Terry L. Levin

Nonoperative management of perforated appendicitis in children: can CT predict outcome?

BackgroundThe optimal treatment of perforated appendicitis remains controversial, but there is a trend toward nonoperative management. CT scanning might be helpful in determining which patients could benefit from this treatment option.ObjectiveTo determine the value of CT imaging in predicting clinical success or failure in children with nonoperative management of perforated appendicitis.Materials and methodsAdmission CT scans of 34 children with perforated appendicitis treated nonoperatively between January 2003 and June 2006 were retrospectively reviewed. All children were given intravenous antibiotics. Clinical outcome was correlated with imaging findings including the maximal area, number and complexity of collections, presence of an appendicolith or extraluminal air, and extent of intra-abdominal disease outside the right lower quadrant. Patients with an accessible simple collection were drained if their clinical condition did not improve.ResultsSuccessful nonoperative management was achieved in 20 patients; 14 patients failed nonoperative therapy. The presence of collections in three or more sectors (defined as the pelvis and four abdominal quadrants) correlated strongly with clinical failure (P < 0.05), while there was no correlation found between clinical outcome and the presence of an appendicolith, extraluminal air, distant ascites, and collection size or complexity.ConclusionIn the nonoperative management of children with perforated appendicitis, admission CT findings demonstrating disease beyond the right lower quadrant correlate with treatment failure.

Pericardial effusion and cardiac hemangioma in the neonate

In the absence of hydrops or sepsis, a pericardial effusion is a rare occurrence in the neonate. We report a case of a neonate with a pericardial effusion in which there was an associated intracardiac hemangioma. Our literature review found 32 cases of pericardial effusion with-out hydrops in infants under 3 months of age; twelve of these cases were associated with intracardiac and pericardial tumors; 20 others were discovered to be randomly associated with other problems.

Maternal renal insufficiency: A cause of congenital rickets and secondary hyperparathyroidism

We present a case of a newborn with congenital rickets and radiographic evidence of secondary hyperparathyroidism in which the infants mother had severe, longstanding untreated renal insufficiency.

Normal Epiphyseal Cartilage Measurements in the Knee in Children An Alternative Sonographic Approach

The purpose of this study was to validate previously reported distal femoral cartilage measurements in healthy children of different ages using an alternative sonographic imaging plane and patient position than previously reported and to provide preliminary proximal tibial epiphyseal cartilage measurements in healthy children.

HIV-associated (non-thymic) intrathoracic lymphoepithelial cyst in a child.

Abstract An unusual case of a juxtabronchial lymphoepithelial cyst in an HIV-positive child with post-obstructive pneumonia is presented. The pathogenesis and similarity with parotid lymphoepithelial cysts is discussed.

Choledochal cyst imaging by telepaque-enhanced computed tomography

A choledochal cyst is an uncommon anomaly of the biliary system requiring surgical intervention. A case of a choledochal cyst imaged by computed tomography following oral administration of cholangiography contrast material (Telepaque) is reported. Telepaque-enhanced computed tomography is an easy, noninvasive method to demonstrate pertinent preoperative anatomy in cases of choledochal cysts, and is especially useful in the pediatric patient.

Duodenal atresia: not always a double bubble

A newborn infant with a prenatal diagnosis of duodenal atresia and abdominal radiographs demonstrating air in distal bowel is presented. An upper gastrointestinal series revealed complete duodenal obstruction and duodenal atresia was confirmed at surgery. The significance of distal bowel gas and the embryological development of this unusual entity is discussed.

Yield of diagnostic tests in obese children with an elevated alanine aminotransferase.

Nonalcoholic fatty liver disease (NAFLD) is associated with obesity and affects roughly 10% of children. However, NAFLD is often diagnosed by exclusion – that is, obese children with an elevated alanine aminotransferase (ALT) are screened for other liver diseases in the absence of a biopsy. This testing is nonstandardized, and professional society recommendations differ. This study examines the yield of testing for disorders other than NAFLD in this patient population.

Necrotizing Fasciitis in a Young Girl With Atopic Eczema

bicarbonate, 19 mEq/L; blood urea nitrogen, 27 mg/dL; serum creatinine, 1.3 mg/dL; and an erythrocyte sedimentation rate of 120 mm/h. A sonogram demonstrated indistinct muscle planes in the upper left arm and chest, all with a 3.7-cm complex fluid collection in the left anterior axillary line. A contrast-enhanced chest computed tomography (CT) scan revealed edema of the soft tissues of the left chest wall and fluid surrounding the pectoralis and latissimus dorsi muscles and extending into the left axilla (Figure 1). Intravenous ceftriaxone, vancomycin, and clindamycin were begun for presumed necrotizing fasciitis. Within 24 hours, she underwent surgical débridement and fasciotomy for extensive deep fascial and muscle necrosis. Wound cultures grew group A Streptococcus. The patient underwent a second débridement on hospital day 2. Acute renal failure subsequently developed and she died.