Nurith Hiller

Sonographic detection of radiographically occult fractures in pediatric ankle and wrist injuries.

Background: In some pediatric ankle and wrist injuries, the clinical picture is suggestive of a fracture despite negative standard radiographs. Objective: The goal of this prospective study was to determine the effectiveness of high-resolution ultrasound (US) in differentiating radiographically occult fractures from sprains. Methods: During a period of 3 years children aged 2 to 16 years, who sustained an acute ankle and wrist injury suggestive of being a fracture on clinical examination, but with negative radiograph, were referred for high-resolution US. Follow-up radiographs were obtained at 2 to 3 weeks. Results: Fifty-eight children (41 children with ankle injury and 17 children with wrist injury) were examined. In 41 patients, US did not reveal fractures, and in 15, small fractures were detected. All patients with negative US studies had negative follow-up x-rays. In 13 patients with positive US, the follow-up radiographs demonstrated a periosteal reaction. In 2 children (1 in each group) in whom a fracture line identified by US was in the depth of the metaphyseal bone, the follow-up radiogram demonstrated an area of increased bone density. In 2 children, 1 in each group, US diagnosed fractures that were not confirmed by follow-up radiograms. Conclusion: Ultrasound is effective in the detecting radiographically silent fractures of the pediatric ankle and wrist. Ultrasound may be used as an adjunct to radiography in clinically suspicious but radiographically negative ankle and wrist injuries. Level of evidence: 1

Spontaneous intramural hematoma of the Esophagus

ABSTRACTSpontaneous intramural hematoma of the esophagus (SIHE) is a rare condition, usually presenting with severe acute chest pain. Vomiting, dysphagia, odynophagia, and hematemesis may appear later. We herein report a case of this disease in a patient treated with low doses of aspirin, and review the literature for possible etiologies for this condition. In addition, we compare the utility of the various diagnostic modalities in this uncommon condition.

A double stomach in an adult

Gastric duplication cysts are uncommon congenital anomalies and are rarely diagnosed in adults. We present a unique case of a communicating type gastric duplication in a young woman with the multimodality imaging findings including barium examination, CT, and endoscopy. The morphological criteria for diagnosis of duplication cyst suggested pathogenetic mechanisms for its formation as well as clinical presentation. Associated pathologies are reviewed.

Pleural Effusion: Characterization with CT Attenuation Values and CT Appearance

OBJECTIVEnThe purpose of this study was to assess the utility of CT in characterizing pleural effusions on the basis of attenuation values and CT appearance.nnnMATERIALS AND METHODSnWe retrospectively analyzed 100 pleural effusions in patients who underwent chest CT and diagnostic thoracentesis within 48 hours of each other. On the basis of Lights criteria, effusions were classified as exudates or transudates using laboratory biochemistry markers. The mean value in Hounsfield units of an effusion was determined using a region of interest on the three slices with the greatest quantity of fluid. All CT scans also were reviewed for the presence of additional pleural features such as fluid loculation, pleural thickening, and pleural nodules.nnnRESULTSnTwenty-two of the 100 pleural effusions were transudates and 78 were exudates. The mean attenuation of the exudates (7.2 HU; [SD] 9.4 HU; range, 21-28 HU) was not significantly lower than the mean attenuation of the transudates (10.1 HU; 6.9 HU; range, 0.3-32 HU), (p = 0.24). None of the additional CT features accurately differentiated exudates from transudates (p > 0.1). Fluid loculation was found in 58% of exudates and in 36% of transudates. Pleural thickening was found in 59% of exudates and in 36% of transudates.nnnCONCLUSIONnThe clinical use of CT attenuation values to characterize pleural fluid is not accurate. Although fluid loculation, pleural thickness, and pleural nodules were more commonly found in patients with exudative effusions, the presence of these features does not accurately differentiate between exudates and transudates.

MRI of the Stener lesion.

AbstractObjective. To assess the utility of MR in detecting surgically induced Stener lesions (displaced thumb ulnar collateral ligaments) in cadaveric models.nDesign. Six cadaver thumbs had ulnar collateral ligament (UCL) tears created surgically. MR examinations (2D STIR and 3D GRASS) were performed identically on all specimens both before displacement (non-Stener) and after displacement (Stener lesion) of the UCL. The MR images were then randomly numbered. Each image was evaluated separately in blinded fashion by four musculoskeletal radiologists for the presence or absence of a Stener lesion. Each radiologist reinterpreted the images after an interval of several days. The interpretation was based on previously published criteria for Stener lesion diagnosis by MR.nResults. The sensitivity of GRASS ranged from 0.17 to 0.67 with the most experienced reader scoring the lowest. The specificity of GRASS ranged from 0.33 to 1.0 (most experienced reader 0.67, 0.83). STIR had a sensitivity of 0.00–0.17 and a specificity of 0.53–0.83. The κ values for inter- and intraobserver agreement were measured. The intraobserver κ for GRASS was 0.27–0.75 (most experienced reader 0.75).nConclusions. 2D imaging is probably inadequate for the evaluation of Stener lesions. The most likely reason is that the STIR slice thickness of 3 mm limits resolution of small UCLs. The poor sensitivity and specificity of GRASS as well as poor interobserver agreement suggest that MR may not be sufficiently accurate for Stener lesion evaluation.

Familial Mediterranean fever : abdominal imaging findings in 139 patients and review of the literature

AbstractBackground: The purpose of this study was to investigate the imaging findings in patients with familial Mediterranean fever (FMF) during and between acute attacks.nMethods: Computerized search of medical records from 1989 to 1998 identified 139 patients with a discharge diagnosis of FMF. Medical records, imaging studies, and pathologic findings were reviewed.nResults: Sixty-eight patients had a documented acute attack of FMF, and 71 patients known to have FMF were asymptomatic. Imaging was performed in 68 patients. Radiologic findings included ascites, splenomegaly, hepatomegaly, lymphadenopathy, focal peritonitis, peritoneal cysts, renal changes, and other incidental findings.nConclusions: Radiologic findings in symptomatic and asymptomatic FMF patients are not uncommon. Imaging in selected cases may facilitate diagnosis and show complications.

Esophageal involvement in chronic granulomatous disease. Case report and review.

A 5-year-old girl with chronic granulomatous disease (CGD) and esophageal narrowing is described. To date, only two cases of esophageal involvement in CGD have been reported. We present a third, well-documented case and a brief review of the literature.

Ileocolic versus Small-Bowel Intussusception in Children: Can US Enable Reliable Differentiation?

PURPOSEnTo assess clinical and ultrasonographic (US) criteria that can be used to confidently differentiate ileocolic from small-bowel intussusception.nnnMATERIALS AND METHODSnInstitutional review board approval was obtained for this retrospective study, and the need to obtain informed consent was waived. US and clinical data for children given a diagnosis of intussusception in the years 2007 through 2011 were evaluated. The diameters of the intussusception and the inner fat core, the outer bowel wall thickness, and the presence or absence of lymph nodes inside the intussusception and mesentery were noted. The Student t test, the Mann-Whitney test, and the Levene test were used for comparison of parametric variables, while the χ(2) and Fisher exact tests were used for comparison of categoric data.nnnRESULTSnThere were 200 cases of intussusception in 174 patients (126 boys, 48 girls; mean age, 17.2 months (range, 0 years to 7 years 1 month); 57 (28.5%) were small-bowel and 143 (71.5%) were ileocolic intussusceptions. Mean lesion diameter was 2.63 cm (range, 1.3-4.0 cm) for ileocolic versus 1.42 cm (range, 0.8-3.0 cm) for small-bowel intussusception (P < .0001). Mean fat core diameter was 1.32 cm (range, 0.6-2.2 cm) for ileocolic versus 0.1 cm (range, 0-0.75 cm) for small-bowel intussusception (P < .0001). The ratio of inner fat core diameter to outer wall thickness was greater than 1.0 in all ileocolic intussusceptions and was less than 1.0 in all small-bowel intussusceptions (P < .0001). Lymph nodes inside the lesion were seen in 128 (89.5%) of the 143 ileocolic intussusceptions versus in eight (14.0%) of the 57 small-bowel intussusceptions (P < .0001). Children with ileocolic intussusception had more severe clinical symptoms and signs, with more vomiting (P = .003), leukocytosis (P = .003), and blood in the stool (P = .00005).nnnCONCLUSIONnThe presence of an inner fatty core in the intussusception, lesion diameter, wall thickness, the ratio of fatty core thickness to outer wall thickness, and the presence of lymph nodes in the lesion may enable reliable differentiation between ileocolic and small-bowel intussusceptions.

Aggressive bone destruction in acute megakaryocytic leukemia: a rare presentation

Abstract Acute megakaryocytic leukemia (AMKL) is a rare subtype of acute myeloid leukemia which is more common in children. Although the bone changes in leukemia are well documented, there are only a few reports of the AMKL subtype. We present an exceptional case of a young girl with very aggressive AMKL, who demonstrated symmetrical destructive lesions of the long bones characteristic of this disease. Lytic lesions of the skull and jaws were also present, and these have not been previously described in AMKL.

Tuberculous peritonitis: a diagnostic challenge.

Tuberculous (TB) peritonitis rarely occurs in developed countries. The clinical presentation and laboratory tests are usually insufficient for diagnosing TB peritonitis and distinguishing it from peritoneal carcinomatosis. We present two cases of TB peritonitis and illustrate the computed tomographic findings of the disease according to the world literature. Recognition of the radiologic manifestations and maintenance of a high index of suspicion in population at risk have paramount importance for diagnosing this uncommon disease.