Sonography and Magnetic Resonance Imaging Characteristics of Testicular Adrenal Rest Tumors

Summary Background: The aim of this study was to describe the gray-scale and color Doppler ultrasonography (US) and magnetic resonance (MR) imaging features of testicular adrenal rest tumors (TART) in patients with congenital adrenal hyperplasia. Material/Methods Forty-one patients with congenital adrenal hyperplasia were evaluated by gray-scale and color Doppler ultrasonography. Totally eighteen adrenal rest tumors in 9 patients were diagnosed TART on US and MR imaging. Gray-scale and color Doppler US and MR findings of the patients were documented. Results: A total of eighteen masses were evaluated in nine patients. The mean age of these patients was 14.3±4.5 (range 10.1–23.3) years. US revealed hypoechoic lesions around the mediastinum testis with hypervascularity dispersing in ten patients and hypovascularity in two patients. In six patients, the lesions were hyperechoic with poor vascularity. Lesions exhibited homogeneous (n=8) and heterogeneous (n=10). Testicular microlithiasis was present in 4 of 9 patients with TART. Doppler ultrasound showed normal testicular vessels passing through the mass which were undisturbed, not displaced and not change in caliber. MRI features were the following: all lesions were hypointense on T2- and hyperintense (n=12) and isointense (n=6) on T1-weighted images. All masses revealed homogeneous contrast enhancement on postcontrast T1-weighted images. Conclusions: Ultrasonography and MRI are good methods for detecting and monitoring TART. US is the first preferable modality because it is quick and cheap than MRI. Bilateral mostly hypoechoic lesions depicted around the mediastinum testis with no mass effect is highly suggestive for the diagnosis of testicular adrenal rest tissues on ultrasonography. Normal testicular vessels coursing through the lesions undisturbed and not change in caliber is described specific for this kind of tumors

The Relationship Between Serum Asymmetric Dimethylarginine Levels and Cardiovascular Risk Factors in Children with Nephrotic Syndrome

Aim:Nephrotic syndrome is a common type of kidney disease during childhood characterized by proteinuria, edema and hypoalbuminemia. Serum asymmetric dimethylarginine (ADMA) inhibits vascular nitric oxide production and may be an independent risk factor for coronary heart disease. The aim of this study was to investigate the relationship between ADMA and atherosclerotic risk factors in children with nephrotic syndrome.Methods:Forty-one children with nephrotic syndrome and 33 healthy children were included in the study. Patients’ demographic and anthropometric characteristics, biochemical tests, serum homocysteine, ADMA and carotid intima-media thickness (CIMT) were assessed. The patients were divided into three groups: group 1 - steroid-free remission; group 2 - steroid-induced remission, still on steroid therapy; and group 3 - active proteinuria.Results:The patient and control groups were similar in terms of age, sex, weight, height, body mass index, and systolic blood pressure (p>0.05). Diastolic blood pressure was significantly higher in children with nephrosis than in controls. Serum ADMA, homocysteine and CIMT measurements were not different between the two groups (p>0.05). There was a positive correlation between diastolic blood pressure and CIMT measurement in patients. In group 3, ADMA was positively correlated with total cholesterol and low density lipoprotein cholesterol.Conclusion:Children with idiopathic nephrotic syndrome did not show signs of endothelial damage assessed by ADMA and CIMT

Multiple Occipital, Parietal, Temporal, and Frontal Foramina: A Variant of Enlarged Parietal Foramina in an Infant

Background: Calvarial lesions are often detected incidentally in routine radiology. Most lytic lesions of the skull are benign. Enlarged parietal foramina are benign lesions caused by deficient intramembranous ossification. Case Report: An 11 month-old female patient was admitted with a mass on the right of the back of the head. Physical examination showed a soft 5 cm mass area with no palpable bone in the right occipital. The family history revealed a similar mass in a maternal cousin that resolved over time. Craniography showed lytic lesions, and there were no other pathologies on a complete skeletal X-ray. Computed tomography (CT) showed regular-shaped defects in the bilateral temporal bones, right parietal bone, bilateral frontal bones in the upper-medial orbital wall, and particularly in the occipital bone. The well-defined contours, absence of a soft tissue component, and normal structure and density of the adjacent calvarial bones all pointed to a congenital defect. No change in the lesions was observed during a three-year ultrasound follow-up period. Conclusion: To the best of our knowledge, this is the first described case of multiple occipital, parietal, temporal, and frontal foramina in the cranium. A diagnosis of enlarged parietal foramina variant should be considered after ruling out the differential diagnosis in patients with multiple calvarial lesions. CT may provide valuable findings for the differential diagnosis, and sonography may be used for follow-up

Bilateral multifocal hamartoma of the chest wall in an infant

BACKGROUND: Hamartoma of the thoracic wall is a rare benign tumor that occurs in infancy and can be mistaken for a malignancy due to its clinical and imaging features. Hamartomas are extrapleural soft tissue lesions that cause rib expansion and destruction and appear on imaging as cystic areas with fluid levels and calcification. They can cause scoliosis, pressure on the neighboring lung parenchyma and mediastinal displacement. While conservative treatment is recommended in asymptomatic cases, growing lesions require surgical excision. CASE REPORT: In this report, we present the imaging findings in a 3-month-old infant that presented with a firm swelling in the chest wall and was histopathologically confirmed to have a bilateral multifocal hamartoma. CONCLUSIONS: Radiological imaging methods are important for accurate diagnosis of this very rare condition that can be confused with a malignancy

A case of Bartter’s syndrome associated with nephrocalcinosis presenting with tetany

A 10-year-old boy was admitted to hospital with a 3 month history of intermittent spasms of the wrists and ankles, and twitching of the eyelids. He also had polyuria, polydipsia, nocturnal enuresis, fatigue and constipation since he was a toddler. Physical examination revealed normal blood pressure, myokymia on the right eyelid and bilateral carpopedal spasms. Laboratory investigation revealed hypocalcemia, hypokalemia, increased plasma renin and aldosterone , hypercalciuria, metabolic alkalosis, and bilateral medullary nephrocalcinosis. Cranial computed tomography was normal. Based on the clinical and laboratory findings he was diagnosed as having Bartter’s syndrome, which is characterized by hypochloremia, hypokalaemia and metabolic alkalosis associated with potassium renal leakage, with normal blood pressure despite increased plasma renin activity. It is well known that tetany is not uncommon in the neonatal form of Bartter’s syndrome and nephrocalcinosis is usually not present in the classic form. Interestingly, our patient had both the clinical manifestations of the neonatal form and of the classic form of Bartter’s syndrome. In conclusion, we would like to emphasize that both the clinical manifestations of neonatal and classic forms of Bartter’s syndrome (as an overlapping syndrome) might be seen in children and that Bartter’s syndrome should also be considered in children with tetany as in our case. (J Pediatr Neurol 2004; 2 (1): 45-47)

Asymptomatic Pulmonary Tuberculosis in a Child under TNF-alpha Inhibitor Therapy

TNF-? inhibitörlerinin klinikte kullanımı mikobakteriyel enfeksiyonlara yatkınlık oluşturmaktadır. Bu hastalarda, altta yatan immün süpresif duruma bağlı olarak tüberküloz hastalığının klinik bulguları belirgin olmayabilir. Burada üç yıldır juvenil romatoid artrit ve üveit tanıları ile takipli olup adalimumab tedavisi altında akciğer tüberkülozu gelişen asemptomatik çocuk olgu sunulmuştur. Üç yıldır juvenil idiyopatik artrit ve üveit tanıları ile takipli 12 yaşında erkek hastaya, metotreksat ve metil prednizolon almakta iken göz bulgularının ilerlemesi üzerine adalimumab tedavisi başlanmıştı. Hastanın tedavi öncesi bakılan TDT 0 mm, posteroanterior akciğer grafisi normal idi. Tedavisinin üçüncü ayında babasının akciğer tüberkülozu tanısı alması üzerine Verem Savaş Dispanseri tarafından izoniazid profilaksisi başlanan hasta bir ay sonra poliklinik kontrolümüze geldi. Fizik muayenesi normal olan hastanın TDT 7 mm ve akciğer grafisinde paratrakeal dolgunluk saptanması üzerine çekilen bilgisayarlı toraks tomografisinde ise sağ üst paratrakeal alanda 40x27x24 mm boyutlarında nekroz alanları içeren, tüberküloz lenfadenit ile uyumlu lezyon mevcuttu. Antitüberküloz tedavi başlanan hastanın takibine devam edilmektedir. TNF alfa inhibitörü kullanan hastalar tüberküloz gelişimi açısından tedavi öncesinde ve süresince yakın takip edilmelidir.The use of TNF-alpha inhibitor agents facilitates mycobacterial infections. Unlike in normal population, active tuberculosis in such patients may be asymptomatic. Here we present the case of an asymptomatic child who developed pulmonary tuberculosis during TNF-alpha inhibitor therapy. A 12-year-old child with a diagnosis of juvenile idiopathic arthritis and uveitis was referred to our clinic before initiation of adalimumab therapy. His tuberculin skin test was negative and chest X-ray was normal prior to therapy. On the third month of his therapy, his father was diagnosed with pulmonary tuberculosis, and he was initiated on isoniazid therapy. A month later, the patient’s tuberculin skin test was measured as 7 mm, and chest X-ray revealed paratracheal opacity. Computerized tomographic scan confirmed a necrotic mass lesion with a size of 40x27x24 mm which was compatible with tuberculosis. He was thus initiated on antituberculosis therapy. Patients undergoing anti TNF-alpha therapy should be followed up for tuberculosis before and during therap

Imaging appearances of paratesticular fibrous pseudotumor

BACKGROUND: In this paper the clinical and radiological features of three cases with paratesticular fibrous pseudotumor were presented after a retrospective analysis of medical archives of our hospital. CASE REPORT: Each of the three cases had unilateral, multiple nodular lesions with smooth borders accompanied by a hydrocele. On sonographic examination, the lesions showed echogenicity similar to, or slightly lower than, the testis, and the two large lesions had posterior acoustic shadowing. Color Doppler ultrasound examination of two cases showed intralesional vascularity of mild-to-moderate degree. All lesions appeared hypointense compared to testicular tissue on T1W and T2W magnetic resonance images. Moderate-to-high enhancement was observed in the diffuse pattern after intravenous injection of contrast material. An intraoperative pathological examination was performed and local excision carried out in all three cases. CONCLUSIONS: Fibrous pseudotumor is a rare benign paratesticular lesion, which can be confused with malignant masses. Imaging procedures play an important role in correct diagnosis. Unfamiliarity with imaging findings of paratesticular fibrous pseudotumor may eventuate in an unnecessary orchiectomy

Evaluation of epidemiological and clinical features of influenza and other respiratory viruses

Amaç: Çalışmamızda moleküler yöntemlerle viral etkeni saptanmış olan solunum yolu enfeksiyonlarının klinik ve epidemiyolojik olarak değerlendirilmesi ve influenza ile diğer solunum yolu virüslerinin bu bağlamda karşılaştırılması amaçlanmıştır. Gereç ve Yöntemler: Aralık 2013-Nisan 2014 arası çocuk acil polikliniğine ateş ve solunum yolu enfeksiyonu bulguları ile başvuran 2 yaş üstü 178 olgunun kayıtları geriye dönük olarak incelendi. Bulgular: Olguların %78,6'sında (s=140) polimeraz zincir reaksiyonu ile en az bir solunum yolu patojeni saptandı: influenza A (H3N2) %33,5, influenza B %16,4, respiratuvar sinsityal virüs %9,2, adenovirüs %7,8, rinovirüs %7,1, koronavirüs %7,1, insan metapnömovirüsü %5,7, insan bokavirüsü %5,7, parainfluenza virüs %3,5, çoklu infeksiyon %2,8 oranında bulundu. Olguların ortalama yaşı 6,3±3,6 olup 69 olgu (%49,2) 2-5 yaş aralığında, 71 olgu ise (%50,7) 5 yaş ve üzerinde idi. Üst solunum yolu enfeksiyonu %65,7, alt solunum yolu enfeksiyonu ise %34,2 oranında saptandı. Solunum yolu virüslerinin dağılımının yaş gruplarına göre farklılık gösterdiği izlendi. Her iki yaş grubunda da en sık influenza A enfeksiyonu görülmekle birlikte, 5 yaş üstünde ikinci sıklıkta influenza B (p=0,008), 2-5 yaş grubunda ise respiratuvar sinsityal virüs enfeksiyonu (p=0,003) saptandı. 'Center for Disease Control and Prevention' rehberlerinde belirtilen 'influenza benzeri hastalık' tanımına uyan 118 olgunun %55,9'unda influenza virüsleri, %44'ünde ise diğer viral etkenler saptandı. İnfluenza ve diğer solunum yolu virüslerinin sebep olduğu klinik tablolar ve radyolojik bulgular arasında fark bulunmadı. Çıkarımlar: Bu çalışmada, influenza ve diğer solunum yolu virüslerinin, aralarında bazı farklılıklar bulunmakla birlikte klinik ve radyolojik olarak kesin ayrımının yapılamayacağı sonucuna varıldıAim: In our study, we aimed to clinically and epidemiologically evaluate respiratory tract infections the viral agents of which were detected by molecular methods and to compare influenza and other respiratory tract viruses in this context.Material and Methods: The records of 178 patients aged above 2 years who presented to pediatric emergency outpatient clinic with fever and respiratory tract infection findings between December 2013 and April 2014 were examined retrospectively. Results: At least one respiratory tract pathogen was detected by polymerase chain reaction in 78.6% (n=140) of the patients: influenza A 33.5%, influenza B 16.4%, respiratory syncytial virus 9.2%, adenovirus 7.8%, rhinovirus 7.1%, coronavirus 7.1%, human metapneumovirus 5.7%, human bocavirus 5.7%, parainfluenza virus 3.5%, coinfection 2.8%. The mean age of the patients was 6.3±3.6 years. Sixty-nine patients (49.2%) were aged between 2 and 5 years. Seventy-one patients (50.7%) were aged 5 years and above. Upper respiratory tract infection was found with a rate of 65.7% and lower respiratory tract infection was found with a rate of 34.2%. It was observed that the distribution of respiratory tract viruses showed variance by age groups. Influenza A infection was observed with the highest rate in both age groups. Influenza B was the second leading agent (p=0.008) above the age of 5 years and respiratory syncytial virus was the second leading agent in the 2-5 year age group (p=0.003). Influenza viruses were detected in 55.9% of 118 patients who were found to be compatible with the definition of "influenza-like illness" specified in the Center for Disease Control and Prevention guidelines and other viral agenst were detected in 44%. No difference could be found between the clinical pictures and radiological findings caused by influenza and other respiratory tract viruses. Conclusions: In this study, it was concluded that influenza and other respiratory viruses can not be differentiated definitely by clinical and radiological findings, though there are some difference

Tuberculosis screening in pediatric patients receiving TNF-alpha inhibitor therapy

Tumor necrosis factor-alpha inhibitors (TNFIs) increase the risk of tuberculosis (TB). The aim of this study was to evaluate pediatric patients who are under TNFIs regarding the emergence of TB, and to determine the effectiveness of screening methods. This was a retrospective observational study of 73 patients receiving TNFIs therapy for at least 6 months duration between January 2011 and January 2016. Detailed demographic and clinical data were gathered from patients' files. Seventy-three patients (female n=41, 56.2%) with a median age of 129 (38-215) months were enrolled. Median follow-up period was 18 (6-60) months. Median duration of primary illness prior to TNFI therapy was 24 (2-184) months. Sixteen patients (21.9%) with latent tuberculosis infection (LTBI) were given isoniazid (INH) prior to TNFI therapy. TNFIs were adalimumab (n=39, 53.5%), infliximab (n=22, 30.1%) and etanercept (n=12, 16.4%). During follow-up, 16 patients (21.9%) were started on INH treatment. Median time of starting INH was 20 (4-42) months. One patient (3.1%) who received INH had elevated liver transaminases. One patient (1.3%) developed active TB during follow-up. In conclusion, patients who are candidates for TNFI treatment should be screened for TB before and during therapy