatológicos de las trombosis venosas renales perinatales y los factores de riesgo asociados, haciendo hincapié en las características clínico rradiológicas y en su evolución a largo plazo. Material y métodos: Se han estudiado retrospectivamente un total de 11 casos de trombosis venosa renal neonatal, con una edad media al diagnóstico de 3 días. Se analizaron la forma de presentación, las manifestaciones clínicas, los hallazgos de imagen obtenidos mediante ecografía (modos B y Doppler), el tratamiento instaurado y las secuelas a largo plazo. Resultados: En el momento del diagnóstico, la tríada de masa palpable, hematuria franca y trombocitopenia estaba presente únicamente en el 63,63% de los pacientes. Resultados: En el 45,45% de los casos pudo identificarse un factor de riesgo protrombótico en los recién nacidos o en sus madres. Todos los recién nacidos mostraron aumento del tamaño renal y pérdida de la diferenciación corticomedular en el estudio ecográfico. En 4 de los 11 casos se identificaron imágenes lineales hiperecogénicas intramedulares, características del estadio inicial de la trombosis. Los estudios funcionales de seguimiento con ácido dimercaptosuccínico (DMSA) y ácido mercapto-acetil-triglicina (MAG-3) revelaron anomalías morfológicas en todos los pacientes, con un riñón no funcionante en 7 casos. Conclusiones: Visualizar bandas ecogénicas intramedulares alerta de la fase inicial de una trombosis venosa renal, por lo que debe instaurarse precozmente un tratamiento adecuado. Exceptuando los casos acontecidos intraútero, la trombosis de la vena renal conlleva un mal pronóstico, con atrofia y fallo renal a largo plazo (AU)

Objective: To describe the physiopathological mechanisms in perinatal renal vein thrombosis and the associated risk factors, with emphasis on the clinical and radiological characteristics and on the long-term evolution. Material and methods: We retrospectively studied a total of 11 cases of neonatal renal vein thrombosis; the mean age of patients at diagnosis was 3 days. We analyzed the type of presentation, the clinical manifestations, and the findings at B-mode and Doppler ultrasonography, as well as the treatment undertaken and the long-term sequelae. Results: At the time of diagnosis, the triad of a palpable mass, unequivocal hematuria, and thrombocytopenia was present in only 63.63% of patients. Results: A prothrombotic risk factor was identified in the newborn or mother in 45.45% of cases. At ultrasonographic examination, all newborns had enlarged kidneys and in all cases it was impossible to differentiate between the renal cortex and the renal medulla. In 4 of the 11 cases, hyperechogenic intramedullary linear images characteristic of the initial stage of thrombosis were identified. Functional follow-up studies using DMSA (dimercaptosuccinic acid) and MAG-3 (mercaptoacetyl triglycine acid) revealed morphological abnormalities in all patients; 7 patients had a nonfunctioning kidney. Conclusions: Visualizing echogenic bands within the medulla should alert radiologists to the initial phase of renal vein thrombosis and enable the appropriate treatment to be administered. With the exception of cases discovered before birth, renal vein thrombosis has a poor prognosis, with atrophy and renal failure in the long term (AU)

Parálisis diafragmática en el postoperatorio de cirugía cardiaca infantil / Diaphragmatic paralysis after pediatric cardiac surgery

Objetivo: Describir la frecuencia, morbimortalidad y tratamiento de la disfunción diafragmática (DD) en el postoperatorio de la cirugía cardiaca infantil. Pacientes y métodos: Serie de casos de DD identificados entre la población de niños intervenidos de cirugía cardiaca en el hospital «12 de Octubre» de Madrid, entre 1997 y 2006. Se obtuvieron retrospectivamente datos demográficos, de la cirugía y del postoperatorio, así como de la estancia hospitalaria yde la morbimortalidad. Resultados: Cirugía cardiaca en 1.063 niños, diagnosticándose 23 casos de DD. Se excluyó un caso secundario a neuropatía generalizada. La frecuencia global fue del 2,1%. La mediana de edad fue de 14 días (1 día-16 meses), siendo 20 de los casos menores de 1 año. Se realizó plicatura en 13 pacientes (62%). Las indicaciones de plicatura fueron: fracaso de extubación (n= 11) y dificultad respiratoria persistente (n= 2).Fue preciso realizar plicatura quirúrgica en 9 de los 13 neonatos. El tiempo de ventilación mecánica invasiva, estancia en unidad de cuidados intensivos pediátricos (UCIP) y estancia hospitalaria en los casos con paresia fue de 8, 12 y 20 días(mediana), respectivamente. Las parálisis precisaron mayor tiempo de ventilación invasiva y de ingreso (19, 34 y 47,5 días). Conclusiones: A todo neonato intervenido de una cardiopatía compleja debería realizársele una ecografía diafragmática en respiración espontánea previa a su extubación, para así establecer el diagnóstico de manera precoz, con el objetivo de reducir el tiempo de ventilación mecánica y la morbilidad asociada (AU)

The objective of this study is to describe the frequency, morbimortality and treatment of diaphragmatic dysfunction (DD) after pediatric cardiac surgery. Patients and methods: Series of DD cases identified among the population of children who underwent cardiac surgery at the hospital 12 de Octubre of Madrid from the years 1997-2006. Demographic, surgical and postsurgical data have been obtained retrospectively, as well as data on hospital stay and the morbimortality. Results: A total of 1,063 children underwent cardiac surgery, diagnosing 23 DD cases. A secondary case was excluded due to generalized neuropathy. The global frequency was of 2.1%,the mean age was 14 days (1 d-16 m), being 20 of the cases under 1 year of age. Reefing was performed in 13 patients (62%). The indications for reefing were due to extubation failure (n= 11) and persistent respiratory difficulties (n= 2).Surgical reefing had to be performed in 9 from the 13 newborns. In the cases of paresis the length of the invasive mechanical ventilation, stay at the PICU and hospital stay was 8,12 and 20 days (mean) respectively. The paralysis required alonger time of invasive ventilation and hospitalization (19, 34 and 47,5 days).Conclusions: A diaphragm echography in spontaneous breathing should be performed on any newborn that underwent a complex cardiopathy surgery previous to the extubation in order to determine an early diagnosis and to reduce the length of mechanical ventilation and associated morbidity (AU)

[Neonatal renal vein thrombosis: early diagnosis using Doppler ultrasonography and long-term sequelae]. / Trombosis venosa renal neonatal: diagnóstico precoz con ecografía Doppler y secuelas a largo plazo.

OBJECTIVE: To describe the physiopathological mechanisms in perinatal renal vein thrombosis and the associated risk factors, with emphasis on the clinical and radiological characteristics and on the long-term evolution. MATERIAL AND METHODS: We retrospectively studied a total of 11 cases of neonatal renal vein thrombosis; the mean age of patients at diagnosis was 3 days. We analyzed the type of presentation, the clinical manifestations, and the findings at B-mode and Doppler ultrasonography, as well as the treatment undertaken and the long-term sequelae. RESULTS: At the time of diagnosis, the triad of a palpable mass, unequivocal hematuria, and thrombocytopenia was present in only 63.63% of patients. A prothrombotic risk factor was identified in the newborn or mother in 45.45% of cases. At ultrasonographic examination, all newborns had enlarged kidneys and in all cases it was impossible to differentiate between the renal cortex and the renal medulla. In 4 of the 11 cases, hyperechogenic intramedullary linear images characteristic of the initial stage of thrombosis were identified. Functional follow-up studies using DMSA (dimercaptosuccinic acid) and MAG-3 (mercaptoacetyltriglycine acid) revealed morphological abnormalities in all patients; 7 patients had a nonfunctioning kidney. CONCLUSIONS: Visualizing echogenic bands within the medulla should alert radiologists to the initial phase of renal vein thrombosis and enable the appropriate treatment to be administered. With the exception of cases discovered before birth, renal vein thrombosis has a poor prognosis, with atrophy and renal failure in the long term.