Robert J. Starshak

Chronic, Recurrent Multifocal Osteomyelitis Case Report and Review of the Literature

Chronic recurrent multifocal osteomyelitis (CRMO) is an unusual inflammatory process involving multiple osseous sites, often recurrently. The authors recently diagnosed CRMO in an 8-year-old girl who had complained of toe pain for several weeks. A number of other involved, asymptomatic areas were discovered by bone scan. Biopsy of the lesions did not reveal any pathogens. Antibiotics and inflammatory agents were not used, and the patient recovered. A review of previously reported cases of CRMO showed 1) that this entity affects children almost exclusively, 2) that from two to 18 sites, usually in the extremities, can be affected at one time, and 3) that about 20 percent of the patients develop a pustular rash on their palms and soles. Other than an elevated erythrocyte sedimentation rate, there are no consistent laboratory abnormalities, and cultures of affected bone are negative. Histopathology typically shows a chronic inflammatory response, sometimes with granulomas. Antiinflammatory agents and antibiotics offer little consistent beneficial effect. The disease is self-limited, and patients usually recover fully, although exacerbations may occur. In the proper clinical setting, CRMO should be considered, since recognition of this entity avoids costly and potentially harmful diagnostic and therapeutic interventions.

Occult fracture of the calcaneus — another toddler's fracture

Fractures of the calcaneus have been considered rare among children. We feel this may be erroneous since in the last 12 months we have seen 10 such fractures among children, 19 and 41 months of age, who presented with acute limping. The fractures were detected with bone imaging which was performed when initial radiographs were noncontributory. Subsequent radiographs of the calcaneus were positive for fracture in 4 of 10 while follow up radiographs confirmed healing fractures in the two children so evaluated. The sensitivity of bone imaging for the detection of occult fractures in toddlers is emphasized.

Intrahepatic biliary tract abnormalities in children with corrected extrahepatic biliary atresia

Summary Three children with surgically corrected extrahepatic biliary atresia developed recurrent cholangitis associated with bile lakes that failed to drain via the hepa-toportoenterostomy. Surgical or percutaneous drainage of these cysts was followed by both resolution of the infection and spontaneous internal drainage. We postulate that the ongoing inflammatory process resulted in intrahepatic biliary obstruction, which caused cholangitis and bile cysts. Successful treatment required not only antibiotics but drainage of the bile lakes. Development of bile cysts is a new cause of recurrent cholangitis seen in extrahepatic biliary atresia.

The role of radionuclide studies in pediatric gastrointestinal disorders

Radionuclide techniques are currently used to fully evaluate many congenital and acquired abnormalities of the gastrointestinal tract of children. Frequently, the anatomic and functional data provided by the nuclear examination are definitive. In the study of many disease entities, tracer techniques have replaced more cumbersome or invasive procedures. Although the radiopharmaceuticals and instrumentation are similar as applied to both children and adults, the uniqueness of children and their disease entities requires special consideration when performing and interpreting their studies. In this review, the principle radionuclide examinations used in the evaluation of pediatric gastrointestinal disorders are detailed and examples are illustrated.

Radionuclide hepatobiliary imaging in the detection of traumatic biliary tract disease in children

Abstract99m Technetium IDA (99m Tc-IDA) hepatobiliary imaging was used as a diagnostic procedure in children with suspected biliary trauma. A total of eleven 99mTc-IDA examinations were performed in eight children and correlated with the standard radiographs, 99mTc sulfur colloid liver scans, ultrasonographic studies and the clinical course. This technique is recommended in children who are clinically stable and in whom trauma to the biliary system is suspected. The 99mTc-IDA images accurately indicate parenchymal and bile duct injury.

Use of irradiated lymphocytes from immune donors for treatment of disseminated varicella

Four children with acute lymphocytic leukemia who had disseminated varicella were treated with infusions of apheresed, irradiated lymphocytes from healthy donors who had recently recovered from infection with varicella-zoster virus. Each patient had cessation of new lesion formation and umbilication of old lesions within 24 hours of the first lymphocyte transfusion. There were no side effects attributable to the infusions. A controlled trial of infusions of irradiated lymphocytes should be considered for treatment of disseminated infection with varicella-zoster virus in immunocompromised hosts.

Cervical kyphosis in diastrophic dwarfism: CT and MR findings

A 3-year-old boy with diastrophic dwarfism was evaluated for truncal and upper extremity weakness. A severe cervical gibbus was found. Cord compression was documented with MRI.

Extraosseous accumulation of Tc-99m MDP. Metastatic intracranial neuroblastoma.

The case of a child with neuroblastoma whose intracranial metastatic lesions accumulated Tc-99m MDP is presented. Cranial computed tomography and autopsy findings corroborated the scintigraphic observations.

Isolated bilateral T-cell renal lymphoblastic lymphoma.

A 3-year-old girl presented with bilateral renal masses. The histologic diagnosis was lymphoblastic lymphoma. Cell surface markers showed a cytotoxic/suppressor T cell phenotype. The patient was treated with APO therapy. She has remained continuously disease-free for 30 months and has been off all therapy for 6 months. This rare case supports the value of precise classification (by histologic and immunologic methods) as a guide to appropriate tumor therapy.

Hepatic Scintigraphy in Caroli's Disease

Carolis disease (communicating cavernous ectasia of the intrahepatic bile ducts) is manifested on the 99Tc-sulfur colloid images as multiple focal defects in the liver. Since several other conditions have a similar presentation, intravenous or transhepatic cholangiography may be of assistance in reaching the correct diagnosis.