A Diagnostic Dilemma: Similarity of Neuroradiological Findings in Central Nervous System Hemophagocytic Lymphohistiocytosis and Aspergillosis.

Central nervous system (CNS) involvement in the context of hemophagocytic lymphohistiocytosis (HLH) is not uncommon. Given the immunosuppressive nature of HLH therapy, infectious complications are also seen. We describe a 9-year-old male who developed acute neurological decline secondary to aspergillosis while undergoing HLH therapy. The significant overlap observed in CNS neuroimaging of HLH and aspergillosis and the subtleties that may help differentiate the two are discussed. The importance of obtaining tissue for definitive diagnosis is underscored.

Pediatric thoracic spine injuries: a single-institution experience.

OBJECTIVE: The objective of our study was to determine the incidence of various fractures of the thoracic spine in pediatric patients. CONCLUSION: Simple compression and process-only fractures were the most common types of fractures and all other fracture types were infrequent. Distraction injury was unexpectedly more common in the nonjunctional thoracic spine than in the junctional thoracic spine.

Association of Abnormal Findings on Neonatal Cranial Ultrasound With Neurobehavior at Neonatal Intensive Care Unit Discharge in Infants Born Before 30 Weeks' Gestation.

Importance: Cranial ultrasound (CUS) findings are routinely used to identify preterm infants at risk for impaired neurodevelopment, and neurobehavioral examinations provide information about early brain function. The associations of abnormal findings on early and late CUS with neurobehavior at neonatal intensive care unit (NICU) discharge have not been reported. Objective: To examine the associations between early and late CUS findings and infant neurobehavior at NICU discharge. Design, Setting, and Participants: This prospective cohort study included infants enrolled in the Neonatal Neurobehavior and Outcomes in Very Preterm Infants Study between April 2014 and June 2016. Infants born before 30 weeks' gestational age were included. Exclusion criteria were maternal age younger than 18 years, maternal cognitive impairment, maternal inability to read or speak English or Spanish, maternal death, and major congenital anomalies. Overall, 704 infants were enrolled. The study was conducted at 9 university-affiliated NICUs in Providence, Rhode Island; Grand Rapids, Michigan; Kansas City, Missouri; Honolulu, Hawaii; Winston-Salem, North Carolina; and Torrance and Long Beach, California. Data were analyzed from September 2019 to September 2021. Exposures: Early CUS was performed at 3 to 14 days after birth and late CUS at 36 weeks' postmenstrual age or NICU discharge. Abnormal findings were identified by consensus of standardized radiologists' readings. Main Outcomes and Measures: Neurobehavioral examination was performed using the NICU Network Neurobehavioral Scale (NNNS). Results: Among the 704 infants enrolled, 675 had both CUS and NNNS data (135 [20.0%] Black; 368 [54.5%] minority race or ethnicity; 339 [50.2%] White; 376 [55.7%] male; mean [SD] postmenstrual age, 27.0 [1.9] weeks). After covariate adjustment, lower attention (adjusted mean difference, -0.346; 95% CI, -0.609 to -0.083), hypotonicity (mean difference, 0.358; 95% CI, 0.055 to 0.662), and poorer quality of movement (mean difference, -0.344; 95% CI, -0.572 to -0.116) were observed in infants with white matter damage (WMD). Lower attention (mean difference, -0.233; 95% CI, -0.423 to -0.044) and hypotonicity (mean difference, 0.240; 95% CI, 0.014 to 0.465) were observed in infants with early CUS lesions. Conclusions and Relevance: In this cohort study of preterm infants, certain early CUS lesions were associated with hypotonicity and lower attention around term-equivalent age. WMD was associated with poor attention, hypotonicity, and poor quality of movement. Infants with these CUS lesions might benefit from targeted interventions to improve neurobehavioral outcomes during their NICU hospitalization.

Pediatric lateral atlantodental interval: how much asymmetry is normal?

Imaging of the cervical spine is commonly performed in the pediatric patient population, typically after trauma, as well as for a variety of nontraumatic reasons. There are many challenges in the interpretation of these studies, particularly at the level of the atlantoaxial joint. We recognized a particular problem with assessing the lateral atlantodental interval in our emergency radiology department. Mild lateral atlantodental interval asymmetry in relatively asymptomatic patients was being interpreted as indicative of atlantoaxial rotatory fixation, which leads to the recommendation for dynamic computed tomographic examinations. The goal of this study was to define the reference range of the lateral atlantodental interval in pediatric patients to help avoid misinterpretation of radiographic findings and resultant excessive imaging.

Relationship between the clinical characteristics of osteomyelitis and the finding of extraosseous fat on MRI in pediatric patients.

BACKGROUND: MRI is frequently utilized to evaluate patients for osteomyelitis. The findings of intramedullary and extramedullary fat globules as well as extramedullary fat-fluid levels can help improve the specificity of MRI for this diagnosis. OBJECTIVE: To correlate these MRI findings with the clinical characteristics in children with osteomyelitis. MATERIALS AND METHODS: A retrospective electronic medical record search for pediatric patient charts from March 2004 to November 2009 that contained the word "osteomyelitis" in the "principal diagnosis" portion of the international classification of disease (ICD) billing code. Each electronic chart was reviewed. MRI examinations of selected children were reviewed by a pediatric radiologist, a general radiologist and a transitional year resident. RESULTS: A total of 10 patients/11 MRI studies were included. Five of the 11 had the MRI finding of extramedullary globular fat signal. There was a significantly increased likelihood of seeing this finding in children of pubertal or postpubertal age compared to those of prepubertal age (p < 0.05). CONCLUSION: This study provides evidence that the MRI finding of extramedullary fat globules in children with acute osteomyelitis is associated with the clinical characteristic of being within or above the age range for puberty.

Sonographic features of neonatal mastitis and breast abscess.

BACKGROUND: Neonatal mastitis and neonatal breast abscess are uncommon. Although well described in the pediatric and surgical literature, there is a paucity of reports describing their sonographic features. OBJECTIVE: To describe and illustrate the sonographic features of neonatal mastitis and neonatal breast abscess. MATERIALS AND METHODS: We reviewed the medical database of a large children's health-care center from 2000 through 2008 for patients presenting in the first 8 weeks of life with mastitis. The findings were correlated with clinical presentation and course, laboratory findings and clinical outcome. RESULTS: Four neonates (three girls and one boy) presented with mastitis. They all had prominent breast buds on the affected side with poorly defined margins, slightly more echogenic focally or diffusely compared to normal with hyperemia on color flow Doppler US. The surrounding subcutaneous tissue was thick and echogenic. Two abscesses presented as avascular areas without color flow on Doppler US, subtly increased through-transmission and surrounding hyperemia. One abscess was of increased echogenicity while the other was anechoic. CONCLUSION: Neonatal mastitis and breast abscess are unusual diseases that should be appropriately treated with antibiotics and drainage to avoid generalized sepsis, breast hypoplasia, and scarring. US is useful in distinguishing mastitis from breast abscess and guiding treatment options.

The incidence of PICC line-associated thrombosis with and without the use of prophylactic anticoagulants.

BACKGROUND: Indications for peripherally inserted central catheters (PICC) for long-term venous access have grown during the last several years. There are various complications associated with PICC lines, a common one being venous thrombosis. This study's purpose was to determine the incidence of venous thrombosis associated with PICCs with and without prophylactic anticoagulants. METHODS: In this observational, prospective, cohort study, patients with PICC lines were evaluated using Doppler ultrasound for the presence of PICC-associated venous thrombosis at 5-7 days and again at 12-14 days after line placement. When present, clinical signs and symptoms of thrombosis were documented. Fifty-six patients were evaluated for the type of anticoagulation used, if any, and other clinical parameters such as smoking, ambulation, and previous surgery. The incidence of thrombus was then calculated for the entire population as well as for specific patient subgroups. RESULTS: Patient age was 55.7 +/- 2.6 (mean +/- SEM) years, and BMI was 28.2 +/- 1.2 (n = 56). There were 38 (67.9%) nonambulatory subjects, 15 (26.8%) smokers, 4 (7.1%) coagulopathic subjects, 2 (3.6%) patients receiving estrogen-containing medications, 25 (44.6%) who had undergone surgery within the past 6 months, and 5 (8.9%) cancer patients. There were 21/56 patients (37.5%) with thrombus. Patients who received anticoagulation had a 22.9% (8/35) incidence of thrombosis, which was significantly less (P < .05) than for those who received no anticoagulant (13/21, 61.9%). CONCLUSION: The use of anticoagulants for prophylaxis in patients with a PICC line was associated with a decreased rate of associated venous thrombosis.

Dysplasia epiphysealis hemimelica (Trevor disease) of the ankle.

An 11-year-old boy presented with a 2-year history of left ankle pain and abnormal gait, worsened with sports activities such as football and wrestling.

Atypical neurologic presentations of new onset type 1 diabetes mellitus in pediatric age group: a report of five unusual cases and review of the literature.

Type 1 diabetes mellitus (T1DM) is one of the most common chronic diseases in childhood and is caused by insulin deficiency resulting from the autoimmune destruction of insulin producing beta cells of the pancreas. Most children in the US with new onset T1DM present with the classic signs and symptoms of hyperglycemia and 30% with diabetic ketoacidosis (DKA). Neurologic manifestations are relatively rare and mostly include lethargy, decreased level of consciousness, and coma as a result of DKA. In this article, five cases of new onset T1DM with exceedingly rare or unreported neurologic manifestations in the pediatric age group are presented, along with a review of the literature.

Use of a dedicated pediatric CT imaging service associated with decreased patient radiation dose.

PURPOSE: The growing use of CT as a diagnostic imaging tool has led to increased concern over radiation dose, particularly in pediatric patients. The ALARA concept has been popularized in dose reduction. ALARA supports the use of low-dose, pediatric-specific protocols. Strict adherence to low-dose protocols can be challenging, particularly in a high-volume radiology department that scans both pediatric and adult patients. The aim of this study was to determine whether the relocation of pediatric radiologic services from a combined high-volume pediatric and adult hospital to a children's hospital improves compliance with adjusted lower CT exposure parameters and thus the estimated effective dose of radiation delivered to pediatric patients. METHODS: A retrospective review of abdominal and pelvic CT console dose and exposure parameter data on 495 patients from a combined pediatric and adult radiology department and subsequently 244 patients from a dedicated pediatric radiology department was performed. The console dose-length product was converted to estimated effective dose. Patients were divided into 1 of 8 weight categories for analysis. RESULTS: A statistically significant decrease in the estimated effective dose for abdominal and pelvic CT studies was observed in all but one of the weight categories at the pediatric radiology department compared with the pediatric and adult radiology department. CONCLUSIONS: Imaging pediatric patients in a dedicated pediatric imaging department with dedicated pediatric CT technologists may result in greater compliance with pediatric protocols and significantly reduced patient dose. Conversely, greater scrutiny of compliance with pediatric dose-adjusted CT protocols may be necessary for departments that scan both children and adults.