Thoracic CT Scan Research Articles

Chest CT scan plus x-ray versus chest x-ray for the follow-up of completely resected non-small-cell lung cancer (IFCT-0302): a multicentre, open-label, randomised, phase 3 trial

Even after resection of early-stage non-small-cell lung cancer (NSCLC), patients have a high risk of developing recurrence and second primary lung cancer. We aimed to assess efficacy of a follow-up approach including clinic visits, chest x-rays, chest CT scans, and fibre-optic bronchoscopy versus clinical visits and chest x-rays after surgery for resectable NSCLC. In this multicentre, open-label, randomised, phase 3 trial (IFCT-0302), patients aged 18 years or older and after complete resection of pathological stage I-IIIA NSCLC according to the sixth edition of the TNM classification were enrolled within 8 weeks of resection from 122 hospitals and tertiary centres in France. Patients were randomly assigned (1:1) to CT-based follow-up (clinic visits, chest x-rays, thoraco-abdominal CT scans, and fibre-optic bronchoscopy for non-adenocarcinoma histology) or minimal follow-up (visits and chest x-rays) after surgery for NSCLC, by means of a computer-generated sequence using the minimisation method. Procedures were repeated every 6 months for the first 2 years and yearly until 5 years. The primary endpoint was overall survival analysed in the intention-to-treat population. Secondary endpoints, also analysed in the intention-to-treat population, included disease-free survival. This trial is registered with ClinicalTrials.gov, NCT00198341, and is active, but not enrolling. Between Jan 3, 2005, and Nov 30, 2012, 1775 patients were enrolled and randomly assigned to a follow-up group (888 patients to the minimal follow-up group; 887 patients to the CT-based follow-up group). Median overall survival was not significantly different between follow-up groups (8·5 years [95% CI 7·4-9·6] in the minimal follow-up group vs 10·3 years [8·1-not reached] in the CT-based follow-up group; adjusted hazard ratio [HR] 0·95, 95% CI 0·83-1·10; log-rank p=0·49). Disease-free survival was not significantly different between follow-up groups (median not reached [95% CI not estimable-not estimable] in the minimal follow-up group vs 4·9 [4·3-not reached] in the CT-based follow-up group; adjusted HR 1·14, 95% CI 0·99-1·30; log-rank p=0·063). Recurrence was detected in 246 (27·7%) of 888 patients in the minimal follow-up group and in 289 (32·6%) patients of 887 in the CT-based follow-up group. Second primary lung cancer was diagnosed in 27 (3·0%) patients in the minimal follow-up group and 40 patients (4·5%) in the CT-based follow-up group. No serious adverse events related to the trial procedures were reported. The addition of thoracic CT scans during follow-up, which included clinic visits and chest x-rays after surgery, did not result in longer survival among patients with NSCLC. However, it did enable the detection of more cases of early recurrence and second primary lung cancer, which are more amenable to curative-intent treatment, supporting the use of CT-based follow-up, especially in countries where lung cancer screening is already implemented, alongside with other supportive measures. French Health Ministry, French National Cancer Institute, Weisbrem-Benenson Foundation, La Ligue Nationale Contre Le Cancer, and Lilly Oncology. For the French translation of the abstract see Supplementary Materials section.

What is the best choice of follow-up procedure following resection of lung cancer?

Follow-up after treatment of all primary cancer aims to detect recurrence at a treatable stage and any potential complications. The type of follow-up regimen is chosen after weighing risks and benefits—ie, likelihood and location of recurrences, possible risks associated with the procedures, or the consequences of the interpretation of findings. Recommendations are released by medical societies (eg, the National Comprehensive Cancer Network), but mostly reflect expert opinion. Chest CT scan plus x-ray versus chest x-ray for the follow-up of completely resected non-small-cell lung cancer (IFCT-0302): a multicentre, open-label, randomised, phase 3 trialThe addition of thoracic CT scans during follow-up, which included clinic visits and chest x-rays after surgery, did not result in longer survival among patients with NSCLC. However, it did enable the detection of more cases of early recurrence and second primary lung cancer, which are more amenable to curative-intent treatment, supporting the use of CT-based follow-up, especially in countries where lung cancer screening is already implemented, alongside with other supportive measures. Full-Text PDF

Calcification of the ascending aorta, left heart valves and coronaries: associated diseases and a new classification.

Aim: The topography of vascular and valvular calcification could help accurately predict cardiovascular post-operative complications. The data on these calcifications remains scarce. Purpose: Identify the topographic distribution of the ascending aortic, left heart valves and coronary calcifications. Materials & methods: We extracted 26 variables from 557 patients, hospitalized between 2017 and 2020. The topography of calcification was evaluated by thoracic CT scans. Both multivariate logistic regression and classification and regression tree (CART) were used for statistical analysis. Results: Several comorbidities were associated with vascular or valvular calcification. This study proposes a CART tree for patients according to their age, sex, Euroscore and lipid profile. Conclusion: The proposed classification could represent an important clinical tool. More studies are warranted to better prune the current CART algorithm.

Correlation Between COVID-19 Severity Status and the Thoracic CT-Scan Examination Results: A Cross Sectional Study

Coronavirus Disease 2019 (COVID-19) has been a pandemic for two years after the World Health Organization (WHO) initially announced it on March 11, 2020. The conventional diagnosis of COVID-19 is often made using a reverse transcription polymerase chain reaction (RT-PCR) and supported by radiographic examinations such as chest CT-SCAN which is regarded to be an additional modality to help quantify the severity of COVID-19 disease. This study's objective is to examine the link between the severity of cases and the chest CT-SCAN pictures observed in COVID-19 patients. The study was conducted at the Wahidin Sudirohusodo Hospital in Makassar. To determine the association between the severity of COVID-19 and the CT-SCAN image of the thorax, a cross-sectional study was conducted and statistical analysis was performed using the chi-square test. A study of 382 samples revealed that the majority of COVID-19 case subjects with a significant relationship to the severity of severe cases were male, older than 50 years, smokers, with comorbid diabetes mellitus, hypertension, kidney failure, heart disease, and evaluation of typical chest CT-SCAN images. Tests of statistical significance revealed a correlation between extreme clinical severity and severe CT-SCAN pictures of the thorax. The thoracic CT-SCAN can modalities shown has a benefit to be utilized as a diagnostic and evaluating tool of the patients. Keywords: Covid-19, case severity status, thoracic CT-scan examination.

An Impressive Case of Compulsive Chicken Bones Ingestion.

CASE REPORT A 53-year-old woman with a medical history of depression and anxiety was admitted because of idiopathic anaphylaxis. Owing to acute respiratory failure, she underwent a thoracic computed tomography scan, which revealed a large number of bone fragments inside the stomach and duodenum (Figure 1). The patient was evaluated by psychiatry and admitted because she had ingested numerous chicken legs in the context of acute alcohol intoxication. We had some concerns about the efficacy and safety of performing an upper gastrointestinal endoscopy in this scenario. Indeed, there were already some bone fragments beyond the proximal duodenum and the objects were numerous and sharp. Thus, there was a high risk of complications (e.g., perforation and aspiration) during the procedure, with the probability of successful removal of all the fragments being very low. Therefore, we chose to start treatment with metoclopramide. During hospitalization, she underwent daily abdominal imaging examinations, which showed progression of the bone fragments through the small bowel and colon (Figure 2), with no evidence of obstruction or perforation. Later, the patient started oral feeding, with good tolerance. Because she maintained abdominal pain, and to exclude local complications, a colonoscopy was performed 10 days after admission. No foreign bodies or mucosal changes were identified. Given the progressive improvement in her clinical condition, the patient was discharged and oriented to immunoallergy and psychiatry consultation.Figure 1.: Computed tomography scan showing multiple chicken legs inside (A) the stomach and (B) the duodenum, with no evidence of obstruction or perforation.Figure 2.: Computed tomography scan showing the progression of the bone fragments through the small bowel and colon, without complications.We report an impressive case of ingestion of large amounts of chicken bones, which crossed the entire gastrointestinal tract without complications and only minor symptoms. Foreign body ingestion remains a common problem both in pediatric and adult populations.1,2 The associated morbidity and mortality are significant, with some reports estimating that nearly 1,500 deaths occur annually in the United States due to foreign body ingestion.3 In fact, sharp foreign bodies such as chicken bones can lead to acute and life-threatening complications, such as obstruction, hemorrhage, perforation, and associated infection, including peritonitis and sepsis.4 Complications and their severity are usually related to the object ingested, its location, and the amount of time that has passed since the ingestion.5 Gastrointestinal tract obstruction and perforations have been reported in all segments but tend to occur at sites of acute angulation. DISCLOSURES Authors contributions: I. Garrido drafted the manuscript and is the guarantor of the article. I. Garrido, P. Moutinho-Ribeiro, and G. Macedo critically revised and finalized the manuscript. All authors approved the final version of the manuscript. Financial disclosure: None to report. Informed consent was obtained for this case report.

Therapeutic bronchoscopy followed by sequential radiochemotherapy in the management of life-threatening tracheal adenoid cystic carcinoma: a case report

BackgroundAdenoid cystic carcinoma of the lung is a distinctive salivary-gland-type malignant epithelial neoplasm that rarely presents as a primary tumor of the respiratory tract. Complete surgical resection remains the treatment of choice for adenoid cystic carcinoma. We present a case of large ACC tumors that caused severe central airway obstruction and were effectively treated with therapeutic bronchoscopy followed by radiotherapy and chemotherapy.Case presentationA 31-year-old Malay Indonesian female patient who was a nonsmoker and had no family history of cancer was admitted to the emergency ward because of worsening breathlessness accompanied by stridor since 1 week prior. Chest computed tomography revealed segmental atelectasis of the left lung; a mass on the left main bronchus, with infiltrates in segments 1, 2, and 3 of the left lung; and consolidation in the left inferior lobe, with narrowing of the main left bronchus. Lobulated masses obstructing almost the entire distal trachea up to the carina and the entire left main bronchus were found on bronchoscopy. Owing to the large tumors causing severe central airway obstruction, the medical team decided to perform central airway mass removal through rigid bronchoscopy. A neodymium-doped yttrium-aluminum-garnet laser was used first to facilitate mass shrinkage. After the laser treatment, mechanical mass removal using a rigid scope was performed. The tracheal and carinal lumens were opened to > 50% of their diameter, with the left main bronchus lumen opened only slightly. After the treatment, the patient was stable, and no stridor was found. Adjuvant intensity-modulated radiotherapy and chemotherapy were performed after the therapeutic bronchoscopy. At the end of the entire treatment, reevaluation by thoracic computed tomography scan and bronchoscopy revealed no remaining mass.ConclusionsIn cases of nonresectable large adenoid cystic carcinoma tumors with life-threatening central airway obstruction, therapeutic bronchoscopy followed by sequential radiochemotherapy might achieve a complete response outcome.

Automated detection and segmentation of non-small cell lung cancer computed tomography images

Detection and segmentation of abnormalities on medical images is highly important for patient management including diagnosis, radiotherapy, response evaluation, as well as for quantitative image research. We present a fully automated pipeline for the detection and volumetric segmentation of non-small cell lung cancer (NSCLC) developed and validated on 1328 thoracic CT scans from 8 institutions. Along with quantitative performance detailed by image slice thickness, tumor size, image interpretation difficulty, and tumor location, we report an in-silico prospective clinical trial, where we show that the proposed method is faster and more reproducible compared to the experts. Moreover, we demonstrate that on average, radiologists & radiation oncologists preferred automatic segmentations in 56% of the cases. Additionally, we evaluate the prognostic power of the automatic contours by applying RECIST criteria and measuring the tumor volumes. Segmentations by our method stratified patients into low and high survival groups with higher significance compared to those methods based on manual contours.

Nodule vascularity as novel radiomics imaging endpoint for lung cancer diagnosis and prognosis.

e20580 Background: The vascularization of lung nodules has been proven as severe risk factor for malignancy, and in lung cancer, indication of worse prognosis (1,2). For this reason, we developed a novel imagining endpoint based on the vasculature surrounding a lung mass and we tested this endpoint for the prediction of malignancy for lung nodules. Methods: The vasculature of the nodules (both arteries and veins) has been computed using the surface intersection between the nodule and the vascular structure 3D meshes. Both 3D structures were obtained by converting the segmentations of the nodule and of the vessels to meshes with a marching cubes algorithm. Nodule and vessels segmentation has been obtained with an in-house deep learning segmentation model. The features considered are the numbers of intersections, the total area of intersection and the mean area of intersection. These features have been used to predict nodule malignancy on thoracic CT scans from the Lung Image Database Consortium image collection (3). Quality controls on clinical data completeness and imaging parameters resulted in a cohort of 894 scans (715 for training and 179 for testing), from the original 1018 cases. The malignancy status is defined as high risk and low risk, based on the consensus classification of a panel of four radiologists. Firstly, an univariate analysis is performed to assess the variability of the features grouped by the malignancy score by using Mann-Whitney and ANOVA tests. After, seven combinations of features have been used to train generalized linear models (GLM) to predict nodule malignancy. To compare the models, the Area Under the Curve (AUC) is used as the main performance metric. Results: Univariate analysis of each feature grouped by the malignancy outcome showed that all the three features have good univariate discriminative power between high risk and low risk categories ( p value ≤ 0.05), with nb_connections as the most predictive singular feature ( p value of 1.343277 × 10-36). All the GLM models developed showed a good performance (AUC equal or higher than 0.7), with the best model in testing based on the combination of mean_area and sum_area (AUC of 0.84). Conclusions: The radiomics vascularity endpoint has been proven capable of predicting nodule malignancy with very good performance. The singular feature that is most related to malignancy is the number of vessels intersecting the nodule while the total area of intersection followed by the number of intersections are the most useful to model risk of malignancy. Wang et al., Lung Cancer 114: 38–43, 2017. Hamanaka et al., Diagn Pathol 10,17, 2015. G. Armato et al., Med. Phys., 38: 915-931, 2011.

PULMONARY COMPLICATIONS OF ESOPHAGEAL DISEASE: ABOUT A CASE REPORT

TYPE: Late Breaking Case Report TOPIC: Pediatrics INTRODUCTION: The close anatomical relationship between the esophagus and the lung makes the latter vulnerable for esophageal diseases which are relatively common in children. CASE PRESENTATION: We report the observation of a 4-year-old girl with poly malformations suggestive of VACTERL syndrome. She underwent surgery on her first day of life for esophageal atresia with a tracheoesophageal fistula. At the age of 5 months, she developed a chronic cough and a recurrent pneumonia. The barium swallow study showed a massive supra carinal GERD, an anastomotic esophageal diverticulum and an early opacification of the bronchial tree evoking a GERD which floods the lungs or a tracheoesophageal fistula (figure). The pulmonary involvement on the thoracic CT scan was impressive with a tree-in-bud sign, parenchymatous condensations, atelectasis in retractile band, bronchiectasis and ground glass areas. she received proton pump inhibitor and anti inflammatory long term azithromycin treatment. The control barium swallow test objectified vanishing of the lung flooding. The outcome was marked by a recurrent wheezing requiring tretatment by inhaled corticosteroid. DISCUSSION: Aspiration pneumonitis is the main complication of esophageal diseases. The challenge is to determine its mechanism; is it GERD, tracheoesophageal fistula, esophageal stenosis or diverticulum as reported in this case. the objective of an early diagnosis is to not delay the appropriate treatment and to stabilize the respiratory function before irreversible damage occur, namely, bronchiectasis, bronchiolitis or lung fibrosis. CONCLUSIONS: Thus, clinical and radiological monitoring of the respiratory system in the context of esophageal disease is a crucial element to watch out for complications at an early stage. DISCLOSURE: Nothing to declare. KEYWORD: lung

THE IMPORTANCE OF GENOTYPING EGFR, ALK, AND PDL1 MUTATIONS IN THE THERAPEUTIC DECISION IN PATIENTS WITH PULMONARY ADENOCARCINOMA

TYPE: Abstract TOPIC: Lung Cancer PURPOSE: The importance of detecting mutations in the EGFR gene, ALK and PDL1 in guiding the therapeutic strategy in patients with pulmonary Adenocarcinoma METHODS: Case of a patient aged 60 years,smoker ( 30 packs per year), with professional exposure, who is under monitoring for COPD, who for 2 months presents dyspnea at medium effort, intermittent productive cough, weight loss,physical asthenia, SpO2 :95 % (a.a). Important systemic inflammatory syndrome and increased level of d-dimer, with suspicion of pulmonary thrombembolism, possibly due to the presence of a tumor. The thoracic CT scan reveals the presence of a left mediastinum-pulmonary tumor of 40/70/65 mm, minimal bilateral pleurisy,mediastinal adenopathies. Fibrobronchoscopy did not have a conclusive result. RESULTS: The patient is delaying the diagnosis and the initiation of treatment by not going on further with the investigations. After 1 year, he suffers a bilobectomy of the middle and the right upper lobe. Additional tests are performed in order to detect and genotyping the activating mutations in the EGFR gene: no activating mutations were found on EGFR gene. ALK is negative so the status of the ALK gene is not favorable for treatment with ALK inhibitors,PDL1 (22C3) positivity >50% (90% in tumor cells) offers a treatment option. CONCLUSIONS: Studies demonstrated that anti–PD-1/PD-L1 agents have important anti-tumor activity increasing survival rate in NSCLC patients . CLINICAL IMPLICATIONS: The importance of obtaining a correct diagnosis as early as possible, as well as the detection and genotyping of the activating mutations in the EGFR gene as well as ALK gene and PDL1 DISCLOSURE: Nothing to declare. KEYWORD: pulmonary adenocarcinoma, EGFR, PDL1

COVID19 INFECTION AND LIBMAN –SACKS ENDOCARDITIS IN PAST VALVE REPAIRED PATIENT

Objective: The patient was a 61-year-old woman who typically underwent mitral valve replacement and tricuspid valve repair in 2011. During these years, she underwent an annual checkup and experienced no particular problems. The potential patient contracted Covid 19 a month ago and underwent conservative treatment. The patient displayed no specific symptoms, no fever, and her Covid 19 disease was mild. In the accompanying echocardiography, we notice a lump on the atrial surface of the Tricuspid valve that we instantly suspect of local vegetation or heart mass. As a result, we admitted the patient to resume the examination. Design and method: Multi-slice (16) spiral thoracic CT scan: Sternotomy and MVR are seen. Cardiomegaly is evident. Patchy peripheral ground-glass opacities are seen bilaterally, suggesting covid-19 pneumonia; correlation with clinical and paraclinical data is recommended. Degenerative changes are perceived in the thoracic spine. There is no pleural effusion. Blood cultures and urinary trachea were requested to diagnose endocarditis, and she was also asked to have an esophageal echocardiogram. The antibiotic Meropenem 500 was started three times a day with vancomycin 1 gram twice a day for prophylaxis. After these examinations, the mass diagnosis was rejected as the image of vegetation on echocardiography did not found echogenicity similar to cardiac tissue and was denser. Consequently, we diagnosed vegetation. According to the negative culture results, and the patient had no symptoms (chills, heart pain), this patient’s diagnosis of an immunological reaction caused by Covid disease was made. Libman –sacks endocarditis is a type of sterile nonbacterial thrombotic endocarditis (NBTE) secondary to inflammation. Results: In this rare case, the vital point is that immunological reaction after covid can give rise to vegetation on the heart artificial valve and can be typically established with endocarditis. Covid can cause libman sac endocarditis, then we consider patients with heart disease maybe get limban sac or other forms of immunological reaction after covid virus. Conclusions: Concerning the explicit rejection of all the causes, the patient was diagnosed correctly with limb sac endocarditis. She underwent anticoagulant therapy and corticosteroid therapy accordingly and was recovered fully.

CONGENITAL CYSTIC ADENOMATOID MALFORMATION OF THE LUNG: REPORT OF THREE CASES

TYPE: Late Breaking Abstract TOPIC: Pediatrics PURPOSE: Congenital cystic adenomatoid malformation (CCAM) is a rare abnormality of lung development. It is a benin lesion, typically discovered during a routine prenatal ultrasound. In low-middle income settings, the prenatal diagnosis is not always available, and these malformations are often revealed by respiratory distress during the neonatal period. METHODS: We report a series of three neonates admitted to our pediatric ICU for respiratory distress secondary to CCAM. RESULTS: Three neonates A, B and C were admitted to the pediatric ICU for respiratory distress. They were aged 18 , 21 and 90 days respectfully. Prenatal diagnosis of CCAM was available in one case. Thoracic CT-scan showed CCAM of the inferior left lobe in case A, of the superior and median right lobes in case B, and of the hole right lung in case C. Case A presented with pneumothorax, he underwent a needle aspiration before surgery. Left inferior lobectomy was performed. Case B presented with severe hemodynamic instability and surgery was not performed. He died 3days later. Case C underwent atypical resection of the cystic malformations. In both surgical cases, neonates were admitted to PICU, were extubated 4 hours post-operatively and put on continous positive airway pressure (CPAP) for 24 hours. Oxygen therapy weaning was successful after 48h.They were tranfered to the pediatric surgery ward. CONCLUSIONS: CCAM is a rare malformation causing respiratory distress in neonates. Surgical procedures such as lobectomy or atypical resections are usualy performed. Complications such as pneumothorax may occur before surgery. CLINICAL IMPLICATIONS: Prenatal diagnosis is essentiel to improve the outcome of CCAM. DISCLOSURE: Nothing to declare. KEYWORD: Congenital cystic adenomatoid malformation

The Validity of Quantifying Pulmonary Contusion Extent by Lung Ultrasound Score for Predicting ARDS in Blunt Thoracic Trauma

Background Thoracic trauma comprises 20–25% of all traumas worldwide and constitutes the third most common cause of death after abdominal injury and head trauma in polytrauma patients. Pulmonary contusion (PC) is a common injury seen after blunt trauma that is associated with significant morbidity and mortality. The aim of this prospective study was to determine the value of PC extent measurements using lung ultrasound in predicting high risk patients for ARDS development. Methods In one year, 50 polytrauma patients with blunt chest trauma were admitted to the ICU at Damanhur Institute. Lung contusion extent was evaluated using a lung US score (LUS) and was compared to the CT contusion score. The ability of the LUS to predict ARDS was tested. The diagnostic accuracy of LUS was compared with chest radiography for lung contusion and pneumothorax with thoracic CT scan as a reference. Patients were restratified by LUS into two groups: severe and nonsevere contusion group. The two groups' data were compared with respect to difference in mortality and injury characteristics. Results Lung contusion assessed by LUS score was well correlated to thoracic CT scan measurements (r = 0.78). A LUS of 4 was defined as a cut-off value for predicting ARDS development within 72 hours of trauma with sensitivity and specificity (91.67% and 84.21%), respectively. Patients with severe lung contusions had a lower hypoxic index on admission, more ventilator days, a higher risk of ARDS development, more fractured ribs; higher rate of hemothorax and a higher ISS score than patients with nonsevere lung contusions. Conclusion LUS on admission can quantify lung contusion extent and the high risk of developing ARDS after blunt thoracic trauma.

Alveolar Hemorrhage: The typical aspect

We report the case of a 56 year-old patient, with a history of leukemia under treatment, who presented to the emergency room with respiratory distress associated to hemoptysis, chest pain and dyspnea NYHA stage IV with a decreased oxygen level to 85% on room air, a CBC revealed a bicytopenia. Plain radiograph showed a bilateral, peri hilar and basal alveolar syndrome, comparable to that observed in pulmonary oedema and thoracic CT scan showed bilateral and symmetrical hilifugal central ground glass areas. Alveolar hemorrhage is defined as diffuse bleeding of pulmonary capillary in distal airspaces. Rapid diagnosis is required for an efficient therapeutical management of the hemorrhage and its cause. Imaging reveals bilateral areas of alveolar condensation and/or ground glass. Negative findings, such as the absence of pleural effusion, adenopathy, cardiomegaly and signs of pulmonary hypertension (Figures 1+2) are very crucial to the diagnosis of alveolar hemorrhage. The pink appearance with siderophagus in the bronchoalveolar lavage confirms the diagnosis.

Atraumatic splenic rupture in a child with COVID 19

BackgroundThe majority of children with COVID-19 have only minor symptoms or none at all. COVID-19, on the other hand, can cause serious illness in some children, necessitating hospitalization, intensive care, and invasive ventilation. Many studies have revealed that SARS-CoV-2 affects not only the respiratory system, but also other vital organs in the body. We report here a child with an atraumatic splenic rupture as the initial and only manifestation of COVID-19.Case presentationA 13-year-old boy with clinical signs of acute abdomen, left-sided abdominal pain, and hemodynamic instability was admitted to the PICU in critical condition. His parents denied any trauma had occurred. In addition to imaging tests, a nasopharyngeal swab was taken for COVID-19 testing, which was positive. The thoracic CT scan was normal, whereas the abdominal CT scan revealed hemoperitoneum, splenic rupture, and free fluid in the abdomen.ConclusionsThe spleen is one of the organs targeted by the SARS-CoV-2. Splenic rupture, a potentially fatal and uncommon complication of COVID-19, can be the first and only clinical manifestation of the disease in children. All pediatricians should be aware of the possibility of atraumatic splenic rupture in children with COVID-19.

Body Surface Mapping system - a potential diagnostic tool for unmasking delayed right ventricular epicardial activation in ARVC patients and phenotype-negative gene-carriers

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Selanders stiftelsen Background Life-threatening ventricular arrhythmias can occur at any stages of ARVC – the detection of early manifestations of the disease may have prognostic implications. Purpose The purpose was to explore the usefulness of a 252-leads noninvasive Body Surface Mapping (BSM) system for the detection of delayed epicardial activation in ARVC patients and phenotype-negative gene-carriers (GC). Methods Twelve patients with ARVC, 20 GC and 8 genotype and phenotype negative family members served as controls (C) were included. 12-lead ECG, signal-averaged-electrocardiogram, echocardiography, 252-lead BSM recordings and thoracic CT scan were performed in all subjects. The noninvasively reconstructed epicardial signals of the right ventricle (RV) were analysed using the Activation Time Editing tool of the BSM system. Local depolarisation was defined as the steepest negative dV/dt of the local epicardial signal. The time from the start of RV epicardial signals to the earliest local depolarisation (ELD) and to the latest local depolarisation (LLD), were measured for the whole RV and separately for the anterior free wall (AW) and inferior wall (IW). The duration of the activation, defined as LLD-ELD, was calculated for AW, IW and the whole RV. Results The ELDs was similar in all study groups whereas the LLD in the IW and whole RV was significantly longer among ARVC patients compared to C. Although the activation durations in the AW and IW did not differ between the groups, the activation duration of the whole RV was significantly longer in ARVC patients. A LLD cut off of 81ms in RV and an activation duration cut off of 49msec in RV discriminated ARVC patients from C with highest sensitivity and specificity. Based on these cut-offs, 35% of GC group had longer LLD times and 70 % had longer activation duration (figure 1). Conclusions ARVC patients as well as the majority of GC demonstrated prolonged LLD and/or activation duration times in RV compared to C, suggesting that the 252-leads noninvasive BSM system may be a useful tool for early detection of delayed RV epicardial activations. Larger studies are required to confirm our results.

Abnormal patterns of noninvasively reconstructed epicardial signals and right ventricle activations in patients with Arrhythmogenic Right Ventricular Cardiomyopathy and gene-carriers

Abstract Funding Acknowledgements Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Selanders stiftelsen Background ARVC primarily affects the epicardium resulting in electrical abnormalities and ventricular arrhythmias that can appear before its clinical correlate with structural changes, which is often hard to evaluate non-invasively. Purpose To evaluate whether a 252-leads Body Surface Mapping (BSM) system can reveal RV activation abnormalities by non-invasively reconstructed epicardial signals of the right ventricle (RV) in ARVC patients and non-affected gene-carriers (GC). Methods Twelve ARVC patients, 20 GC and 8 genotype-negative family members serving as controls (C) underwent 12-leads ECG, signal-average ECG, echocardiography and 10 minutes recording with a non-invasive 252-leads BSM System. A thoracic CT scan was required for the construction of anatomically adapted epicardial signals. The reconstructed epicardial signals were studied using the Activation Time Editing tool of the BSM system. The morphologies of QRS complexes and T waves in predefined areas, including anterior free wall (AW), apex, RV base, RV inferior wall (IW) and RVOT, were studied. The pattern of RV activation was also studied. Results In controls the QRS morphology showed a rS pattern in most RV regions except for in the RVOT showing a rSr’ pattern and the IW where the signals had either a rS or rSr’ morphology. The T waves were positive in all areas, except for in the RV basis and in the IW, where 6 and 3 controls, respectively, had negative/isoelectric T waves. The earliest activation of the RV occurred in the anterior paraseptal region in 7/8 C, while the latest activation occurred in RVOT in 7/8 C (figure 1). ARVC patients also more commonly had a rS pattern in all regions except for in the RVOT (rSr’ pattern) and IW (rS or rSr’ pattern), but had a higher variation in the QRS morphology. Fractionated signals were seen in 7/12 cases. The epicardial T waves were negative/ isoelectric in 11/12 cases. Even though the RV activation more commonly started in the anterior paraseptal region and ended at the RVOT, 58% of ARVC patients had different areas of earliest and/or latest activation (figure 1). GC had the same distribution of QRS morphology as in C, but up to 75% of the T waves were negative or isoelectric, particularly in the RV base and IW. Fractionated signals were seen in two cases. In 60% of GC the earliest and/or latest activation location differed from those see in C. Conclusions Using the 252-leads BSM system, distinct characteristics of reconstructed epicardial signals and RV activation patterns were detected in ARVC patients, distinguishing them from C. The observation that similar changes were observed in epicardial signals and activation patterns among GC suggest that the 252-leads BSM system may be useful as a non-invasive tool evaluating genetically predisposed subjects for early manifestations of the disease.

Spontaneous Pneumomediastinum Revealing Asthma: The Macklin Effect

Pneumomediastinum is defined by the presence of air in the mediastinum, which may be either secondary to trauma, pneumothorax or perforation of the airways, or spontaneous. We report the case of a 28-year-old female patient with pneumomediastinum revealing asthma in acute exacerbation. The patient wasn’t known to be asthmatic or to have an atopic background, no history of surgery, nor any notion of trauma, or recent iatrogeny. She presented with sudden onset of tachypnea associated with chest tightness and productive cough with greenish sputum. Auscultation of her chest revealed audible sibilant rales with the presence of subcutaneous emphysema. Chest radiograph objectivated an aeric border along the edge of the cardiac silhouette associated with subcutaneous hyperclarity of the cervical region. The thoracic CT scan confirmed the presence of a diffuse moderate pneumomediastinum. The patient was put under nasal oxygen, nebulized Ventolin and given intravenous corticosteroid therapy. The patient evolved favorably within three days marked by clinical improvement, the persistence of discrete sibilant rales at the apexes, as well as subcutaneous emphysema in regression after oxygen therapy and conventional medical treatment.

Handheld ultrasound as an adjunct to physical examination in the diagnosis of cardiopulmonary disease.

Handheld 2D ultrasound devices (HUDs) have become available as an adjunct to physical examinations, visualizing the heart and lungs in real time and facilitating prompt patient diagnosis and treatment of cardiopulmonar.y disorders. These devices provide simple and rapid bedside alternatives to repetitive chest x-rays, standard ultrasound examinations and thoracic CT scans. Two currently available HUDs are described. This paper discusses the use of HUDs in the diagnosis of patients with pericardial effusion and tamponade, ventricular dilation, aortic and mitral regurgitation, cardiogenic pulmonary edema, viral and bacterial pneumonia, pleural effusion and pneumothorax. The use of a HUD by physicians increases clinical diagnostic accuracy, adds quantitative information about cardiopulmonary disease severity and guides the use of medications and interventions.

Intrathoracic mass in a 5-month-old infant: fetus in fetu—a case report

BackgroundThe fetu in fetu (FIF) is an extremely rare congenital condition characterized by a 2nd fetus that grows into the body of the healthy twin. Its thoracic location is more exceptional.Case presentationWe report a case of intrathoracic mass in a 5-month-old female infant, diagnosed after an assessment for respiratory distress. She underwent an emergency left thoracotomy which allowed for the removal of a large thoraco-mediastinal mass inside a membranous sac containing a clear liquid mixed with vernix caseosa. The mass was completely covered with normal skin, three lobes similar to rudimentary outline of the head and limb. It was attached to a single large vascular pedicle. The pathological examination concluded that there was a high possibility of FIF. The postoperative follow-up was uncomplicated, and the child is still in good clinical condition after the 5-month follow-up.ConclusionThe assessment of the respiratory distress in an infant with a mass centered by an axial skeleton on the chest x-ray and thoracic CT scan may suggest a diagnosis of intrathoracic FIF.