Biomedical subjects
Publications and source records attributed to D Pariente.
The authors report a case of septic venous sinus thrombosis (VST) and meningitis occurring as an early complication of mastoiditis caused by Fusobacterium necrophorum. CT scan was normal, and cerebral angiography was required to diagnose the VST. The evolution was favourable with appropriate antimicrobial therapy and steroids.
Diaphragmatic paralysis, a difficult diagnosis in the pediatric age group, has classically been made by fluoroscopy or B-mode ultrasound. We report our experience with TM-mode exploration. Twenty-seven patients suspected to have diaphragmatic paralysis were examined by means of inspiratory and expiratory chest radiography, fluoroscopy and B-mode ultrasound. The diaphragmatic echo was recorded on TM-tracing during spontaneous breathing using coronal oblique scans. Direction, excursion and the pattern of the transition between inspiration and expiration were analysed. In 7 patients examination was normal and TM mode demonstrated movement of normal direction and excursion with a sharp aspect of the transition zone. Diaphragmatic paralysis was present in 11 patients: unilateral in 9 and bilateral in 2 cases. TM mode demonstrated paradoxical movement, reduced excursion and a smooth transition zone. In 9 patients with diaphragmatic dysfunction TM mode demonstrated movement in the normal direction but with reduced excursion and a smooth transition zone. Compared to other imaging modalities, TM-mode records diaphragmatic movements more objectively. It can identify direction of the movement even if they are fast and of weak amplitude and in the case of bilateral paralysis. TM can differentiate paralysis from dysfunction. Moreover, this low-cost, non-irradiating made of imaging can be performed at the bedside and is available on all basic devices.
A retrospective pediatric study of 30 angiograms in congenital hepatic fibrosis (CHF) was undertaken to analyze the different aspects of the portal venous system in this disease. Besides the classical angiographic signs (hepatofugal veins and intrahepatic duplications), a hepatopetal venous network was present in ten children, contrasting with the patency of the portal venous system. Analysis of the medical charts for these ten patients showed that the clinical signs and outcome were similar to classical CHF. Liver biopsies were available in six cases and, in addition to the diagnostic features of CHF, demonstrated paucity or absence of portal venules. This unusual association of hepatopetal and hepatofugal collateral veins in an intrahepatic block could be explained by hypoplasia or thrombosis of portal venules. Thus, the association between hepatomegaly and hepatopetal collateral veins without portal obstruction should be suggestive of CHF.
Thymic hemorrhage related to coagulopathy by vitamin K deficiency is a rare condition. We report a case in a 4-week-old boy presenting with acute onset of respiratory distress and anemia. Ultrasound examination of a compressive anterior mediastinal mass established the diagnosis of thymic hemorrhage and allowed us to follow resolution under medical treatment.
We report on 56 children with sclerosing cholangitis (SC) seen between 1972 and 1992. The first symptoms occurred at a mean age of 3.7 years; 15 infants had neonatal cholestatic jaundice. At diagnosis, cholestatic jaundice was present in 25 children, hepatomegaly in 54, splenomegaly in 41, and ascites in 12. Serum alkaline phosphatase activity was increased in 49 patients and gamma-glutamyltransferase activity in all patients tested. Most often the histopathologic findings were extensive portal fibrosis and neoductular proliferation. Cholangiography showed abnormal intrahepatic bile ducts in all children and abnormal extrahepatic bile ducts in 35 (63%). The children were separated into three groups: (1) those with SC of neonatal onset (27%); (2) those with SC of postneonatal onset associated with another disease (55%)--histiocytosis X in 14 children, immunodeficiency syndromes in 8, chronic inflammatory bowel disease or autoimmune hepatitis in 8, and congenital psoriasis in 1; and (3) those with SC of postneonatal onset without an associated disease (18%). Biliary cirrhosis was present in all but three children after 6 months to 19.3 years of follow-up. Eleven children died of portal hypertension or liver failure, and six died of a complication related to the associated disease. Fifteen children had liver transplantation; 11 of these are alive 6 months to 6 1/2 years later without recurrence of SC. The overall estimated median survival time of children with SC was 10 years from clinical onset. These results indicate that SC should be suspected in all children with a chronic cholestatic disease and increased serum gamma-glutamyl transferase activity, especially when diseases known to be associated with SC are present. The prognosis is poor, but liver transplantation should be considered except in those with severe immunodeficiency syndromes.
Severe hemobilia after liver transplantation is a rare complication. We report one case of fatal hemobilia resulting from arterio-biliary fistula after a liver graft needle biopsy in a 7-year-old girl transplanted with a reduced-size graft. Arterial reconstruction was performed by an iliac conduit implanted in the aorta. The diagnosis of hemobilia was made by angiography but the hemorrhage could not be controlled by selective embolization of the bleeding arterial branch. The patient died from early and massive recurrent bleeding before surgery. The prevention of iatrogenic hemobilia and current therapeutic strategies are discussed.
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BACKGROUND: Pneumomediastinum is a rare complication of anorexia nervosa. It may occur in patients with severe weight loss and a history of induced vomiting. CASE REPORT: A 14 year-old girl was admitted suffering from severe anorexia nervosa. Shortly after admission, she complained of anterior thoracic pain. Examination showed subcutaneous emphysema of the supraclavicular fossae and the base of the neck. Thoracic X-ray showed pneumomediastinum without pneumothorax. At the time, the patient admitted to a history of surreptitious chronic induced vomiting. Gastrografin esophagography ruled out an oesophageal tear. The pneumomediastinum gradually disappeared over a period of several days with simple clinical and radiological monitoring. CONCLUSIONS: This case, along with seven others reported in the literature, confirms that pneumomediastinum in anorexia nervosa is usually not accompanied by pneumothorax. An oesophageal perforation must always be ruled out. Spontaneous pneumomediastinum invariably has a favorable outcome.
Vascular complications constitute a major cause of morbidity and mortality after liver transplantation. They are dominated by arterial complications, the most frequent being hepatic artery thrombosis. Venous complications essentially consist of portal vein thrombosis. The preventive treatment of vascular complications is based on a better understanding of the risk factors. Close cooperation between surgeon, and radiologist is essential for effective surgical correction, which requires a rapid diagnosis and is designed to save not only the patient's life, but also, whenever possible, the liver transplant.
The authors report their experience of imaging of 286 liver transplantations (LT) in children. Hepatic artery thrombosis is the most serious complication (9%), with a maximum risk during the first two weeks. Its clinical presentation is very variable and its diagnosis is based on Doppler ultrasonography. Emergency surgical disobstruction prevented the development of biliary or ischaemic complications in one half of cases. Portal thrombosis (4.5%) is due, in the majority of cases, to hypoplasia of the recipient's portal vein. Patency of intrahepatic portal branches with inversion of flow can delay the ultrasonographic diagnosis. Biliary complications are frequent (20%) and occur after a very variable interval. Their diagnosis is ultrasonographic, but sometimes delayed compared to the histological signs. Transhepatic cholangiography visualises the lesions and allows external drainage or even percutaneous dilatation. In 1 out of 4 cases, the aetiology was hepatic artery thrombosis. The imaging protocol after LT consists of ultrasonography with daily Doppler (or even twice-daily) in the patient's bed for the first two weeks and then as required. Computed tomography is useful to demonstrate parenchymal ischaemia and intraperitoneal abscess in multi-operated children. Angiography and cholangiography confirm the ultrasonographic signs. Interventional Radiology plays an increasingly important role.
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A severe form of hypomelanosis of Ito is reported, which presented as fetal macrocephaly and neonatal epileptic encephalopathy. Lymphocyte karyotypes were normal. MRI showed an absence of delineation between cortical grey matter and white matter. The prominent neuropathological finding was an abnormal cortical morphogenesis, with the co-existence of cells migrating normally and cells exhibiting arrêt en route or even the complete absence of migration. Intense astrocytic reaction with moderate dystrophic features was present. Juxtaposition of two migration behaviours in the neural cells paralleled the cutaneous findings and reinforced the hypothesis of a genetic chimerism.
During a 17-year period, 40 infants less than 1 year of age were investigated for cholelithiasis; 32 infants were seen within the past 10 years. Seventeen of them had no recognizable predisposing factors. In 6 infants, gallbladder lithiasis was a fortuitous finding on a plain radiograph or sonogram with no signs of common bile duct obstruction; under conservative management, no complications of lithiasis were observed on follow-up of 3 infants and spontaneous resolution occurred in 2 others. In the remaining 34 infants with lithiasis of the common duct or cystic duct or both, the initial symptoms were cholestatic jaundice in 21, acholic stools in 8, sepsis in 4, and abdominal pain in 1. Ultrasonography, performed in 33 of them, showed dilation of the biliary tract in 28, and stones in the gallbladder in 13 and in the bile ducts in 10. Percutaneous transhepatic cholangiography or operative cholangiography in 26 infants showed stones in the bile ducts in 23. In 3 infants, no lithiasis was visible, suggesting the spontaneous elimination of stones. Treatment was initially surgical in 9 infants, but starting in 1981 interventional radiologic procedures were attempted in 15 infants and were successful in 12. Spontaneous resolution of cholelithiasis occurred in 10 other infants with cholestasis. Recurrence of biliary stones was observed in 3 infants only after a follow-up of 7 months to 10 years. These results suggest that common bile duct lithiasis should be considered among the causes of cholestatic jaundice in infancy, and that some of the gallbladder calculi found in older children may have resulted from a lithogenic process that occurred during fetal life or shortly after birth. Percutaneous cholangiography with biliary drainage appears to be an effective means of treatment of infants with common bile duct obstruction; surgery can then be restricted to a limited number of cases, especially those with associated strictures of the bile ducts.
OBJECTIVE: The vast majority of patients with Cushing's disease have a corticotroph adenoma, the selective removal of which, through the transsphenoidal route, has the potential to offer a definitive and complete cure. This study was designed to compare the diagnostic accuracy of computerized tomography (CT) and magnetic resonance imaging (MRI) to identify the presence, evaluate the size, and assess the topographic characteristics of pituitary corticotroph adenomas. METHODS: Forty-two patients with Cushing's disease were included in this prospective study, of whom 16 were subsequently explored transsphenoidally. Computerized tomography used a CE 12,000 CGR apparatus with 1.5-mm coronal slices and a 2-mm interslice gap. Magnetic resonance imaging used an MR Max 0.5T GE apparatus; adjacent 3-mm slices were obtained with a T1-weighted gradient echo before and after gadolinium injection. RESULTS: Lesions compatible with an adenoma were identified in 29 patients by MRI and in 21 patients by CT (69 vs 50%, P < 0.02). Seven macroadenomas were identified as well by the two methods. Eight of the 22 microadenomas detected by MRI were not identified by CT. Evidence for intracavernous tumour extension was found in nine patients: it was more frequently detected by MRI (8 patients) than by CT (4 patients). Fourteen patients with positive MRI had a pituitary examination: in one case the adenoma could not be reached because of purely suprasellar location; of the other 13 all were found by the surgeon and the surgical outcome was successful in 12 cases. CONCLUSION: MRI is superior to CT for the examination of the pituitary gland in patients with Cushing's disease.
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In a previous study based upon the cavography of 100 patients, we determined that the average diameter of the infrarenal inferior v. cava (IIVC) was 21.3 mm (range 10-31 mm) at its end [1]. We discuss the value of different methods to measure IIVC, and particularly computed tomography (CT) scans reviewed in our department. It showed that the largest diameter of IIVC was not in a frontal plane and the width observed in a cavography was in fact the projection of a transverse diameter on the film. The real diameter of the IIVC is larger than that showed by cavography. This present study shows the results of measurements of the IIVC obtained from 50 consecutive CT scans. The average transverse diameter is 24.26 mm (range 14-33.3). The average anteroposterior diameter is 13.4 mm (range 5-22) and the average angle alpha between the transverse diameter and the frontal plane is 30 degrees 45' (range 12 degrees-55 degrees). We discuss the different methods of measurement of IIVC and we conclude that at present, CT scan is one of the most reliable methods to measure the real diameter of IIVC.
Eight patients affected with endocrine tumor of the pancreas were examined, within the same period of time, by MRI and CT. Results from those two examinations were similar for the detection of the primary tumor (succeeding to visualize the lesion 5 times out of 8) and the evaluation of locoregional and vascular extension. No tumor smaller than 3 cm was diagnosed by MRI. Most of cases the pancreatic tumor appeared as hypointense in T1 and hyperintense in T2 sequences. MRI was a little more efficient than CT for the detection of liver metastases. MRI seems to be an interesting method for the follow-up of those patients needing a regular and prolonged surveillance after primary tumor ablation.