Colovesical fistula resulting from a perforated colonic duplication.

Colovesical fistulas in children are most often associated with high anorectal imperforations. Acquired enterovesical fistulas in children only rarely have been reported as a consequence of an inflammatory process. We present a case of an acquired colovesical fistula formed by the erosion of an abscess at the distal end of a colonic duplication in a child who presented with fever of unknown origin.

Postoperative neurologic complications after open heart surgery on young infants.

OBJECTIVE: To ascertain the relation between postoperative neurologic complications and variables occurring before, during, and after hypothermic cardiopulmonary bypass surgery to correct congenital heart disease in young infants. DESIGN: Prospective analysis of mortality and neurologic morbidity before hospital discharge; systematic comparison with patient characteristics, metabolic status, surgery variables; and preoperative neurologic findings of the patients. SETTING: Intensive care unit in tertiary care center. PATIENTS: Consecutive sample of 91 full-term infants who underwent 100 operations between January 1989 through December 1992. Nine infants had more than one operation during the study period. MAIN OUTCOME MEASURES: Levels of alertness, tone, focal signs, dyskinesia, pyramidal signs, seizures, and death. RESULTS: Reduced level of alertness at discharge from the hospital in 19% of patients; seizures in 15% (70% focal); severe hypotonia in 11% before surgery, and in 7% at discharge from hospital; generalized pyramidal findings in six (7%); asymmetry of tone in 5%; and chorea that did not persist in 11%. Results of cranial ultrasound tests were abnormal in 20% of patients. Of these those with abnormal cranial ultrasound examinations 55% were abnormal before surgery. Overall mortality was 18%. Of the patients who died, 59% had interrupted aortic arch or hypoplastic left heart syndrome. Mortality for patients with these lesions was 40%. Alertness (P = .005), chorea (P = .03), and hypotonia (P = .02) were associated with duration of deep hypothermia longer than 60 minutes. No association was found among other outcomes and study variables, except the relation between severe left-sided heart lesions and mortality. CONCLUSIONS: Mortality and neurologic morbidity after open heart surgery on young infants may be due to several factors, including type of lesion, preexisting brain abnormalities, duration of deep hypothermia, and strokes.

Nodules, masses, and pseudomasses in the pediatric lung.

The vast majority of pulmonary masses in children are nonmalignant. Most pediatric nodular disease is granulomatous in origin. Infections and congenital lesions outnumber neoplastic lesions. Pulmonary metastatic disease most often results from Wilms' tumor and is followed in frequency by the sarcomas. Primary pulmonary malignancy is rare in the child.

Ewing's sarcoma.

Ewing's sarcoma is a highly malignant tumor of uncertain origin. A strong relationship is suggested between Ewing's sarcoma and tumors of neural origin. The radiologic manifestation of Ewing's sarcoma are protean and lesions may be lytic, mixed lytic-sclerotic, or rarely, predominantly sclerotic. The lower extremity long bones are predominantly affected and most lesions are diaphyseal or metadiaphyseal. CT and particularly MR imaging are invaluable in further delineating the extent of disease not readily manifested on plain radiographs. Gallium scintigraphy and gadolinium-enhanced MR images are best for following the response to therapy. Ewing's sarcoma must be distinguished from other round cell tumors including lymphoma, neuroblastoma, and primitive neuroectodermal tumor of bone as well as from osteosarcoma.

Radiation dose from DXA scanning to reproductive tissues of females.

The objective of this study was to use an anatomically arrayed whole-body phantom to measure radiation exposure to the ovaries and uterus during standard dual-energy Xray absorptiometry (DXA) scanning. DXA instrument manufacturers' published entrance skin exposure is about 3 mR (0.77 microC/kg), which is equivalent to the radiation exposure received during a transcontinental plane trip. Nonetheless, since DXA scanning is used more frequently with very young females, the need for pregnancy testing has become an issue that requires attention and formulation of research guidelines. We attached thermoluminescent dosimeters (TLDs) to anatomically arrayed balloon models for ovaries and the uterus, and placed these in the appropriate sites within a small human skeleton along with appropriate amounts of aqueous and fat soft tissue equivalents. Whole-body scanning with a Hologic QDR-2000W was performed 10 times with the pencil beam mode and, using separate TLD detectors, 10 times with the fan beam mode. Overall, the average exposures at skin entrance were 0.89 mR (0.23 microC/kg) with doses for the ovaries of 0.52 mrad (5.2 microgy) and 0.59 mrad (5.9 microgy) for the uterus. These doses are equivalent to 2 d of ambient background radiation in central Pennsylvania or 1 h of flying at 39,000 ft. Although different DXA models by Hologic and DXA instruments by other manufacturers will have different radiation outputs, we believe that these low radiation levels do not require pregnancy testing or questioning of whether the scan subject might be pregnant.

The newer radiographic contrast media.

The 1980s witnessed the development of many new contrast agents useful in radiographic and MRI to enhance the contrast discrimination between tissues and improve lesion conspicuity. In addition to improved efficacy, these agents are generally safer and cause less patient discomfort than older radiographic contrast media. The injection of any foreign material into the body always holds some risk, however, and it is the responsibility of clinicians and radiologists jointly to use these agents judiciously in the best interest of the patient.

Radiographic observations of subtalar joint effusion in two children.

Recognition of the combination of retromalleolar swelling and talocalcaneal distraction seen on well positioned lateral radiographs of the ankle suggests the presence of subtalar joint distention, either in association with ankle joint abnormality or as an isolated finding.

Color Doppler sonography in pyelonephritis.

Renal sonography detects abnormality in only 40% of pediatric pyelonephritis. In eight patients shown to have acute pyelonephritis by 99mTc DMSA renal cortical scintigraphy, five were found to have focal abnormalities of renal perfusion by color Doppler sonography in the same sites as the scintigraphic defects (sensitivity-63%). Two of the five patients had normal plain sonograms. False positive studies occurred in patients with documented chronic renal scarring. The specificity of vascular asymmetry was 70%. This preliminary report suggests that, particularly in the patient without pre-existing renal scarring, color Doppler evaluation of the renal vasculature may increase the sensitivity of sonography in the diagnosis of pyelonephritis in children.

Sonographic evaluation of superior mesenteric vascular relationship in malrotation.

We report sonographic demonstration of abnormal and characteristic superior mesenteric vascular anatomy in three cases of surgically proved intestinal malrotation. Sonographic screening examinations of children with abdominal pain should include an evaluation of the superior mesenteric vessels.

Lap-belt injuries of the lumbar spine in children: a pitfall in CT diagnosis.

A retrospective review of 365 consecutive CT studies in children assessed for intraabdominal trauma yielded five children in whom lap-belt-associated injuries of the lumbar spine were missed on CT. Facet subluxation and anterior dislocation of the third lumbar vertebra were present in four patients and multiple compression fractures were present in one. Clinical presentations included acute abdominal symptoms; two had acute back pain, and three experienced delayed onset of back pain. Although the injuries to the spine were visible retrospectively on anteroposterior radiographs, the findings were subtle and their extent was best appreciated on lateral lumbar spine views. Five of 365 patients with blunt abdominal trauma were identified as having sustained midlumbar spinal injury that was clearly visible only on a lateral radiograph of the spine.

Neonatal pneumatosis cystoides intestinalis caused by volvulus of the mid intestine.

A case of malrotation of the mid intestine with volvulus is reported in an infant in whom the clinical and radiological appearances were unusual, and had led to a misdiagnosis of necrotising enterocolitis. If the correct diagnosis had been made earlier, operation might have saved the infant's life.

Vascular ring due to right aortic arch with mirror-image branching and left ligamentum arteriosus: complete preoperative diagnosis by magnetic resonance imaging.

Magnetic resonance imaging (MRI) has been increasingly employed in the evaluation of aortic arch abnormalities. We present a rare form of vascular ring, that of a right aortic arch with mirror-image branching and left ligamentum arteriosus, which was clearly defined preoperatively by MRI. The patient subsequently underwent successful surgical division of the vascular ring followed by improvement in respiratory symptoms.

Diagnosis of acute pyelonephritis in children: comparison of sonography and 99mTc-DMSA scintigraphy.

Ninety-one children 1 week to 10 years old with culture-documented febrile urinary tract infection were evaluated with renal sonography and renal cortical scintigraphy by using 99mTc-labeled dimercaptosuccinic acid (DMSA). On the basis of previous experimental studies, DMSA scintigraphy was used as the standard of reference for the diagnosis of acute pyelonephritis. The DMSA scans showed changes consistent with acute pyelonephritis in 63% (57/91) of the patients. Sonograms showed changes consistent with acute pyelonephritis in 24% (22/91) of the whole group and in only 39% (22/57) of the patients with scintigraphically documented acute pyelonephritis. Pertinent sonographic findings were areas of increased cortical echogenicity in 14 patients and decreased echogenicity in eight, including three patients with renal abscesses. Dilatation of the renal collecting system was noted in nine patients and renal enlargement was noted in three. We conclude that renal sonography is a relatively insensitive test for the detection of acute inflammatory changes of renal cortex. Therefore, it should not be used as the primary imaging technique for the diagnosis of acute pyelonephritis. However, sonography is a useful technique in evaluating the nature of the defects seen on the DMSA scan and in detecting obstructive uropathies that may be associated with urinary tract infections.

Recognition of malposition of the liver and spleen: CT, MRI, nuclear scan and fluoroscopic imaging.

Thirteen children initially suspected to have an intrathoracic or intraabdominal mass had malposition of the liver and/or spleen discovered by ultrasound. This group consisted of five children with diaphragmatic eventration or hernia and eight with wandering spleen or liver. Careful ultrasonographic examinations were diagnostic in all patients; seven had surgical confirmation. CT, MRI, nuclear scan and fluoroscopic imaging were useful in select instances. The liver and spleen have a characteristic anatomic configuration and sonographic appearance that should enable them to be recognized, and pathological alterations appreciated, even when these organs are ectopic in location or malformed.

Juvenile xanthogranuloma: non-X histiocytosis with systemic involvement.

Two patients with different patterns of soft tissue and bone involvement demonstrate the variability of extracutaneous manifestations of juvenile xanthogranuloma, a non-X histiocytosis, better known to dermatologists than to radiologists.

Three-dimensional quantitation of pediatric tumor bulk.

In pediatric oncology, therapeutic decisions are made based on tumor response to chemotherapeutic agents. Sequential measurement of tumor bulk and its percent change on therapy must be accurately assessed. Will 3-dimensional (3-D) volumetric determination improve our ability to assess tumor response to therapy? Forty-five CT scans of pediatric patients with unresectable thoracic or abdominal neoplasia were assessed for tumor bulk by the standard "2-dimensional (2-D)" volume formula (cross-sectional area x length) and by 3-D volumetric analysis. Thirty-two examinations were performed in follow-up, and percent change in tumor size was calculated. The 2-D volume calculation overestimated tumor volume by more than 50% on all but two examinations when the 2-D volume was compared with the 3-D volume. In 28% of follow-up examinations, the 2-D calculation of percent change differed by more than 10% from the 3-D volume. Fifteen percent differed by over 25%. This changed the response category of one patient from "no response" to "partial response". 3-D volumetric analysis, easily performed by a trained technologist, will give more accurate assessment of the actual tumor bulk and its subsequent changes in size in response to therapy.

Delayed diagnosis of esophageal perforation by aluminum foreign bodies.

Two pediatric patients presented with long-term respiratory or gastrointestinal complaints after swallowing aluminum poptops. The delay in diagnosis was due in part to poor appreciation of the relative radiolucency of aluminum.