High frequency oscillatory ventilation for respiratory failure due to RSV bronchiolitis

Objective: To describe the time course of high frequency oscillatory ventilation (HFOV) in respiratory syncytial virus (RSV) bronchiolitis. Design: Retrospective charts review. Setting: A tertiary paediatric intensive care unit. Patients and participants: Infants with respiratory failure due to RSV infection. Intervention: HFOV. Measurements and results: Pattern of lung disease, ventilatory settings, blood gases, infant's vital parameters, sedation and analgesia during the periods of conventional mechanical ventilation (CMV, 6 infants), after initiation of HFOV (HFOVi, 9 infants), in the middle of its course (HFOVm), at the end (HFOVe) and after extubation (Post-Extub) were compared. All infants showed a predominant overexpanded lung pattern. Mean airway pressure was raised from a mean (SD) 12.5 (2.0) during CMV to 18.9 (2.7) cmH2O during HFOVi (P<0.05), then decreased to 11.1(1.3) at HFOVe (P<0.05). Mean FiO2 was reduced from 0.68 (0.18) (CMV) to 0.59 (0.14) (HFOVi) then to 0.29 (0.06) (P<0.05) at HFOVe and mean peak to peak pressure from 44.9 (12.4) cmH2O (HFOVi) to 21.1 (7.7) P<0.05 (HFOVe) while mean (SD) PaCO2 showed a trend to decrease from 72 (22) (CMV) to 47 (8) mmHg (HFVOe) and mean infants respiratory rate a trend to increase from 20 (11) (HFOVi) to 34 (14) (HFOVe) breaths/min. With usual doses of sedatives and opiates, no infant was paralysed and all were extubated to CPAP or supplemental oxygen after a mean of 120h. Conclusion: RSV induced respiratory failure with hypercapnia can be managed with HFOV using high mean airway pressure and large pressure swings while preserving spontaneous breathin

Partial Rhombencephalosynapsis and Chiari Type II Malformation in a Child: a True Association Supported by DTI Tractography

Partial rhombencephalosynapsis (PRECS) has been recently reported in association with Chiari II (CII). However, its existence as a true malformation is challenged due to the anatomical changes potentially induced by CII. The aim of this report was to investigate the contribution of midbrain/hindbrain tractography in this setting. A 13-year-old boy with a known CII malformation and operated myelomeningocele was referred for brain imaging after a first complex partial seizure. In addition to the classical features of CII, MRI showed partially fused cerebellar hemispheres and multiple supratentorial abnormalities. Diffusion tensor imaging (DTI) color map and tractography showed absent transverse fibers on the midsection of the cerebellum, scarce fibers of the middle cerebellar peduncle (MCP), absence of the middle pontine crossing tract, and fibers running vertically in the medial part of the cerebellum. Vertical mediocerebellar fibers are a feature of classical RECS and the paucity or absence of MCP fibers is mainly described in CII. In our patient, DTI and FT therefore demonstrated structural characteristics of both RECS and CII confirming their potential coexistence and suggesting possible shared embryological pathwa

Can early MRI distinguish between Kingella kingae and Gram-positive cocci in osteoarticular infections in young children?

Background: K. kingae is a common causative organism in acute osteoarticular infections (OAIs) in children under 4years of age. Differentiation between K. kingae and Gram-positive cocci (GPC) is of great interest therapeutically. Objective: Our aim was to identify early distinguishing MRI features of OAIs. Materials and methods: Thirty-one children younger than 4years of age with OAI underwent MRI at presentation. Of these, 21 were caused by K. kingae and ten by GPC. Bone and soft tissue reaction, epiphyseal cartilage involvement, bone and subperiosteal abscess formation were compared between the two groups. Interobserver agreement was measured. Results: Bone reaction was less frequent (P = 0.0066) and soft tissue reaction less severe (P = 0.0087) in the K. kingae group. Epiphysis cartilage abscesses were present only in the K. kingae group (P = 0.0118). No difference was found for bone abscess (P = 0.1411), subperiosteal abscess (P = 1) or joint effusion (P = 0.4414). Interobserver agreement was good for all criteria. Conclusion: MRI is useful in differentiating K. kingae from GPC in OAI. Cartilaginous involvement and modest soft tissue and bone reaction suggest K. kinga

Inflammatory myofibroblastic tumor of the lung: a rare cause of atelectasis in children

Although rare, inflammatory myofibroblastic tumor is the most common primary lung mass in children. We report the case of an 11-year-old boy investigated for persistent cough and dyspnea with complete left lung atelectasis mimicking pneumonia. CT and MRI showed an endobronchial mass of the left main bronchus. The boy underwent endoscopic resection of the tumor and histology was in favor of an inflammatory myofibroblastic tumor of the lung. This diagnosis should be suspected in children with recurrent pneumonia. The prognosis is good after complete resectio

Acoustic radiation force impulse imaging—normal values of liver stiffness in healthy children

Background: Acoustic radiation force impulse imaging (ARFI) is a recent ultrasound technique to assess tissue stiffness. Objective: Our aim was to describe the feasibility and to define normal ARFI values in liver in children. Materials and methods: ARFI values were measured in 103 children (ages 2weeks to 17years) divided into four age groups, at a minimum depth of 3cm. In 20 children, measurements were done at 3-, 4- and 5-cm depth in the liver to assess the suitability of measurement location. The impact of age groups and of depth groups was examined using multilevel models. The precision of the measurements was determined using intraclass correlation coefficient (ICC). Results: There was no statistical difference between measurements taken at different ages, with a mean propagation velocity of 1.12m/s (range: 0.73 to 1.45m/s). There was no significant difference according to the depth of the regions of interest (up to 5cm). The ICC was 0.77 (95% CI 0.69-0.83). Conclusion: ARFI is feasible in children at any age with an acceptable reliability. The depth of measurements in the liver seems to have no influence on test results. We set the standard ARFI elastography values for healthy liver in childre

Diffusion-weighted imaging findings in Perthes disease with dynamic gadolinium-enhanced subtracted (DGS) MR correlation: a preliminary study

Background: Legg-Calvé-Perthes disease (LCP) is necrosis of the proximal femoral epiphysis of vascular origin. Clinical course and outcome in LCP disease varies considerably between different patients. Earlier prognostic criteria than those offered by conventional radiography are necessary to identify children who require prompt surgical treatment. Objective: To assess the significance of signal alteration on diffusion-weighted MR imaging (DWI MR) in LCP. Materials and methods: Twelve boys with unilateral LCP disease (Catterall grade 2 and 3), at the initial sclerotic stage and early fragmentation phase, underwent dynamic gadolinium-enhanced subtracted (DGS) and DWI MR. For DGS MR, the lateral pillar enhancement was recorded. For DWI imaging, we measured ADC values in the diseased and the unaffected epiphyses and metaphyses. Receiver operating characteristic curves were performed to analyze the performance of DWI in establishing agreement with the results of DGS MR, which is the gold standard for prognosis. Results: Femoral epiphysis increased diffusivity was observed in the affected hip in all cases. Increased metaphysis diffusivity in the affected side was observed in all cases with absent lateral pillar enhancement at DGS MR. Conclusion: DWI seems to be a noninvasive means of distinguishing between Perthes disease with favourable and unfavourable prognosi

Extra-osseous involvement of Langerhans' cell histiocytosis in children

The predominant clinical and radiological features of Langerhans' cell histiocytosis (LCH) in children are due to osseous involvement. Extra-osseous disease is far less common, occurring in association with bone disease or in isolation; nearly all anatomical sites may be affected and in very various combinations. The following article is based on a multicentre review of 31 children with extra-osseous LCH. The objective is to summarise the diverse possibilities of organ involvement. The radiological manifestations using different imaging modalities are rarely pathognomonic on their own. Nevertheless, familiarity with the imaging findings, especially in children with systemic disease, may be essential for early diagnosi

Noninflammatory fallopian tube pathology in children

Noninflammatory tubal abnormalities are rare in children and usually not well covered by traditional educational material. The presenting symptoms are nonspecific and are common to many other conditions, so its preoperative diagnosis is rarely made. The purpose of this study was to review the hospital charts and imaging findings in children and sexually inactive adolescents who showed fallopian tube pathology. Understanding of the pertinent findings of previous imaging examinations might assist radiologists in making the correct preoperative diagnosis and increase the likelihood of preserving the fallopian tubes. The clinical entities described in this article include isolated tubal torsion, paratubal cysts, hydrosalpinx, undescended/ectopic fallopian tube, and tubal inguinal herni

Correlation of lung abnormalities on high-resolution CT with clinical graft-versus-host disease after allogeneic versus autologous bone marrow transplantation in children

Background: Late-onset noninfectious pulmonary complications (LONIPCs) are life-threatening complications of bone marrow transplantation (BMT). Several pathological patterns are described in the literature with different prognoses, and with different relationships to graft-versus-host disease (GVHD). The role of high-resolution CT (HRCT) is not yet well established. Objective: To illustrate different patterns of LONIPCs on HRCT in allogeneic versus autologous BMT in order to investigate the correlation with chronic GVHD (cGVHD). Materials and methods: A total of 67 HRCT scans were performed in 24 patients with noninfectious pulmonary disease at least 3months after BMT (16 allogeneic, 8 autologous). Abnormality patterns and extension on HRCT images were correlated with the clinical outcome and with the severity of cGVHD. Results: Of 24 patients, 9 showed LONIPCs (1 autologous, 8 allogeneic). There was a significant association between abnormalities on HRCT and severe cGVHD (P = 0.038), with no specific pattern. Prognosis seemed to be related to the severity of cGVHD and not to the extent of abnormalities on HRCT. Conclusion: The significant association between abnormalities on HRCT and severe GVHD suggests that LONIPCs can be a pulmonary manifestation of the disease. HRCT is a useful tool when combined with clinical dat

Bird breeder's disease: a rare diagnosis in young children

Bird breeder's lung disease is the most common form of hypersensitivity pneumonitis and is a rare entity in young children. We report three cases of children under 7 years of age in whom this diagnosis was confirmed early in the course of the disease. Three children aged 4.4 to 6.5 years presented with dry cough lasting for more than 1 month, dyspnoea, variable loss of appetite, weight loss, fatigue, fever and mild signs of respiratory distress. Chest X-ray films and CT scans showed a bilateral micronodular infiltrate. All three patients had strongly suggestive bronchoalveolar lavage fluid findings with lymphocytosis; two had elevated cell counts and decreased CD4/CD8 ratios. Lung biopsy confirmed the diagnosis in all children. Contact with allergens was identified in all children: two had spent holidays close to a farm in the previous month and one was living next to a pigeon house. In all children, avian precipitins were positive. The symptoms rapidly resolved after allergen avoidance and treatment with oral prednisone. Corticoid treatment was given between 11 and 15 weeks. One child relapsed and required long-term low-dose corticotherapy for 1 year. Lung function tests were normal in all three patients, 3.9 to 5.7 years after diagnosis. Conclusion:Bird breeder's lung disease is a rare entity but should be considered in young children presenting long lasting cough. While rapid allergen exclusion and start of treatment can avoid the evolution into irreversible lung fibrosis, clinical and biological evolution should be monitored carefully even after stopping corticoid treatment because of the possibility of relaps