Jack O. Haller

Imaging of the brain in the HIV-positive child

Abstract The prevalence of human immune-deficiency virus (HIV) infection around the world, coupled with increasing population movement, make it likely that many physicians will treat HIV-infected patients. New treatment protocols for the specific manifestations of acquired immune-deficiency syndrome (AIDS) make distinguishing the different neurological diseases of great importance. The pattern of disease in children differs from those of adults both in its distribution and etiology. This article encapsulates the salient aspects relating to the imaging of the brain in HIV-positive children, paying particular attention to recent advances and the different features of the various pathological conditions affecting the HIV-infected brain in children.

Imaging features of Mycobacterium avium-intracellulare complex (MAC) in children with AIDS

Purpose. The purpose of this paper was to review the imaging features of Mycobacterium avium-intracellulare complex (MAC) in 16 pediatric patients with human immunodeficiency virus (HIV).¶Materials and methods. We reviewed the pertinent clinical records of 16 children diagnosed with MAC between January 1990 and June 1998. These 16 cases were blood- or biopsy-proven to have MAC infection. Their plain films, abdominal, and chest CT scans were then reviewed and the findings were analyzed with reference to the few reported cases of children with MAC.¶Results. Abdominal findings: all but one had retroperitoneal adenopathy, mesenteric adenopathy or both. Ten patients had hepatomegaly, while nine patients were found to have splenomegaly. Four patients had nonspecific thickened gallbladder wall, while intestinal wall thickening and thickened stomach folds were identified in six of ten patients. Necrotic, fluid-filled nodes were also found. Chest findings included mediastinal adenopathy, cystic/cavitary lesions and bronchiectasis. One patient developed a fistula between the mediastinal lymph nodes, esophagus, and bronchial tree.¶Conclusion. Pediatric patients with HIV who develop MAC infection may present with massive lymph-node enlargement. This can occur not only in mesenteric and retroperitoneal nodes but also in hilar and posterior mediastinal nodes as well. As in MTB infection, these nodes can break down with development of fistulous tracts to both esophagus and adjacent lung. The major differential diagnostic consideration besides MTB is lymphoma.

Vertebral osteoid osteoma masquerading as a malignant bone or soft-tissue tumor on MRI.

Purpose. Four pediatric patients were sent to our institution with the diagnosis of soft-tissue/malignant bone tumor. In all cases an MRI was the initial study performed for neck or back pain. All were surgically proven to have an osteoid osteoma/osteoblastoma (OO) as a final diagnosis. The MRI findings are reviewed.¶Methods. Four patients, three boys and one girl, ranging in age from 5 to 17 years, presented with symptoms of neck or back pain for 2 months to 2 years. Two had neurological findings. All patients underwent MRI.¶Results. All MRIs demonstrated decreased T1 signal and increased T2 signal in the soft tissues and bone surrounding the lesions consistent with edema. Enhancement was observed in the adjacent soft tissues and in the lesion nidus retrospectively.¶Conclusion. Investigating neck or back pain with an initial MRI may lead to misleading diagnoses unless the radiologist is aware of the typical MRI appearance of vertebral osteoid osteoma.

Iatrogenic vertebral body compression fracture in a premature infant caused by extreme flexion during positioning for a lumbar puncture

Abstract We present a case of vertebral body compression fracture that resulted from manual flexion of the spine of a premature infant in preparation for a lumbar puncture. Vertebral body fractures due to abnormal flexion in child abuse have been described. However, such fractures due to lumbar puncture-related positioning have not been reported. We present a pre-term infant who developed an L3 vertebral body compression fracture immediately after lumbar puncture.

Imaging Neuroblastoma in Children

Neuroblastoma is a common solid tumor of childhood that can involve the abdomen, thorax, pelvis, or the head and neck. The clinical manifestations are dependent on the widespread distribution of neural crest tissue and the length of the sympathetic chain involvement. Abdominal pain and hypertension may occur as a result of renal vasculature compression; respiratory distress may be evident in thoracic tumors; and Homers syndrome or heterochromia of the iris may manifest from neuroblastoma of the head and neck. In addition, symptoms of cord compression and back pain may result from spinal cord compromise due to epidural invasion. Metastatic involvement of the liver, skin, periorbital regions, or bone may cause hepatomegaly, skin nodules, proptosis, or bone marrow failure, respectively. Clinical findings along with tumor metastasis may be studied by various imaging modalities to assess the nature and extent of the tumor. Diagnostic tests include plain radiography, ultrasonography, CT scanning, and MR imaging. Bone marrow studies, bone scans, and scintigraphy with 131I-metaiodobenzylmandelic may be utilized for metastatic evaluation. By using these imaging studies to detect the nature and behavior of neuroblastoma, early intervention may indeed improve patient survival.

Periosteal reaction with normal-appearing underlying bone: a child abuse mimicker

Abstract. Any irritation or disruption to the underlying bone will cause a periosteal reaction and result in new periosteal bone deposition. Periosteal bone formation may be due to either physiologic or pathologic causes. Pathologic bone formation generally results from an adjacent inflammatory process or a hypoxic or toxic stimulus. Common causes of pathologic periosteal reaction in children include trauma to the underlying bone. However, other causes such as hypervitaminosis A, prostaglandin therapy, cortical hyperostosis (Caffeys disease), hypertrophic osteoarthropathy (primary and secondary), osteomyelitis, leukemia, trauma, and syphilis must also be considered. The last four are usually associated with some degree of bone destruction, while in the first four diseases the underlying bone is left radiologically intact. This paper will concentrate on those diseases that appear to leave the underlying bone intact. The clinical and radiological features that help to differentiate some of these entities are presented.

Characteristic pancreatic injuries secondary to child abuse

A review of the most common visceral injuries which arise as a result of child abuse is presented. Duodenal and pancreatic injuries are the most characteristic injuries secondary to abuse. The clinical presentation may not be suggestive of the nature of the patients injury, and these descriptions may help the radiologist to discern their true etiology.

Radiologic Features of Pediatric Thalamic and Hypothalamic Tumors

A variety of histologic subtypes of tumor may affect the thalamus and the hypothalamus in the pediatric population. These tumors have radiologic features that are useful in predicting pathology. We discuss the radiologic findings of childhood thalamic and hypothalamic tumors and provide imaging examples.

Tracheoesophageal fistula (H-type) in neonates with imperforate anus and the VATER association.

We report three patients with imperforate anus and other stigmata of the VATER syndrome who were diagnosed as having tracheoesophageal (TE) fistula, H-type, with intact esophagus. The fistula was diagnosed in two of the three patients only after recurrent respiratory infections.

Mongolism and Down's syndrome

Attending a recent meeting of pediatric radiologists, I was struck by a comment by one of the presenters. He reported a case history that started as follows, aThis is a 2 year-old Mongol child . . .o referring to a child with Downs syndrome. Having not heard that term used for that disease in a number of years, I decided to look up the history of the terms mongol ± mongolism ± mongolian idiot and their relationship to the syndrome we now refer to as trisomy 21/Downs syndrome. John Langdon Down (who later changed his name to John Langdon Haydon Langdon-Down) was born in November 1828 in Torpoint, England. He spent a brief period with a surgeon at Whitechapel and then studied at the laboratory of the Pharmaceutical Society. After his father died in 1848, Down decided to give up a career in science, and in 1853 he entered London Hospital Medical College as a medical student. He was subsequently granted membership in 1858 to the Royal College of Surgeons and became medical superintendent at Earlswood Asylum for Idiots at Redhill in Surrey in 1859. In that same year he received his MD and MRCP. He ran the asylum for 10 years, and in 1869 he started the Teddington Institution for training children with learning disabilities. Three generations of the Down family (father, son, and grandson) managed the institution until it was turned over to the National Health Service in 1952 [1±3]. In 1866, Down published his now famous article, aObservations on an ethnic classification of idiots,o in the London Hospital Reprints. In that essay he attempted to classify the mentally retarded patients by comparing them to five ethnic groups. He described them as follows: athe great Caucasian family, the most advancedo; the aEthiopian (i. e., African) varietyo; aMalay varietyo; the apeople . . . who originally inhabited the American continento (i. e., American Indians) and finally, those who resembled athe great Mongolian familyo [4]. To understand the ramifications of this essay one must have a sense of the social tenor of the times. In the late 1800 s there were the monogenists and the polygenists. The former believed that Adam and Eve were created and that they in turn gave rise to the various races. According to the monogenists, then, the alower raceso were fixed at an early stage of development while white Caucasians were considered to be fully developed. Polygenists (pro-slavery theorists) believed that Adam and Eve gave rise to the white race and separate creations subsequently gave rise to the other races. This justified the non-humanness of those separately created races and one, therefore, had the right to enslave them [5]. Down wrote, aIf these great racial divisions are fixed and definite, how comes it that disease is able to break down the barrier, and to simulate so closely the features of the members of another division. I cannot but think HISTORICAL INTERLUDE