Akshay Kumar Saxena

An alternate method of classifying allergic bronchopulmonary aspergillosis based on high-attenuation mucus.

Background and Aim Allergic bronchopulmonary aspergillosis (ABPA) is classified radiologically based on the findings of central bronchiectasis (CB) and other radiologic features (ORF). However, the long-term clinical significance of these classifications remains unknown. We hypothesized that the immunological activity and outcomes of ABPA could be predicted on HRCT chest finding of high-attenuation mucus (HAM), a marker of inflammatory activity. In this study, we evaluate the severity and clinical outcomes of ABPA with different radiological classifications. Methods Patients were classified based on CT chest findings as: (a) serologic ABPA (ABPA-S) and ABPA-CB; (b) ABPA-S, ABPA-CB, and ABPA-CB-ORF; and, (c) ABPA-S, ABPA-CB and ABPA-CB-HAM. The clinical, spirometric and serological (total and A fumigatus specific IgE levels, eosinophil count) severity of the disease and clinical outcomes in various classifications were analyzed. Results Of the 234 (123 males, 111 females; mean age, 34.1 years) patients, 55 (23.5%) had normal HRCT, 179 (76.5%) had CB, 49 (20.9%) had HAM, and 27 (11.5%) had ORF. All immunological markers were consistently higher in the HAM classification, while in other classifications these findings were inconsistent. On multivariate analysis, the factors predicting frequent relapses were presence of HAM (OR 7.38; 95% CI, 3.21–17.0) and CB (OR 3.93; 95% CI, 1.63–9.48) after adjusting for ORF. Conclusions The classification scheme based on HAM most consistently predicts immunological severity in ABPA. Central bronchiectasis and HAM are independent predictors of recurrent relapses in ABPA. Hence, HAM should be employed in the radiological classification of ABPA.

Clinical significance of decline in serum IgE levels in allergic bronchopulmonary aspergillosis

BACKGROUND AND AIMS The total serum IgE level is a marker of immunological activity in allergic bronchopulmonary aspergillosis (ABPA), and a 35% decline beyond six weeks is traditionally taken as criteria for remission. The aim of this study was to evaluate the magnitude and clinical significance of decline in serum IgE levels at six weeks in patients with ABPA. METHODS All consecutive patients with ABPA presenting to the Chest Clinic were followed up with clinical evaluation, total IgE levels and chest x-ray every six weeks for three months. We analyzed the percentage decline in IgE levels and correlated it with clinical outcomes of relapse and complete remission. RESULTS Of the 242 asthmatics, 54 were diagnosed with ABPA (29 males, 25 females; mean age-34 years). There was clinical and radiological improvement at six weeks in all patients receiving glucocorticoid therapy. The IgE levels fell by a mean of 38.8%, and the decline was significantly higher in patients with baseline IgE levels >2500IU/mL than with levels <or=2500IU/mL (44% vs. 26%). Twenty-two patients did not attain a 35% decline in IgE levels, and this number was significantly higher in patients with IgE levels <2500IU/mL. On multivariate analysis, the decline in IgE levels at six weeks did not predict clinical outcomes. CONCLUSIONS A 35% decline in serum IgE levels at six weeks is not seen in all patients with ABPA, and the decline is slower in patients with baseline IgE levels <2500IU/mL. The quantum decline in serum IgE levels does not predict clinical outcomes.

Role of tissue harmonic imaging in focal hepatic lesions: comparison with conventional sonography.

Background: The purpose of the present study was to compare iissue harmonic imaging (THI) and conventional sonography in focal hepatic lesions.

Utility of multidetector CT and virtual bronchoscopy in tracheobronchial obstruction in children

Purpose:  The aim of this study was to evaluate the potential use of multidetector CT (MDCT) and virtual bronchoscopy (VB) in the evaluation of tracheobronchial patency in children with suspected bronchial obstruction and to compare its findings with fibreoptic/rigid bronchoscopy or surgery.

Rapid lung MRI in children with pulmonary infections: Time to change our diagnostic algorithms

To determine the diagnostic utility of a new rapid MRI protocol, as compared with computed tomography (CT) for the detection of various pulmonary and mediastinal abnormalities in children with suspected pulmonary infections.

Rapid lung MRI - paradigm shift in evaluation of febrile neutropenia in children with leukemia: a pilot study

Immunocompromised children with hematological malignancies are at increased risk of developing potentially fatal pulmonary infections. Early detection and prompt treatment is critical to combat morbidity and mortality in these children. Twenty-six children with leukemia (age range: 5–13years) presenting with fever and neutropenia were included in this prospective study, which was approved by the institutional ethics committee. All patients underwent HRCT and MRI of the chest on the same day. The findings of HRCT and MRI were compared, with HRCT as the standard of reference. There was perfect agreement between MRI and CT examinations findings by kappa test (κ = 1). No significant difference was observed between the two modalities by the McNemar test (p > 0.05). Rapid lung MRI is technically feasible; has a high correlation, sensitivity and specificity to CT scan; and can emerge as the first line modality for the detection of pulmonary nodules in children with leukemia and persistent febrile neutropenia.

CT virtual bronchoscopy: New non invasive tool in pediatric patients with foreign body aspiration

A 2-year-old girl presented with recurrent cough, wheese and breathing difficulty. Her imaging (CT and virtual bronchoscopy) revealed a foreign body in tracheobronchial tree, that was removed by rigid bronchoscopy.

Triangular Cord Sign in Biliary Atresia: Does It Have Prognostic and Medicolegal Significance?

Editor: We read with interest the article by Lee and colleagues (1) in the December 2011 issue of Radiology regarding the efficacy of ultrasonography (US)–guided percutaneous cholecystocholangiography for the early diagnosis and characterization of biliary atresia. We believe that the case illustrated in figure 3 of their article has additional importance. Although the triangular cord sign has been a highly specific US finding of extrahepatic biliary atresia (EHBA), its sensitivity has shown large variations in different studies (2). A recent study evaluated US findings in infants younger than 90 days old with conjugated hyperbilirubinemia (2). The authors reported a sensitivity of only 23.3% for the triangular cord sign in the diagnosis of biliary atresia. They suggested that one of the reasons for low sensitivity could be the young age of the patients “if the tissue interfaces responsible for producing the triangular cord sign evolve with the age of patients” and noted that “in the absence of data on serial sonographic findings in infants with EHBA, the exact impact of screening at a younger age cannot be predicted.” It is in this context that it is interesting to note that the patient illustrated in figure 3 of the article by Lee and colleagues was 22 days old at the time of initial US examination and developed a triangular cord sign at the follow-up examination performed 2 weeks later. The development of the triangular cord sign at a subsequent examination has possible clinical as well as medicolegal significance. Because the triangular cord sign is due to the presence of fibrosis (3), it is possible that patients with biliary atresia who have a positive triangular cord sign at abdominal US may have a poorer prognosis than those in whom the triangular cord sign is absent. Radiologists and clinicians screening babies at an earlier age should remain alert to the diagnosis of biliary atresia, even if the triangular cord sign is absent, and use percutaneous transhepatic cholecystography for early diagnosis. From a medicolegal viewpoint, absence of the triangular cord sign at US performed at a younger age should not be considered an error on the part of the radiologist; that is, if a radiologist performs a US examination in a young baby suspected of having EHBA and reports the triangular cord sign to be absent, the presence of the triangular cord sign at an examination performed after a few weeks to months should not lead to the conclusion that the triangular cord sign, and therefore the diagnosis of EHBA, was “missed” at the initial examination.

Efficacy of two oral premedicants: midazolam or a low‐dose combination of midazolam–ketamine for reducing stress during intravenous cannulation in children undergoing CT imaging

Background:  Pain, anxiety and fear of needles make intravenous cannulation extremely difficult in children. We assessed the efficacy and safety of oral midazolam and a low‐dose combination of midazolam and ketamine to reduce the stress and anxiety during intravenous cannulation in children undergoing computed tomography (CT) imaging when compared to placebo.

Role of shunts with antisiphon device in treatment of pediatric hydrocephalus.

OBJECTIVE The use of ventriculo-peritoneal shunts having antisiphon device has been reported in adult patients, but there is a dearth of experience with such shunts in pediatric age group. This study is being undertaken to compare the effectiveness of these types of shunt for the treatment of congenital hydrocephalus. PATIENTS AND METHODS Forty patients with congenital hydrocephalus with or without neural tube were divided randomly into two groups (A and B). Patients in antisiphon group were treated with shunts with differential valve including antisiphon device (Vygon shunt) while patients in non-antisiphon group were treated with differential valve shunts (Chhabra shunt and Ceredrain). Mann-Whitney test, asymmetric t-test and Chi-square test were used to assess the correlation and the significance. RESULTS The mean age was 3.5 months and 3.4 months in antisiphon group and non-antisiphon group, respectively. The M:F ratio was 2.3:1 in antisiphon group while it was 3:1 in non-antisiphon group. The mean decrease in OFC was more in non-antisiphon group than antisiphon group during the follow up from 3 months to 6 months while mean decrease in MEI was more in non-antisiphon group from 0 month to 3 months than antisiphon group. There were two cases of shunt overdrainage in non-antisiphon group. The shunt blockage rate was 20% in antisiphon group and 15% in non-antisiphon group, respectively. There was 20% and 15% shunt infection rate in antisiphon group and non-antisiphon group, respectively. This study demonstrated overdrainage syndrome in two of the patients of differential valve shunts. CONCLUSION Though rare, complication associated with overdrainage is certainly a problem in children. In our study, the patients who received shunts with antisiphon device do not show any overdrainage.