Clive Levine

Bone metabolism in children with asthmatreated with inhaled beclomethasone dipropionate

Previous studies have shown that inhaled corticosteroids can affect bone metabolism in adults. A study to assess the effect of inhaled beclomethasone, 300 to 800 micrograms/day for at least 6 months (mean 25 months), was therefore undertaken in children. In part 1 of the study, 18 children with asthma, aged 4 to 17 years (mean 10.1 years), were compared with an age- and sex-matched group of children with asthma not treated with corticosteroids. In part 2, eight more pairs were compared. Comparisons were also made with 61 healthy children. Bone mineral density measured by radiographic absorptiometry, and bone mineral content measured by single-photon absorptiometry and by dual-energy x-ray absorptiometry, showed no significant differences. Serum levels of calcium, magnesium, zinc, total alkaline phosphatase, bone specific alkaline phosphatase, parathyroid hormone, 25-hydroxyvitamin D, and 1,25-dihydroxyvitamin D also showed no differences. The activity of tartrate-resistant acid phosphatase, a marker of bone resorption, was significantly lower in the beclomethasone group than in both the asthma control and the normal control groups, but urine calcium excretion did not differ. Patients with asthma had lower serum osteocalcin and higher serum copper levels than control subjects without asthma, but treatment with beclomethasone did not affect these values. We conclude that inhaled beclomethasone (up to 800 micrograms/day) does not reduce bone mineralization or increase bone resorption. Effects on bone formation were difficult to assess because asthma per se caused a significant reduction in osteocalcin, a sensitive marker of bone formation.

Primary disorders of the lymphatic vessels ― a unified concept

Congenital defects of lymphatics constitute a spectrum of disorders that may manifest with a variety of clinical presentations including lymphedema, chylous effusions, lymphangiomatous malformations with cystic masses and localized gigantism, and intestinal lymphangiectasia with malabsorption. These entities constitute a relatively rare group of disorders, the origin of which remains somewhat controversial, but in some it appears to be due to early lymphatic obstruction. Five cases are described, which demonstrate the anatomical pathology of these entities. A classification and description of the defects is also presented. An attempt is made to present a unified theory of origin for this seemingly diverse group of diseases. While these entities may be challenging from a diagnostic and therapeutic standpoint, a wide variety of imaging modalities, which includes lymphography, computed tomography scanning, and ultrasound, may be used to diagnose the extent and internal structural characteristics of the abnormalities.

Primary Macronodular Hepatic Tuberculosis: US and CT Appearances

Tuberculosis of the liver is uncommon except in association with miliary dissemination. Although hepatic involvement by tuberculosis tends to be diffuse, the macronodular or pseudotumor forms are rare. In addition, reports of actual imaging of tuberculous liver involvement are rare. A 5-year-old boy with a febrile illness due to macronodular hepatic tuberculosis, demonstrated by abdominal computed tomography (CT), and diagnosed by liver biopsy is presented.

Hereditary multiple exostoses and cervical cord compression: CT and MR studies.

Hereditary multiple exostoses usually involve the long bones, but occasionally the spine. When the spine is involved, serious neurologic deficits may occur. We report a case of a 12-year-old girl with an exostosis in the cervical spine (C5), which caused a spastic quadriplegia.

Familial pheochromocytomas with unusual associations

Pheochromocytoma occurs in a familial pattern in approximately 10% of patients. Although most familial pheochromocytomas are an expression of the genetic abnormality of neuroectodermal dysplasia or the genetic syndrome of multiple endocrine neoplasia, some familial pheochromocytomas occur without associated disease. Two patients with familial pheochromocytoma are described. One had an extraadrenal tumor, producing severe renal artery stenosis and in whose family pheochromocytomas were found in three successive generations. A second had multiple pheochromocytomas associated with von Hippel-Lindau disease and a family member with multiple endocrine neoplasia type 2. The combinations and permutations of these genetic entities form discrete syndromes, with other peculiar interrelationships, pathologically related to an aberration in the migration, growth, and differentiation of the neural crest cells, and emphasizing their common neuroectodermal origin. The unique features that characterize the familial pheochromocytomas and cause diagnostic and therapeutic challenges are reviewed.

Renal infarction associated with an extraadrenal pheochromocytoma

A patient with an abdominal extraadrenal pheochromocytoma showed computed tomography findings of renal infarction. Selective angiography of the affected kidney showed no evidence of arterial occlusion or emboli. We postulate that the renal infarcts were caused by reversible severe vasospasm associated with high systemic blood levels of norepinephrine and angiotensin II.

Small Pediatric Renal Neoplasms Detected by CT

We describe three children without renal symptoms who had small solitary renal neoplasms detected by CT during a 1 year period. One patient had a benign Wilms tumor variant, another had a renal cell carcinoma, and the third had a solitary focus of renal lymphoma. Although CT helps in preoperative tumor staging and in evaluating the contralateral kidney, it usually cannot distinguish among the various pediatric renal neoplasms. Accordingly, surgical exploration is usually required when a small renal tumor is discovered in a child. When confined to the kidney, small Wilms tumors and renal cell carcinomas are often amenable to local resection or partial nephrectomy.

Computed tomography in the diagnosis and follow-up of American Burkitt's lymphoma

CT scans of Burkitts lymphoma in 8 American patients are presented. Computed tomography was the major diagnostic imaging modality in 4, and the abdomen was the most commonly involved site in our patients. CT was found to be the method of choice for diagnostic purposes and for assessing the size of abdominal masses. Furthermore, because of the relative effectiveness of modern chemotherapeutic agents in treatment of this type of lymphoma, CT did and can play a unique role in follow-up of these cases during therapy.