Supika Kritsaneepaiboon

MDCT Pulmonary Angiography Evaluation of Pulmonary Embolism in Children

OBJECTIVE The purpose of our study was to determine the prevalence and anatomic distribution of pulmonary embolism (PE) in a group of consecutive pediatric patients with clinically suspected PE using MDCT pulmonary angiography (pulmonary CTA). MATERIALS AND METHODS We used our hospital information system to retrospectively identify all consecutive pediatric patients (< 18 years of age) with clinically suspected PE who underwent pulmonary CTA from July 2004 to August 2007. Two experienced pediatric radiologists retrospectively reviewed by consensus a series of 98 consecutive pulmonary CTA studies. Each examination was reviewed for the ability to visualize pulmonary arteries and the presence of PE. For positive cases, the level of involvement was classified as central, lobar, segmental, or subsegmental. Lobar location was also recorded using standard nomenclature. Pulmonary CTA results were compared with the results of lower extremity ultrasound studies in the subset of patients who underwent both procedures. RESULTS The study population consisted of 84 children who underwent a total of 98 pulmonary CTA studies. All pulmonary CTA studies were technically successful in visualizing arteries to the level of segmental pulmonary arteries, but the evaluation of subsegmental pulmonary arteries was limited in 78 (80%) examinations. Thirteen (15.5%) of 84 children were found to have PE on pulmonary CTA. PE was localized in the lobar pulmonary artery in 12 (39%), the segmental pulmonary artery in 11 (35%), the subsegmental pulmonary artery in five (16%), and the main or central pulmonary artery in three (10%) patients. PE was distributed in the right lower lobe in 12 (37%), the left lower lobe in eight (24%), the right upper lobe in five (15%), the right middle lobe in four (12%), and the left upper lobe in four (12%) patients. Ten of 13 patients with PE underwent lower extremity Doppler ultrasound, of whom one (10%) was positive for deep venous thrombosis. CONCLUSION The prevalence of PE may be more common among pediatric patients than previously reported and has a similar distribution to that in adult patients.

Beyond the Pulmonary Arteries: Alternative Diagnoses in Children With MDCT Pulmonary Angiography Negative for Pulmonary Embolism

OBJECTIVE A potential advantage of pulmonary CT angiography (CTA) is its ability to show alternative diagnoses in patients without evidence of pulmonary embolism (PE), but the frequency and spectrum of alternative diagnoses have yet to be determined in the pediatric population. Our purpose was to determine the frequency and types of alternative diagnoses identified in children with clinically suspected but excluded PE. MATERIALS AND METHODS We used our hospital information system to identify all consecutive pediatric patients (< 18 years old) with clinically suspected PE who underwent pulmonary CTA from July 2004 to March 2008. Two experienced pediatric radiologists reviewed by consensus a series of 96 consecutive diagnostic-quality pulmonary CTA studies without evidence of PE from 89 patients. Each study was systematically reviewed by consensus for a possible alternative diagnosis in the lungs, mediastinum, central airways, cardiovascular system, pleura, and skeleton. RESULTS The study population consisted of 89 children (28 boys and 61 girls; mean age 13.4 +/- 4.7 years; range, 2 months-18 years; 34 inpatients, 62 outpatients) who underwent a total of 96 pulmonary CTA studies without evidence of PE. Thirty-nine (41%) of 96 pulmonary CTA studies were normal. Alternative diagnoses were identified for each of the remaining 57 (59%) studies, including: pneumonia (n = 22), atelectasis (n = 22), malignancy (n = 3), congenital heart disease (n = 2), pulmonary hypertension (n = 2), pericardial effusion (n = 2), pulmonary nodules (n = 1), rib fractures (n = 1), right atrial thrombus (n = 1), and fat embolism (n = 1). Seventeen patients showed pleural effusions that were associated with coexisting pneumonia (n = 8), atelectasis (n = 8), or rib fractures (n = 1). CONCLUSION Among children with clinically suspected but excluded PE, pulmonary CTA frequently shows positive findings. Although pneumonia and atelectasis are most common, a variety of other alternative diagnoses may be detected throughout the thorax.

Survey of pediatric MDCT radiation dose from university hospitals in Thailand: a preliminary for national dose survey

Background Increasing pediatric CT usage worldwide needs the optimization of CT protocol examination. Although there are previous published dose reference level (DRL) values, the local DRLs should be established to guide for clinical practice and monitor the CT radiation. Purpose To determine the multidetector CT (MDCT) radiation dose in children in three university hospitals in Thailand in four age groups using the CT dose index (CTDI) and dose length product (DLP). Material and Methods A retrospective review of CT dosimetry in pediatric patients (<15 years of age) who had undergone head, chest, and abdominal MDCT in three major university hospitals in Thailand was performed. Volume CTDI (CTDIvol) and DLP were recorded, categorized into four age groups: <1 year, 1–< 5 years, 5–<10 years, and 10–<15 years in each scanner. Range, mean, and third quartile values were compared with the national reference dose levels for CT in pediatric patients from the UK and Switzerland according to International Commission on Radiological Protection (ICRP) recommendation. Results Per age group, the third quartile values for brain, chest, and abdominal CTs were, respectively, in terms of CTDIvol: 25, 30, 40, and 45 mGy; 4.5, 5.7, 10, and 15.6 mGy; 8.5, 9, 14, and 17 mGy; and in terms of DLP: 400, 570, 610, and 800 mGy cm; 80, 140, 305, and 470 mGy cm; and 190, 275, 560,765 mGy cm. Conclusion This preliminary national dose survey for pediatric CT in Thailand found that the majority of CTDIvol and DLP values in brain, chest, and abdominal CTs were still below the diagnostic reference levels (DRLs) from the UK and Switzerland regarding to ICRP recommendation.

Unsuspected Pulmonary Emboli in Pediatric Oncology Patients: Detection With MDCT

OBJECTIVE The purpose of this study was to determine the prevalence, distribution, risk factors, and clinical outcome associated with the detection of unsuspected pulmonary emboli (PE) in routine thoracic MDCT examinations of pediatric oncology patients. MATERIALS AND METHODS We used our hospital information system to retrospectively identify all consecutively registered pediatric oncology patients 18 years old and younger who underwent contrast-enhanced thoracic MDCT for indications other than PE from July 2004 to May 2008. Two pediatric radiologists in consensus reviewed diagnostic-quality images from consecutive routine thoracic MDCT examinations for the presence and anatomic distribution of PE. The distribution of PE was assessed according to pulmonary arterial level and lobe. Clinical and radiology reports were reviewed for demographic data, type of underlying neoplasm, prospective embolus detection, risk factors, treatment, and outcome. Subgroups of patients with and without PE were compared with respect to type of neoplasm and risk factors. RESULTS The study sample consisted of 468 children (249 boys, 219 girls; mean age, 9.5 +/- 5.7 years) who underwent a total of 1,002 thoracic MDCT examinations. Nine of the 468 children (1.9%) had PE, including seven with venous thromboembolism and two with tumor emboli. In these nine patients, the pulmonary arterial locations of 17 emboli were nine (53%) segmental, five (29%) lobar, two (12%) central, and one (6%) subsegmental. Classified by lobar location, six of 11 PE (55%) were in the left lower lobe, four (36%) were in the right lower lobe, and one (9%) was in the right upper lobe. PE were not detected prospectively in five of the nine patients (56%). All PE in this subgroup were solitary and located either within the segmental pulmonary arteries (four PE) or a lobar pulmonary artery (one PE). Underlying coagulation disorder (p < 0.001) and history of deep venous thrombosis or PE (p < 0.01) were risk factors for unsuspected PE. Two of nine patients (22%) with unsuspected PE died of causes not directly related to PE. The other seven patients survived, four of whom were not treated for PE. CONCLUSION PE are unsuspected findings at nearly 2% of routine thoracic MDCT examinations of pediatric oncology patients. More than one half of PE were not detected prospectively at initial CT image interpretation, but lack of diagnosis and treatment did not appear to have a negative influence on patient outcome. Underlying coagulation disorder and a history of deep venous thrombosis or PE were risk factors for unsuspected PE.

Systemic lupus erythematosus-related pancreatitis in children.

We report on three patients who developed four episodes of acute pancreatitis while their systemic lupus erythematosus was active and being treated with prednisolone. In all three, gastritis was first considered and treated due to abdominal pain, vomiting, and epigastric tenderness, but their symptoms did not improve. Then pancreatic enzymes were measured, which confirmed pancreatitis. Imaging studies showed an enlarged pancreas in one case, a normal pancreas in two cases, and a focal hypodense nonenhancing parenchyma in one case. Corticosteroids were prescribed for both active SLE and SLE-related pancreatitis. Pulse methylprednisolone was prescribed in one episode, increasing oral prednisolone in one episode, and the same dose of prednisolone continued in the other two episodes. All cases recovered without complications. SLE-related pancreatitis should be considered in SLE patients when the SLE is active and a patient develops abdominal pain and vomiting.

Posterior Periosteal Disruption in Salter-Harris Type II Fractures of the Distal Femur: Evidence for a Hyperextension Mechanism

OBJECTIVE Patterns of periosteal disruption are important factors in assessing the mechanism of injury of radiologically evident Salter-Harris (SH) fractures. The purpose of this study is to assess the frequency of posterior periosteal disruption on MRI in radiographically occult or subtle SH type II fractures of the distal femur and to evaluate associated soft-tissue findings that support a hyperextension mechanism of injury. CONCLUSION We found that all children in our experience with occult or subtle SH type II fractures of the distal femur have posterior periosteal disruption and other MRI findings to indicate a hyperextension mechanism of injury. Direct indicators of fracture may be inconspicuous, and the presence of posterior periosteal disruption is a clue that should prompt a search for other features of this serious pediatric injury, which may be followed by limb shortening or angular deformity.

Atypical presentation of Kawasaki disease in young infants mimicking a retropharyngeal abscess

Kawasaki disease (KD), also known as acute febrile mucocutaneous lymph node syndrome, is self-limited vasculitis of an unknown etiology which typically affects smalland medium-sized arteries. Due to the non-specific symptoms and lacks of a specific laboratory test, the diagnosis is based on presence of fever at least 5 days concurrently with four of five clinical criteria: nonpurulent bulbar conjunctivitis, changes in mucosa of oropharynx, changes in peripheral extremities, polymorphous exanthema, and cervical lymphadenopathy >1.5 cm. However, only 40% of KD patients present with clinically fulfilled criteria [1]. We reported two infants with KD who initially presented with an atypical retropharyngeal abscess-like lesion that lead to delayed diagnosis and potentially increased risk of cardiac complications and mortality. Case reports

Primary synovial sarcoma of the abdominal wall: a case report and literature review

Synovial sarcoma (SS) is the fourth most common type of soft tissue sarcoma, following malignant fibrous histiocytoma, liposarcoma, and rhabdomyosarcoma. It usually occurs in the extremities near the large joints of middle-aged patients. We describe a case of synovial sarcoma of the anterior abdominal wall (SSAW) in an adolescent girl and undertake a review of the literature.

Cushing's Syndrome in an Infant Secondary to Malignant Adrenocortical Tumors with Somatic Mutation of Beta-Catenin

A role of beta-catenin (CTNNB1) in the molecular pathogenesis of adrenocortical carcinoma (ACC) has been suspected in adult ACC and pediatric pigmented nodular adrenocortical disease, but it has never been reported in pediatric ACC. We present the case of a 4-month-old Thai infant who had Cushings syndrome secondary to bilateral adrenal tumors with hepatic metastasis. The child was successfully treated with a bilateral adrenalectomy and wedge resection of the liver nodule. Histopathology revealed bilateral adrenocortical tumors with different histologic grades; the right tumor had a higher score, according to modified Weiss criteria. On molecular study, a deletion mutation of beta-catenin involving codons 44 to 45 was detected in the right adrenal tumor. The same mutation was found in peripheral blood before treatment; this mutation disappeared after tumor removal. The left tumor harbored wild-type beta-catenin. Immunohistochemistry showed nuclear accumulation of beta-catenin on the right adrenal tumor and the metastatic nodule. In summary, we present evidence that supports the role of the Wnt-signaling pathway in the carcinogenesis of pediatric adrenocortical carcinoma.

CT Imaging findings of malignant neoplasms arising in the epigastric region in children

The purpose of this article was to review the spectrum of common and rare malignant neoplasms arising in the epigastric region in children and to illustrate their characteristic computed tomography (CT) imaging features. Understanding the characteristic CT appearance of various malignant neoplasms, which can occur in the epigastric region in children, aids in accurate diagnosis and optimizes pediatric patient care.