Anmol Bhatia

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.

Pancreatic volvulus with wandering spleen and gastric volvulus: An unusual triad for acute abdomen in a surgical emergency

Wandering spleen is a rare clinical condition which occurs due to laxity or absence of the normal intraperitoneal ligaments that hold the spleen in place. Gastric volvulus and wandering spleen share a common etiology of absence or laxity of intraperitoneal ligaments. The occurrence of simultaneous pancreatic volvulus has never been described before in adolescence. Herein, we report a case having wandering spleen with torsion, and gastric and distal pancreatic volvulus, an unusual triad in acute abdomen in an emergency setting, which has never been described before to the best of our knowledge.

Role of Diffusion Weighted Imaging (DWI) for Hepatocellular Carcinoma (HCC) Detection and its Grading on 3T MRI: A Prospective Study

BACKGROUND Limited studies have evaluated the role of diffusion weighted imaging (DWI) and apparent diffusion coefficient (ADC) for histologically grading the hepatocellular carcinoma (HCC). OBJECTIVE To compare the efficacy of DWI with dynamic contrast enhanced magnetic resonance (DCEMR) in detection of HCC in cirrhosis, and to evaluate whether DWI can be used instead of DCEMR. METHODS 20 patients of either sex with cirrhosis and suspected of having HCC on screening USG were included in this prospective study approved by the Institutional Ethics Committee. All patients underwent DCEMR of the abdomen on 3T scanner and fine needle aspiration of the lesions. MR protocol included T1WI, T2WI, DWI, and dynamic CEMR. The results of diffusion weighted imaging were compared with DCEMR to find the efficacy of DWI vis-à-vis CEMR. RESULTS DWI had a sensitivity and specificity of 100%, for diagnosis of lesions in cases having single lesion on CEMR, and sensitivity of 75% and specificity of 100% for diagnosis of lesions in cases having multiple lesions. There was a decreasing trend of ADC values with increasing grade of the tumor; however, the decreasing trend was not statistically significant. A cut-off ADC value of 0.8705 resulted in a sensitivity of 75% and specificity of 50% for differentiating between well-differentiated and other grades of HCC. CONCLUSION DWI can be used as an alternative for the detection and characterization of HCC, especially in patients with impaired renal function or contrast allergies precluding the use of contrast. In addition, DWI with ADC measurement may be helpful for non-invasive and preoperative prediction of the degree of differentiation of HCC.

Visceral scalloping on abdominal computed tomography due to abdominal tuberculosis

Objective: Scalloping of visceral organs is described in pseudomyxoma peritonei, malignant ascites, among other conditions, but not tuberculosis. Methods: We report findings from a retrospective study of patients with abdominal tuberculosis who had visceral scalloping on abdominal computed tomography (CT). Diagnosis of abdominal tuberculosis was made on the basis of combination of clinical, biochemical, radiological and microbiological criteria. The clinical data, hematological and biochemical parameters, and findings of chest X-ray, CT, Mantoux test, and HIV serology were recorded. Results: Of 72 patients with abdominal tuberculosis whose CT scans were included, seven patients had visceral scalloping. The mean age of these patients was 32.14 ± 8.43 years and four were men. While six patients had scalloping of liver, one had splenic scalloping. The patients presented with abdominal pain (all), abdominal distension (five patients), loss of weight or appetite (all), and fever (four patients). Mantoux test was positive in five, while none had HIV infection. The diagnosis was based on fluid (ascitic or collections) evaluation in four patients, ileo-cecal biopsy in one patient, fine needle aspiration from omental thickening in one patient, and sputum positivity for acid fast bacilli (AFB) in one patient. On CT examination, four patients had ascites, five had collections, one had lymphadenopathy, four had peritoneal involvement, three had pleural effusion, and two had ileo-cecal thickening. All except one patient received standard ATT for 6 months or 9 months (one patient). Pigtail drainage for collections was needed for two patients. Discussion: This report is the first description of visceral scalloping of liver and spleen in patients with abdominal tuberculosis. Previously, this finding has been reported primarily with pseudomyxoma peritonei and peritoneal carcinomatosis. Conclusion: Visceral scalloping may not conclusively distinguish peritoneal tuberculosis from peritoneal carcinomatosis or pseudomyxoma peritonei.

Rapid MRI of the lungs in children with pulmonary infections.

We read with interest the review article entitled “Chest magnetic resonance imaging: a protocol suggestion” by Hochhegger et al.. The authors have reviewed the technical aspects and suggested a protocol for performing chest MRI. The authors have also described three major clinical indications for MRI of the lungs: staging of lung tumors; evaluation of pulmonary vascular diseases; and investigation of pulmonary abnormalities in patients who should not be exposed to radiation. Radiation exposure is particularly more serious in children, as they are at a greater risk of experiencing harmful effects from radiation compared to adults. In our recent prospective study in 26 children with leukemia presenting with febrile neutropenia, we evaluated role of rapid lung MRI in the detection of nodules, consolidation and ground glass opacity (GGO) in this population. The duration of all the four sequences combined in our study was less than 2 minutes. The findings of HRCT and MRI were compared, with HRCT as the standard of reference. No significant difference was observed between the two modalities by the McNemar test (p > 0.05). For the detection of nodules and consolidation by MRI, per-patient sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were all 100%. For the detection of GGO by MRI, per-patient sensitivity, specificity, PPV and NPV were 66.67%, 100%, 100% and 90.91%, respectively. The kappa test showed perfect agreement between MRI and CT scan for the detection of nodules and consolidation (κ = 1), and a substantial agreement in the detection of GGO by MRI and CT scan (κ = 0.755). The results of our study indicated that pulmonary MRI has great potential as a diagnostic modality for the detection of lung parenchymal findings in patients with febrile neutropenia. Similarly, we determined the diagnostic utility of rapid lung MRI for the detection of various pulmonary and mediastinal abnormalities in 75 children with suspected pulmonary infections. MRI demonstrated sensitivity, specificity, PPV, and NPV of 100% for detecting pulmonary consolidation, nodules (> 3 mm), cyst/ cavity, hyperinflation, pleural effusion, and lymph nodes. The kappa test showed almost perfect agreement between MRI and MDCT in detecting thoracic abnormalities (κ = 0.965). No statistically significant difference was observed between MRI and MDCT for detecting thoracic abnormalities by the McNemar test (p = 0.125). As MRI does not have any radiation risks, it can be repeated to assess disease progression or regression without exposing the patients to radiation (as against performing the CT scan). We propose rapid lung MRI may also be used as an initial radiological investigation in patients with suspected pulmonary infections especially where repeated follow up imaging is required.

Rapid lung magnetic resonance imaging in children with pulmonary infection

Dear Editor, We read with interest the original article “Magnetic resonance imaging of pulmonary infection in immunocompromised children: comparison with multidetector computed tomography” by Ozcan et al. [1]. The authors compared MRI and multidetector CT findings in pulmonary abnormalities in immunocompromised children in whom pulmonary infections are serious causes of morbidity and mortality. They evaluated pulmonary abnormalities (nodules, consolidations, ground-glass opacities, atelectasis, pleural effusion and lymph nodes) and compared the results among MRI sequences and between MRI and CT, and concluded that lung MRI is promising for detection of pulmonary abnormalities in immunocompromised children with clinically suspected pulmonary infection. Radiation exposure is of serious concern in children, as they are at a greater risk of harmful effects as compared to adults [2]. In a prospective study of 26 children with leukemia with febrile neutropenia [3], we evaluated the role of rapid lung MRI using four different pulse sequences for the detection of ground-glass opacities, nodules and consolidation. The combined duration of the four sequences in our study was less than 2 min. We evaluated this MRI protocol using highresolution CT as the standard of reference. We found no significant difference between the two modalities. Per-patient sensitivity, specificity, positive predictive value and negative predictive value were all 100% for the detection of nodules and consolidation by MRI. However, for the detection of ground-glass opacities, per-patient sensitivity, specificity, positive predictive value and negative predictive value were 67%, 100%, 100% and 91%, respectively. Perfect agreement was found between MRI and CT for the detection of nodules and consolidation, and substantial agreement was found in the detection of ground-glass opacities. The results of our study indicate that rapid lungMRI has great potential as a diagnostic modality for the detection of lung parenchymal findings in patients with febrile neutropenia, especially during follow-up. Similarly, in another study we determined the diagnostic utility of four sequence rapid lung MRI for detecting various pulmonary and mediastinal abnormalities in children with suspected pulmonary infections [4]. In this study, we found 100% sensitivity, specificity and predictive values of MRI for pulmonary consolidation, nodules (>3 mm), cyst/cavity, hyperinflation, pleural effusion and lymphadenopathy. Almost perfect agreement was found between MRI and multidetector CT in detecting thoracic abnormalities, and no statistically significant difference was seen between MRI and multidetector CT for detecting various abnormalities. Ozcan et al. [1] concluded that lung MRI is promising for detection of pulmonary abnormalities in immunocompromised children with clinically suspected pulmonary infection. We agree asMRI can be repeated to assess disease progression or regression during follow-up without exposing the children to radiation, especially in those with DNA repairing deficiency syndromes (e.g., ataxia telangiectasia, Bloom syndrome, Fanconi anemia). Hence, this rapid lung MRI protocol may be useful in this group of children. With the advancements in MR technology and emergence of new lung MR techniques, such as ultrashort echo time, accuracy of lungMRI is likely to increase further. * Anmol Bhatia anmol_bhatia26@yahoo.co.in

Sclerosing cholangitis and intracranial lymphoma in a child with classical Wiskott-Aldrich syndrome.

Patients with Wiskott–Aldrich syndrome (WAS) are predisposed to malignancy and autoimmunity in addition to infections. We report a male child with WAS, who had presented with recurrent pneumonia, eczema, thrombocytopenia, autoimmune hemolytic anemia, and vasculitic skin lesions. Genetic analysis revealed a classical genotype WAS 155C>T; R41X. At 2 years of follow‐up, he developed persistent headache and progressive hepatomegaly. Brain imaging showed a mass in the right frontal region, which on histopathology was shown to be high‐grade non‐Hodgkin lymphoma. Magnetic resonance cholangiopancreatography showed features of sclerosing cholangitis. This report extends the clinical spectrum and highlights unusual manifestations of sclerosing cholangitis and intracranial lymphoma in a patient with WAS.

Role of HRCT in detection and characterization of pulmonary abnormalities in patients with febrile neutropenia.

Background: Fever is of grave concern in the management of patients with neutropenia with early detection of a focus of infection being the major goal. As lungs are the most common focus, chest imaging is of vital importance. This Institute Review Board approved prospective study was undertaken to assess the usefulness of high resolution computed tomography (HRCT) in early detection and characterization of pulmonary abnormalities in febrile neutropenia. Materials and Methods: A total of 104 consecutive patients (M:F:75:29, age range 11–66 years) with fever of 38.2°C or more with an absolute neutrophil count <500/μl underwent HRCT chest. HRCT diagnosis was compared with final diagnosis based on ancillary investigations. Results: HRCT could detect pulmonary abnormalities in 93 patients (89.4%) with air space consolidation being the predominant finding (n = 57), followed by ground-glass opacities (Ground glass opacity (GGO), n = 49) and nodules (n = 39). HRCT could correctly characterize the infective lesions in 76 patients (81.7%). Presence of random or pleural-based nodules >10 mm with or without surrounding GGO or cavitations was sensitive (95.23%) and specific (96.7%) for fungal infection, while small (1–4 mm) random or centrilobular nodules with tree-in-bud appearance was sensitive (90%) and highly specific (97.02%) for tuberculosis. Diagnosis of pyogenic infection based on presence of air-space consolidation, pleural effusion, GGO or centrilobular nodules showed a sensitivity of 84.78% and specificity of 93.84%, whereas patchy or diffuse GGO, interstitial thickening and/or air-space consolidation showed high sensitivity (86.7%) and specificity (96.8%) for Pneumocystis jiroveci pneumonia. Conclusion: HRCT chest is an excellent modality in the diagnostic work-up of patients with febrile neutropenia allowing early detection and characterization of pulmonary abnormalities.

Intravenous contrast enhanced computed tomography colonoscopy in children with suspected colonic polyps

OBJECTIVE The purpose of this study was to evaluate the diagnostic performance of intravenous contrast enhanced computed tomographic colonoscopy (IVCTC) in the diagnosis of clinically suspected colorectal polyps in children, using conventional colonoscopy (CC) as the gold standard. METHODS This was a prospective study conducted between July 2008 and June 2010. 30 pediatric patients with history of rectal bleeding and clinically suspected to have colorectal polyps were enrolled. All of the patients underwent IVCTC followed by CC. 30 IVCTC and 31 CC were performed in 30 patients. The findings of IVCTC were compared with those of CC. Statistical analysis was performed to obtain diagnostic performance values of IVCTC on per polyp (sensitivity and positive predictive value) and per patient (sensitivity, specificity, positive predictive value and negative predictive value) basis. RESULTS By IVCTC, 63 polyps were detected in 28 patients of which 53 polyps were eligible for inclusion in the statistical analysis. 60 polyps were detected by CC in 28 patients of which 50 polyps were eligible for inclusion in the statistical analysis. The per polyp sensitivity and positive predictive values were 94% and 88.6% respectively. The per patient sensitivity, specificity, positive predictive value, and negative predictive values were 96.4, 50, 96.4, and 50% respectively. Twenty polyps, in 10 patients, were visualized only after intravenous contrast administration of which 5 polyps, in 5 patients, were likely to have been missed in the absence of the intravenous contrast injection as these polyps were submerged in fluid. Four patients would have had a false negative CTC examination if the intravenous contrast had not been injected; while in another patient, the number of polyps would have been underestimated. CONCLUSION CTC is capable of serving as a safe and efficient non-invasive tool for evaluating children with clinically suspected colorectal polyps. Administration of intravenous contrast improves the sensitivity of polyp detection on CTC.