Inflammatory Stranding Research Articles

Emphysematous Pancreatitis in an Immunocompetent Patient

Emphysematous pancreatitis (EP) is a quite rare complication of acute pancreatitis (AP) but has a grave prognosis. Gas-forming organisms from the bowel may enter the pancreas to cause EP. Successful treatment requires aggressive management of the infection with early surgical debridement. We report a case of an immuncompetent patient who presented with acute pancreatitis that was complicated with EP. A 65 year-old male with prior cholecystectomy presented with one day of acute diffuse abdominal pain with mild nausea but no vomiting. He reported no new medication, no alcohol use or recent illness. Exam showed diffusely distended tender abdomen with no rebound. His serum lipase and amylase were 29, 3000 and 4735 U/L in order with normal serum triglycerides. CT abdomen showed diffuse peripancreatic inflammatory stranding and fluid consistent with AP (image 1). Diagnosis of AP of unknown cause was made. The patient was treated with bowel rest, IV fluids, and pain medications. He did not improve clinically and was intubated 4 days after due to altered mental status and respiratory distress. One week after, he was found to have worsening abdominal distention, hypotension, tachycardia, oliguria and rising lactate; picture of septic shock although pancreatic enzymes remained low. Urgent CT abdomen showed severe emphysematous pancreatitis complicated by pneumatosis, portal venous gas and free intraperitoneal air in addition to a large extrapancreatic collection containing air and fluid (image 2). He underwent emergent exploratory laparotomy, pancreatic necrosectomy and GJ tube placement. E coli and numerous Bacteroides fragilis were isolated from the necrotic tissue. He was discharged 5 weeks after surgery. EP is a very rare, potentially fatal variant or complication of severe acute pancreatitis with gas in the pancreatic bed. Mortality and morbidity rates approach about 40% and 100%, respectively. There are isolated case reports describing this condition. EP iscaused by necrotizing infection of the pancreas with gas-forming bacteria as E coli, C perfrigens, Staphylococcus, Streptococcus, Klebsiella and Pseudomonas species. The diagnosis is made clinically and and radiologically. Retroperitoneal gas in a patient who has clinical evidence of pancreatitis warrants early use of antibiotics, percutaneous drainage of the fluid collection, and surgical resection of the infected necrotic tissue if there is no clinical response to those measures.Figure 1Figure 2

Beyond acute appendicitis: imaging and pathologic spectrum of appendiceal pathology

While acute appendicitis is a common and important clinical problem, a variety of other disease processes can affect the appendix. Simple and perforated appendicitis, tip appendicitis, and stump appendicitis share a common clinical presentation including anorexia, right lower quadrant pain, and fever. By imaging, most cases of acute appendicitis exhibit luminal dilation, wall thickening, and periappendiceal inflammatory stranding. In tip appendicitis, these changes are isolated to the distal appendix, often with an obstructing appendicolith. Perforated appendicitiscan exhibit mural discontinuity, periappendiceal abscess, and/or extraluminal appendicoliths. After appendectomy, the appendiceal remnant or "stump" can become inflamed, often necessitating repeat surgery. Inflammatory bowel disease can involve the terminal ileum, secondarily involving the appendix, or may primarily involve the appendix. Patient symptoms can be chronic in such cases, and mucosal hyperenhancement is a pronounced imaging feature. In asymptomatic patients without appendiceal inflammation, the appendix can be dilated by intraluminal material such as inspissated succus in cystic fibrosis or mucus from benign appendiceal mucocele. Finally, neoplasms such as typical appendiceal carcinoid tumor and mucinous adenocarcinoma can involve the appendix. Carcinoids are often small and incidentally discovered at pathologic examination, while malignant mucinous adenocarcinoma tends to present with advanced disease including pseudomyxoma peritonei. Cecal cancers can also obstruct the appendiceal lumen and cause acute appendicitis; an astute radiologist can recognize this prospectively and facilitate definitive resection (right hemicolectomy) at the time of surgery. Attention to mural features, cecal configuration, and periappendiceal inflammation is essential to the correct prospective diagnosis of complicated appendicitis and less common appendiceal pathologies.

Inferior Vena Cava Thrombosis in Acute Pancreatitis: A Rare Vascular Complication

Introduction: The systemic complications of acute pancreatitis are myriad and are mostly a consequence of systemic inflammatory response. Isolated portal and superior mesenteric vein thrombosis are well recognized complications of acute pancreatitis, while thrombosis involving the inferior vena cava (IVC) is extremely rare. Case Report: A 79-year-old male with history of chronic alcoholism presented with upper abdominal pain of 3 weeks' duration. Initial evaluation revealed epigastric tenderness and a serum lipase level of 1,041 U/L. Abdominal computerized tomography showed inflammatory stranding in the pancreatic head, 7-mm pancreatic duct calculus, and punctate calcifications in the pancreatic body suggestive of acute on chronic pancreatitis. He also had a pancreatic pseudocyst and 3.4-cm thrombosis in the IVC above the level of right renal vein with 60% luminal obstruction. He was started on intravenous heparin. He developed abdominal distension and a fall in the hematocrit in the next 2 days. Repeat imaging revealed hemorrhage into the pseudocyst with probable rupture into the peritoneal cavity. Anticoagulation was stopped and he was conservatively managed with blood transfusion. An IVC filter was placed. The workup for hypercoagulabe state including factor V Leiden mutation, prothrombin gene mutation, and activity of protein C, protein S, and antithrombin III was unremarkable. An ERCP done later showed pancreatic duct stricture with calculus that was not amenable to endoscopic treatment. He is on followup and is doing symptomatically well. Discussion: Venous thrombosis occurring outside the splanchnic circulation is very rarely described in pancreatitis. Release of pancreatic proteolytic enzymes due to acute inflammation is the most likely mechanism responsible for thrombosis of the splenic, portal, and superior mesenteric veins. IVC thrombosis can result from systemic inflammatory response with hypercoagulable state or a pancreatic cyst that compresses or penetrates the IVC. Pulmonary thromboembolism is a potential cause of mortality and morbidity in patients with IVC thrombosis, hence early recognition of this complication is vital. There are isolated reports of patients with acute pancreatitis and extra-splanchnic venous thrombosis who have been successfully treated with anticoagulation. In the setting of a pancreatic pseudocyst, anticoagulation is fraught with danger as it can result in hemorrhage into the cyst as described in our case. IVC filter placement is a good alternative in patients who cannot undergo anticoagulation or develop bleeding after anticoagulation. Literature regarding the optimal strategy and the duration of anticoagulation in these patients is minimal.

Gastrointestinal basidiobolomycosis: mimicking Crohn’s disease case report and review of the literature

Gastrointestinal basidiobolomycosis (GIB) is an unusual fungal infection that manifests in the skin and rarely involves other systems. All of the few cases of GIB reported so far were diagnosed with difficulty, necessitating laparotomy and resection of the inflamed part of the bowel. We report a child with GIB who was successfully diagnosed endoscopically without surgical intervention.

Aortoduodenal Fistula: Not Always Bleeding

1Division of Gastroenterology, Department of Medicine; 2Division of Vascular Surgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia Correspondence: Dr Michael F Byrne, Division of Gastroenterology, Department of Medicine, University of British Columbia, 5153-2775 Laurel Street, Vancouver, British Columbia V5Z 1M9. Telephone 604-875-5640, fax 604-875-5378, e-mail michael.byrne@vch.ca Received for publication March 17, 2013. Accepted May 12, 2013 Case Presentation A 73-year-old woman presented to a community hospital with three months of intermittent, followed by continuous epigastric pain. There was no gastrointestinal bleeding, nausea, vomiting or fever. A noncontrast abdominal computed tomography scan identified gas locules around an aortobifemoral bypass graft performed in 1992, with surrounding inflammatory fat stranding (Figure 1A). Graft infection was suspected. Metronidazole was prescribed with outpatient follow-up by a vascular surgeon who referred her for gastroscopy. At the third part of the duodenum, a wall defect 3 cm × 2 cm in size was replaced by a yellow-coloured foreign body suspected to be the external surface of an aortic Dacron graft (Figure 1B). The aortoduodenal fistula was treated with an axillofemoral graft, removal of the infected graft and a duodenal-jejunostomy, in which the lateral wall defect at the junction of the third and fourth parts of the duodenum was closed with a loop of proximal jejunum (Figure 1C). Cultures from the excised graft had growth of Candida lusitaniae and Streptococcus constellatus. Antimicrobials were commenced, with recovery in two months.

Emergent and Nonemergent Nonbowel Torsion: Spectrum of Imaging and Clinical Findings

Although bowel torsion is more commonly described in the medical literature, torsion can affect various organs within the chest, abdomen, and pelvis, including the testes, ovaries, gallbladder, spleen, heart, and pulmonary lobes. A structural abnormality such as a mass (a "lead point") that promotes twisting around a vascular pedicle often predisposes an organ or other anatomic structure to torsion. Radiologists play a central role in detecting torsion, identifying the anatomy involved, and triaging patients for either emergent surgical intervention, which may be critical for organ salvage, or conservative management. Imaging findings that are suggestive or indicative of emergent torsion include an ectopic location and enlargement or edema of part or all of an organ, decreased blood flow at color Doppler ultrasonography, and a twisted vascular pedicle. Blood flow to an organ is quickly compromised by the constriction of vessels within the twisted pedicle, and ischemia may result; a delay in diagnosis and surgical treatment can lead to complications such as infarction, hemorrhagic necrosis, and abscess. By contrast, torsion of mobile fatty structures such as testicular appendages, epiploic appendages, omental fat, and pericardial fat pads, although it may produce pain mimicking that in an emergent condition, requires only conservative management. Imaging features of this nonemergent condition include a fatty mass, which is usually located alongside the colon when torsion involves the omentum or an epiploic appendage, with associated inflammatory stranding and tenderness at palpation. The radiologist should be familiar with these manifestations of nonemergent torsion to prevent unnecessary surgical intervention.

Deep Vein Thrombosis /Pulmonary Embolism in a Patient with Retroperitoneal Fibrosis: A Case Report

Introduction: Retroperitoneal Fibrosis (RPF) is a clinicopathological condition characterized by inflammatory fibrotic reaction around infrarenal aorta, iliac vessels and surrounding retroperitoneum with myriad presentations. This case report shows how a Deep Vein Thrombosis (DVT) and subsequent Pulmonary Embolism (PE) can be a potential complication of this disease. A potential temporal association was seen with chronic beta blocker use and retroperitoneal fibrosis. Case presentation: A 62-year-old Caucasian male with history of hypertension on chronic beta-blocker therapy for 2 years (Metoprolol 50 mg twice daily) presented with sub-acute left sided non-radiating lower back pain of 5-day duration. Computerized Tomography (CT) scan with contrast of the abdomen and pelvis revealed large segment of inflammatory stranding involving the periaortic retroperitoneum extending from the level of the kidneys upto the pelvis and incasing the left Iliac veins. CT guided retroperitoneal core biopsy was done which was consistent with retroperitoneal fibrosis. Two months later, patient presented with complain of acute onset shortness of breath and increasing lower extremity edema, on the left side. Electrocardiogram was consistent with a finding of new onset Atrial fibrillation (A fib). Ultra Sono Gram (USG) Doppler study of lower extremities unveiled occlusive left sided DVT of the popliteal vein. A CT Angiography demonstrated segmental and sub-segmental pulmonary emboli of the right lower lobe with no evident pulmonary edema. He was treated with steroids, digoxin and warfarin. On follow up a repeat CT scan three months later of the abdomen and pelvis showed stable retroperitoneal mass with no further progression. Conclusion: Our patient presented with lower extremity edema and imaging revealed extension of RPF to involve common iliac vessels. With beta-blockers as a possible inciting event, RPF causing venous stasis, iliac vein compression and thus DVT/PE is the most plausible explanation This case reports add to the medical literature how DVT/PE can be cause by an underlying disease entity not related to the usual causes and if not worked up patients may be labeled as having unprovoked events. Any relationship between beta blockers and RFP is questionable and has not been proven in any randomized trials, but should be thought of by the physician if such clinical situation is encountered.

Acute appendicitis: relationships between CT-determined severities and serum white blood cell counts and C-reactive protein levels

The aim of this study was to evaluate the relationships between the severity of appendicitis as depicted on CT and blood inflammatory markers of serum white blood cell (WBC) count and C-reactive protein (CRP). CT images in 128 patients (109 surgically proven and 19 with clinically excluded appendicitis) were retrospectively reviewed. Two radiologists by consensus evaluated and scored (using a 0, 1 or 2 point scale) severities based on CT-determined appendiceal diameters, appendiceal wall changes, caecal changes, periappendiceal inflammatory stranding and phlegmon or abscess formation. We investigated whether CT findings were significantly related to elevated WBC counts or CRP levels and performed the correlations of WBC counts and CRP levels with CT severity scores. Patients were also subjectively classified using four grades from normal (Grade I) to perforated appendicitis (Grade IV) on the basis of CT findings to evaluate differences in WBC counts and CRP levels between grades. Only appendiceal wall changes and the phlegmon or abscess formation were related to elevated WBC counts and CRP levels, respectively (p<0.05). CT severity scores were found to be more strongly correlated with CRP levels (r = 0.669) than with WBC counts (r = 0.222). On the basis of CT grades, the WBC counts in Grade I were significantly lower than in other grades (p<0.001), whereas CRP levels in Grade IV were significantly higher than in other grades (p<0.001). CRP levels were found to correlate with CT-determined acute appendicitis severity and could be a useful predictor for perforated appendicitis, whereas WBC counts might be useful to detect early acute appendicitis.

Chronic Pancreatitis an Extraintestinal Manifestation of Crohnʼs: Fact or Fiction?

Purpose: 32 year old male with history of pancreatitis, presents with 2 days of severe epigastric pain. Patient denied weight loss, night sweats, or bloody diarrhea. Medical history is significant for 2 bouts of acute pancreatitis 4 years ago, takes no medications and drinks 2 beers a month. On exam vitals were stable with epigastric tenderness. Labs: amylase 662U/L (0-137U/L), lipase 1395U/L (12-70 U/L), total bilirubin 0.3mg/dL (0.1-1.5 mg/dL), AST 13 IU/L (7-40IU/L), ALT 10 IU/L (7-40 IU/L), calcium 9.5 mg/dL (8.5-10.5 mg/dL), triglyceride 44 mg/dL (35-150 mg/dL), IgG subclasses 1-4 normal and WBC 11 K/uL (4.5-11.5 K/uL). CT: mild peripancreatic inflammatory stranding extending throughout the pancreas. Ultrasound: normal gallbladder without cholelithiasis or ductal dilatation and unremarkable pancreas. Patient was treated with narcotics and IV fluids. Hospital day #3 patient had worsening abdominal pain and distention. Patient was treated with nasogastric tube, followed by colonoscopy for decompression. Colonoscopy: scattered erythema, blunting of vascular pattern, and ulcers extending from cecum to descending colon; biopsies taken. Pathology: chronic active colitis with non-caseating granuloma without dysplasia; consistent with Crohn's disease (CD). EUS showed features suggestive of mild chronic pancreatitis. We report a case of pancreatitis as the initial presentation of CD. Pancreatitis is one of several known extraintestinal manifestations of CD and UC. The incidence of pancreatitis as a true extraintestinal manifestation has been a difficult task to prove, as it is rare and many of the drugs used to treat IBD may also cause pancreatitis. Barthet et al found a 1.2% incidence chronic pancreatitis by following all IBD patients over a 15 yr period at a group of French hospitals. Seyrig et al. similarly reported a 1.5% incidence. The previously reported studies may easily be underestimating the incidence in IBD, considering they only evaluated symptomatic patients. It has been reported that some cases of pancreatic involvement may indeed be asymptomatic in IBD. Generally in the natural history of IBD most extraintestinal manifestation occur after the diagnosis, however, a literature review proves that pancreatitis may precede the diagnosis of IBD. The mechanism of pancreatic involvement in IBD is unknown. It has been suggested that inflammatory involvement of the duodenal papilla may cause pancreatic obstruction, thereby leading to pancreatitis. However Barthet et al, reported only 1 periampullary involvement. Others have reported on intrapancreatic granulomatous inflammation. It is important that more research be conducted to understand the mechanism of injury to the pancreas in IBD.

Focal Chronic Ischemic Colitis Involving the Cecum Mimicking a Neoplasm

Purpose: Chronic ischemic colitis of right colon is rare and the exact pathogenesis remains unclear. We present a case of chronic focal ischemic colitis of cecum presenting as a neoplasm. An 87 year old Caucasian male with a history of coronary artery disease, hypertension, type 2 diabetes mellitus, chronic anemia, peripheral vascular disease, severe aortic stenosis and paroxysmal atrial fibrillation, not on anticoagulation, presented with a two day history of exertional dyspnea, orthopnea and right lower quadrant (RLQ) abdominal pain. He also reported some weight loss but denied hematochezia, melena or a change in bowel habits. Clinical diagnosis of NSTEMI and CHF exacerbation was made and appropriate medical treatment was initiated. A CT scan of the abdomen and pelvis was obtained to further evaluate the RLQ abdominal pain and tenderness. It showed focal nodular thickening in the cecal area with pericecal inflammatory stranding suspicious for a mass lesion, and sigmoid colon diverticulosis. Due to a recent NSTEMI, and absence of active bleeding, colonoscopy was deferred. His condition improved and he was discharged on day 7. He returned four days later with hematochezia and worsening anemia. On physical examination, he had an irregularly irregular rhythm, 2/6 systolic murmur and no palpable mass in the abdomen. There was no abdominal tenderness, rebound tenderness or guarding. Laboratory studies showed WBC 4130 hemoglobin 9.8 g/dl, platelets 429,000, and BNP 2039 pg/ml (0-120). CEA was normal at 1.02 ng/ml (0-3.4). A colonoscopy showed small non-bleeding internal hemorrhoids, diverticulosis and a circumferential, ulcerated mass in cecal region suspicious for a neoplasm, absence of cecal landmarks, and presence of blood and clots in the colon. Colonoscopic biopsies revealed colonic mucosa with non-specific architectural distortion. Due to an underlying suspicion of a neoplasm, the patient underwent a right hemicolectomy. Surgical pathology revealed 4 cm × 5 cm firm ulcerated lesion adjacent to the ileocecal valve with histopathological findings of localized chronic ischemic colitis. Multiple thrombi were also identified in arterioles in the vascular distributions of the ulcerated area. There was no evidence of malignancy. Patient had an uncomplicated postoperative course with complete resolution of symptoms. This is a rare case of chronic focal ischemic colitis of cecum presenting as cecal mass and mimicking a neoplasm. However, histopathology of the resected specimen confirmed the diagnosis of chronic ischemic colitis. We propose that focal chronic ischemic colitis of the cecum should be considered in the differential diagnosis of RLQ abdominal mass in the appropriate setting.

CT findings in children with Meckel diverticulum

Approximately 0.04% of the general population will present with a complication related to Meckel diverticulum. The classic teaching is that symptomatic children with Meckel diverticulum present with painless rectal bleeding and are evaluated with a radionuclide scan. Our subjective experience is that we see children with Meckel diverticulum who present with abdominal pain and are evaluated by CT. We reviewed the findings on CT in children with pathologically proven Meckel diverticulum to identify characteristic patterns of presentation. Databases were searched (2004-2008) for all children who had a pathologic diagnosis of Meckel diverticulum and a CT scan performed prior to surgery. Demographics, pathology, and CT features were reviewed. CT features reviewed included: soft-tissue stranding, abnormal calcifications, bowel obstruction, free air, free peritoneal fluid, cystic mass, intussusception, obvious lead point, location, and whether a normal appendix was identified. The frequency of Meckel diverticulum encountered on CT scans was compared to that found during the same period of time on technetium pertechnetate studies. The review identified 16 subjects (mean age 9.5 years, M:F 9:7). CT findings included: soft-tissue stranding in nine (56%), small-bowel obstruction (SBO) in nine (56%), intussusception in three (19%), free fluid in ten (63%), cystic mass in four (25%), calcification in none (0%), free air in one (6%), and no abnormalities in two (13%). A normal appendix was identified in only five children (31%). There were three basic patterns of presentation of abnormalities: SBO only in five, intussusception with SBO in three, or cystic mass with inflammatory stranding in four (one with SBO). Also, 2.3 times more Meckel diverticulum was encountered on CT than on technetium pertechnetate studies. Meckel diverticulum is currently more commonly encountered in children on CT performed for abdominal pain than on technetium pertechnetate studies. There are three categories of appearance on CT: SBO only, intussusception, or a cystic inflammatory mass.

Radiologic testing in Crohnʼs disease

Answer: The diagnosis of CD is usually the result of a constellation of clinical, endoscopic, radiological, and histological findings. CD, a systemic, segmental chronic granulomatous disease affects the terminal ileum and proximal colon in 70% of cases, small bowel alone in 30%–40%, and isolated colonic disease in 20%.1 Radiological studies are important in making the diagnosis of CD, assessing the extent and severity of disease, and defining the response to medical and surgical therapy. The ideal imaging technique should be one that is cheap, readily available, and highly accurate. Traditionally, small bowel follow-through (SBFT) and small bowel enteroclysis have met this criteria and have been the diagnostic tools of choice for small bowel CD.2,3 Although there is controversy as to which technique is superior, local expertise usually determines which of these modalities is preferred. The SBFT requires ingestion of a barium meal, whereas an enteroclysis requires placement of a nasoduodenal tube through which barium and air are passed. The earliest CD lesions detectable on a barium x-ray are aphthous ulcers. In more advanced CD, the ulcers enlarge and coalesce to form stellate, serpiginous, or deep linear ulcers that appear as cobblestoning on barium x-rays. In penetrating CD the deep ulcers form fissures, sinus tracks, and fistulas; these are readily identified by pooling or tracking of barium transmurally. Chronic inflammatory CD results in intramural fibrosis and scarring that is depicted by circumferential thickening of the bowel wall and significant luminal narrowing. Patients with obstructive symptoms often develop bowel dilation proximal to the stricture that connotes a degree of chronicity and “fixed” fibrostenosis. Often luminal narrowing from inflammatory stenosis and fibrostenotic stricture may be difficult to delineate on barium studies. The treatment implications are important, as patients with obstructing fibrotic strictures require surgery, whereas patients with inflammatory stenosis may respond to medications and have return of normal caliber lumen after treatment.2,4–6 Computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US) are the preferred modalities for evaluating extraluminal CD, e.g., abscesses or phlegmon. The most common finding on CT in CD patients is mural thickening, often associated with perienteric inflammatory stranding.6,7 CT scan is the modality of choice for diagnosing and treating intraabdominal abscesses. Many abscesses detected on CT are amenable to percutaneous drainage. This allows for elective definitive medical or surgical therapy and often avoids the need for emergent surgery and ileostomy. Endoscopic ultrasound (EUS) and pelvic MRI have been particularly useful in diagnosing perirectal and perianal fistula and guiding therapy.8,9 EUS is over 90% accurate in identifying perianal fistula and abscesses. Combined with MRI and surgical exam under anesthesia the diagnostic accuracy rates approach 100%. EUS and MRI may delineate which fistula are simple and complex, and which fistula require surgical intervention alone or in combination with medical therapy. Likewise, EUS and MRI may guide infliximab therapy by determining which fistula are completely healed and which persist despite the external skin portion closing. Video capsule endoscopy (CE) is a useful tool in assessing small bowel CD.10 The role of CE in CD has yet to be firmly established. The CE is more sensitive than barium studies at detecting small mucosal defects that may be of little clinical significance.11 It has been our experience that CE may be a useful study in patients with a known diagnosis of CD and persistent symptoms despite normal SBFT. For example, we have detected significant small bowel CD, i.e., inflammatory stenosis, deep ulcers, stricture, in patients with normal SBFT. This finding has led to alteration in treatment and in a few cases surgery. Also, CE may play a role in patients with indeterminant colitis (IC) scheduled for surgery. Patients with IC and small bowel disease on CE should have a permanent ileostomy rather than ileal pouch anal anastomosis. A combination of CT scan with SBFT affords simultaneous evaluation for intraand extraluminal CD while assessing the abdominal viscera. The recent advent of CT enterography and CT enteroclysis has married these modalities in 1 exam.12,13 The patient is administered oral and IV contrast dye simultaneously. The downside to this combined modality From the Inflammatory Bowel Disease Center, Division of Gastroenterology, Hepatology, & Nutrition, University of Pittsburg School of Medicine, Pennsylvania, USA. Copyright © 2008 Crohn’s & Colitis Foundation of America, Inc. DOI 10.1002/ibd.20614 Published online in Wiley InterScience (www.interscience.wiley.com).

Sudden loss of consciousness and right flank pain associated with renal infarction.

While at home, a 77-year-old woman with atrial fibrillation (Af), coronary artery disease, hypertension and a 10-year history of hyperlipidaemia experienced a loss of consciousness combined with sudden onset of right flank pain and fell on the ground. She was brought to our hospital where brain computerized tomography (CT) revealed an acute infarction over the left middle cerebral artery and posterior cerebral artery. Electrocardiography showed Af with a ventricular rate of 116 beats per minute. Her blood pressure was 130/70 mmHg, and her heart beat was irregular. She had normal pupil size and light reflex. There was a throbbing pain over her right costo-vertebral angle but no local abdominal tenderness was seen. No bruit was heard. Her white blood cell count was 20420/cumm, haemoglobin 12.5 g/dL and platelets 208 × 103/cumm. Her serum lactate dehydrogenase was 1000 IU/dL, creatinine 2.1 mg/dL, urea nitrogen 24 mg/dL and potassium 3.2 mmol/L. Urine analysis revealed protein 2+, red cell 2–5/ high power field (HPF) and white cell 1–3/ HPF. Markers for anticardiolipin antibody, lupus anticoagulant, anti-thrombin III, and protein C and S were unremarkable. Abdominal contrast with CT revealed a markedly less-enhanced right renal parenchyma (Figure 1). An enhancement of the left kidney was also noted. There were no stones and no perinephric inflammatory stranding. Renal arterial angiography (Figure 2A) revealed total occlusion of the right renal artery and

Masticator space abscess in a 21-month-old child

A 21-month-old male presented with fever, dehydration and severe trismus. A computerized tomogram of the head and neck was obtained that showed inflammatory stranding involving the right pterygoid, masseter and parotid spaces as well as fluid collection within the right pterygoid (masticator) space. Intraoral drainage was successful. S. Aureus was identified on culture from the drainage site. No apparent focus of infection was identified. Appropriate antibiotics were given and the patient recovered. It is postulated that an ascending infection from the oral cavity to the parotid gland with subsequent involvement of the right masticator space occurred.

Differentiation of Nonperforated from Perforated Appendicitis: Accuracy of CT Diagnosis and Relationship of CT Findings to Length of Hospital Stay

To determine retrospectively the sensitivity and specificity of computed tomographic (CT) signs in differentiating acute nonperforated appendicitis from perforated appendicitis and to compare CT findings with the length of hospital stay. Institutional Review Board approval was obtained for this study, and patient informed consent was obtained for record review for research purposes. Two radiologists were blinded to patient identification but were informed that all patients presented to the emergency department with abdominal pain and underwent appendectomy. Radiologists independently reviewed CT images of 86 consecutive patients (45 males, 41 females; mean age, 33.7 years; age range, 8.2-87.1 years) who presented to the emergency department with acute abdominal pain, who underwent CT after initial emergency department assessment, and who underwent appendectomy within the subsequent 24 hours. Individual findings and confidence level for the diagnosis of perforated appendicitis were noted. Consensus interpretation was performed with a third radiologist. The consensus CT findings were correlated with the surgical and pathologic findings by using chi(2) or Fisher exact tests for univariate analysis and logistic regression for multiple variable analysis. Wilcoxon rank sum tests were used to assess the association between consensus CT findings and length of hospital stay. Twenty-one (24%) of the 86 patients had appendiceal perforation. Extraluminal air and either moderate or severe periappendiceal inflammatory stranding were statistically significant independent predictors for perforation (P < .001). A focal defect in enhancing appendiceal wall was significantly associated with perforation (P < .001) and had a sensitivity of 58.8% and specificity of 85.7% on consensus review, with eight false-positive results. There was a strong association between the degree of periappendiceal inflammatory stranding and the length of hospital stay (P < .001). Extraluminal air and moderate or severe periappendiceal inflammatory stranding are statistically significant independent predictors for appendiceal perforation and are associated with increased hospital stay.

Lymphadenitis due to nontuberculous mycobacteria in children: presentation and response to therapy.

The most common manifestation of infection due to nontuberculous mycobacteria (NTM) in children is cervical lymphadenitis in an otherwise healthy patient. We identified and reviewed 19 cases of proven or presumptive lymphadenitis due to NTM seen at our hospital over the course of 13 months. Nine patients underwent initial surgical excision of involved lymph nodes. Ten children did not have involved lymph nodes excised initially and were treated with macrolide-containing antibiotic regimens. Of these patients, five required subsequent surgical excision and five were cured with combination chemotherapy. Six patients underwent radiographic imaging of the head and neck that revealed asymmetrical adenopathy with ring-enhancing masses but minimal inflammatory stranding of the subcutaneous fat, a finding that may distinguish adenitis caused by NTM from staphylococcal and streptococcal adenitis. Our data suggest that if surgical excision is not considered feasible, antimicrobial therapy for adenitis due to NTM may be beneficial for some patients.