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Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery: April Cases

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Drs. Potter and Richardson are interested in education and Pediatric Emergency Medicine. Follow along with the EMGuideWire.com team and Dr. Michael Gibbs as they post these educational, self-guided radiology slides on Pediatric Emergency Medicine Radiology Topics including:
• VP Shunt Disconnection
• E-cigarette Vaping Associated Lung Injury
• Apical Lung Mass
• Pulmonary Metastasis
• Vascular Ring

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Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery: April Cases

  1. 1. Pediatric Chest X-Rays Of The Month Nikki Richardson MD & Jennifer Potter MD Department of Emergency Medicine Carolinas Medical Center & Levine Children’s Hospital Michael Gibbs MD, Faculty Editor Chest X-Ray Mastery Project April 2020
  2. 2. Disclosures  This ongoing chest X-ray interpretation series is proudly sponsored by the Emergency Medicine Residency Program at Carolinas Medical Center.  The goal is to promote widespread mastery of CXR interpretation.  There is no personal health information [PHI] within, and ages have been changed to protect patient confidentiality.
  3. 3. Process  Many are providing cases and these slides are shared with all contributors.  Contributors from many CMC departments, and now… Tanzania and Brazil.  Cases submitted this week will be distributed monthly.  When reviewing the presentation, the 1st image will show a chest X-ray without identifiers and the 2nd image will reveal the diagnosis.
  4. 4. Normal CXR For Your Reference
  5. 5. HPI: 8-year-old male with history of TBI and VP shunt presents for vomiting and increased head banging (which he usually does when upset or in pain). On exam vital signs are within normal limits and patient nontoxic appearing.
  6. 6. VP shunt coiled in abdomen No VP shunt in neck or chest HPI: 8-year-old male with history of TBI and VP shunt presents for vomiting and increased head banging (which he usually does when upset or in pain). On exam vital signs are within normal limits and patient nontoxic appearing.
  7. 7. Dx: VP Shunt Disconnection VP shunt coiled in abdomen No VP shunt in neck or chest HPI: 8-year-old male with history of TBI and VP shunt presents for vomiting and increased head banging (which he usually does when upset or in pain). On exam vital signs are within normal limits and patient nontoxic appearing.
  8. 8. CXR After Neurosurgical Repair. Shunt Should Traverse Through The Chest.
  9. 9. HPI: 16-year-old presents with 4 days of fever, chills, cough, chest pain. On exam, the patient is febrile, tachypneic and tachycardic. No focal findings on lung auscultation.
  10. 10. Dx: Pneumonia Bilateral opacities HPI: 16-year-old presents with 4 days of fever, chills, cough, chest pain. On exam, the patient is febrile, tachypneic and tachycardic. No focal findings on lung auscultation.
  11. 11. Patient was admitted to the hospital and later developed an increasing oxygen requirement. On further discussion, the patient admits to vaping intermittently - last use 2 weeks prior. A chest CT was obtained.
  12. 12. Dx: E-cigarette vaping associated lung injury (EVALI) Diffuse subpleural ground glass opacities 16-year-old with a history of intermittent vaping develops worsening hypoxia.
  13. 13. Since we last discussed EVALI in December 2019…
  14. 14. Latest Outbreak Information Updated every Thursday This complex investigation spans almost all states, involves over a thousand patients, and a wide variety o brands and substances and e-cigarette, or vaping, products. Case counts continue to increase and new ca being reported, which makes it more difficult to determine the cause or causes of this outbreak. As of October 22, 2019, 1,604* cases of e-cigarette, or vaping, product use associated lung injury (EVALI) h been reported to CDC from 49 states (all except Alaska), the District of Columbia, and 1 U.S. territory. Thirty-four deaths have been confirmed in 24 states: Alabama, California (3), Connecticut, Delaware, Georgia (2), Illinois (2), Indiana (3), Kansas (2), Massachusetts, Michigan, Minnesota (3), Mississippi, M Montana, Nebraska, New Jersey, New York, Oregon (2), Pennsylvania, Tennessee, Texas, Utah, and Vi More deaths are under investigation. The median age of deceased patients was 49 years and ranged from 17 to 75 years. Among 1,358 patients with data on age and sex (as of October 15, 2019)(as of October 15, 2019): 70% of patients are male. The median age of patients is 23 years and ages range from 13 to 75 years.
  15. 15. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/Quick-Facts-on-the-Risks-of-E-cigarettes-for-Kids-Teens-and-Young-Adults.html Check out the section on the CDC website geared toward E cigarettes and children
  16. 16. HPI: 6-week-old presents with cough and difficulty breathing for 3 weeks. There is no fever. The mother reports that the patient becomes sweaty with breastfeeding. On exam, the patient requiring supplemental oxygen, heart sounds are more prominent on right, distant breath sounds with a “gurgling” noise on the left. Many thanks to our friends in Tanzania for this case!
  17. 17. HPI: 6-week-old presents with cough and difficulty breathing for 3 weeks. There is no fever. The mother reports that the patient becomes sweaty with breastfeeding. On exam, the patient requiring supplemental oxygen, heart sounds are more prominent on right, distant breath sounds with a “gurgling” noise on the left. Rightward mediastinal shift Loops of bowel in left chest Dx: Diaphragmatic hernia
  18. 18. HPI: 6-year-old presents with left elbow pain and fatigue since yesterday. Mother noticed left eye drooping at approximately 01:00 this morning. On exam, the patient has pupil asymmetry with L < R as well as swelling of the left arm.
  19. 19. HPI: 6-year-old presents with left elbow pain and fatigue since yesterday. Mother noticed left eye drooping at approximately 01:00 this morning. On exam, the patient has pupil asymmetry with L < R as well as swelling of the left arm. Dx: Left apical mass 6.5 cm x 5.5 cm Mass
  20. 20. CT performed as an inpatient to further characterize the mass. Differential: Neuroblastoma, lymphoma, germ cell tumor, thymoma Mass arising out of the superior and middle mediastinum Mass effect on the trachea Pathologic Dx: Neuroblastoma
  21. 21. HPI: 4-year-old with a past medical history of renal mass s/p resection presents to the ED for 7 days of cough. The patient became progressively worse at home and parents were concerned about increased work of breathing. On exam, the patient is tachypeic and tachycardic.
  22. 22. HPI: 4-year-old with a past medical history of renal mass s/p resection presents to the ED for 7 days of cough. The patient became progressively worse at home and parents were concerned about increased work of breathing. On exam, the patient is tachypeic and tachycardic. Dx: Pulmonary metastasis secondary to primary Wilm’s tumor Innumerable bilateral pulmonary nodules
  23. 23. Most Common Primary Sites of Pulmonary Metastatic Disease in Children • Wilms tumor • Neuroblastoma • Rhabdomyosarcoma • Osteosarcoma • Ewing sarcoma https://radiopaedia.org/articles/pulmonary-metastases?lang=us Image Shutterstock
  24. 24. VISUAL DIAGNOSIS
  25. 25. VISUAL DIAGNOSIS Dx: Endotracheal tube in the right mainstem bronchus ETT terminates in right bronchus Completely opacified left lung fields
  26. 26. What’s With These Kids? For the next section, we will review a series of cases/images with a unifying diagnosis. Try to identify the similarities and come up with the diagnosis! After each series of cases, we will discuss the pathophysiology and imaging characteristics of the diagnosis. These images and cases have been graciously shared with us from our collogues in the pediatric cardiovascular surgery department. We thank you for your continued support of this project!
  27. 27. HPI: 10-year-old male with history of multiple hospitalizations for URIs presents for near syncope after getting out of water where he was holding his breath. Mother also notes that patient has had noisy breathing his whole life and intermittent apnea. Exam reveals noisy breathing but lungs clear to auscultation
  28. 28. HPI: 6-year-old female with history of tonsillectomy and adenoidectomy presents to urgent care for increased work of breathing and stridor. Mother reports that patient has been seen almost yearly for similar complaints. Physical exam with tachypnea and expiratory stridor.
  29. 29. HPI: 8-month-old male presents for vomiting with almost every feeding of solid food. Gaining weight appropriately. Mother reports that patient had an echo performed soon after birth but she cannot recall the results. Physical exam is unremarkable.
  30. 30. HPI: 2-month-old male presents for noisy breathing. Noisy breathing has been present since birth. Expiratory stridor on exam, otherwise unremarkable.
  31. 31. HPI: 4-month-old diagnosed with right aortic arch and left ductus arteroisus in utero presents with cough, congestion and noisy breathing. On exam, patient with increased work of breathing and expiratory stridor.
  32. 32. So, What’s With These Kids??
  33. 33. Vascular Ring • Anatomic variants of the aortic arch encircle the trachea and/or esophagus • Symptoms are produced by the extrinsic compression on the trachea (stridor) or esophagus (dysphagia) • 12% are associated with congenital heart disease Backer, Carl L., et al. “Vascular Rings.” Seminars in Pediatric Surgery, vol. 25, no. 3, 2016, pp. 165–175., doi:10.1053/j.sempedsurg.2016.02.009. Photo: https://www.chop.edu/conditions-diseases/vascular-ring
  34. 34. Vascular Ring: Embryology • Remember this?!? • Vascular rings develop because of a failure of specific arches to involute OR involution of the incorrect arch • Right aortic arch is most often secondary to failure of right 4th arch to involute • Double arch occurs when left 4th arch also remains patent Poletto, Erica, et al. “Imaging Review of Aortic Vascular Rings and Pulmonary Sling.” Journal of the American Osteopathic College of Radiology , vol. 6, no. 2, 2017. Backer, Carl L., et al. “Vascular Rings.” Seminars in Pediatric Surgery, vol. 25, no. 3, 2016, pp. 165–175., doi:10.1053/j.sempedsurg.2016.02.009.
  35. 35. Vascular Ring: Clinical Presentation History • Infants • Noisy breathing • Toddlers • Difficulty swallowing food • Noisy breathing with illness • Older Children • Recurrent URIs Physical Exam • Expiratory stridor Poletto, Erica, et al. “Imaging Review of Aortic Vascular Rings and Pulmonary Sling.” Journal of the American Osteopathic College of Radiology , vol. 6, no. 2, 2017.
  36. 36. Vascular Ring: ED Evaluation • Not all stridor is croup or airway foreign body! • History and Chart review • Multiple presentations for stridor with URI symptoms • Physical Exam • Listen to phase of stridor • If expiratory, consider vascular ring • Imaging • Chest XR; PA and lateral • Consider CT angiography chest if significant distress CT reconstructions from Pediatric Cardiovascular Surgery Department at Levine’s Children’s Hospital
  37. 37. • 95% of patients with vascular ring have a visible abnormality on CXR • Segmental tracheal deviation • Anterior tracheal bowing on the lateral projection • Right sided aortic arch • Absent left aortic contour Poletto, Erica, et al. “Imaging Review of Aortic Vascular Rings and Pulmonary Sling.” Journal of the American Osteopathic College of Radiology , vol. 6, no. 2, 2017. Knipe, Henry, and Francis Deng. “Vascular Rings and Slings: Radiology Reference Article.” Radiopaedia, radiopaedia.org/articles/vascular-rings-and-slings?lang=us. Vascular Ring: CXR
  38. 38. Vascular Ring: CXR Limitations • Atretic or hypoplastic arch may be too small to cause visible displacement • Thymus can cover aortic arches • Lack of lateral view due to acute illness/portable CXR • If suspicion is high and patient with respiratory distress, consider CT angiography to make diagnosis Poletto, Erica, et al. “Imaging Review of Aortic Vascular Rings and Pulmonary Sling.” Journal of the American Osteopathic College of Radiology , vol. 6, no. 2, 2017.
  39. 39. Vascular Ring: Preoperative Studies • CT angiography OR MRI of the chest • Preoperative planning • Echocardiogram • 12% have associated congenital heart defect • Bronchoscopy • Assess for tracheomalacia or other tracheal pathology Backer, Carl L., et al. “Vascular Rings.” Seminars in Pediatric Surgery, vol. 25, no. 3, 2016, pp. 165–175., doi:10.1053/j.sempedsurg.2016.02.009.
  40. 40. Vascular Ring: Surgical Repair Backer, Carl L., et al. “Trends in Vascular Ring Surgery.” The Journal of Thoracic and Cardiovascular Surgery, vol. 129, no. 6, 2005, pp. 1339–1347., doi:10.1016/j.jtcvs.2004.10.044. • Based on data from 209 cases at Children’s Memorial Hospital at Northwestern • Muscle sparing left thoracotomy; right sided approach can be used as anatomy on CT or MRI dictates • If double arch anatomy, the lesser or atretic arch should be divided to release the vascular ring. If equally balanced, the site of division is chosen by clamping one arch and measuring the blood pressure in the lower extremities. The clamped arch that produces the lower blood pressure is then divided • If Kommerrell diverticulum is present it should be resected and the left subclavian artery (LSA) should be transferred to the left carotid artery (LCA) • Tube thoracostomy is no longer recommended postoperatively
  41. 41. Summary Of This Month’s Diagnoses • VP shunt disconnection • E-cigarette vaping associated lung injury • Diaphragmatic hernia • Apical lung mass: Neuroblastoma • Innumerable pulmonary metastasis secondary to Wilms Tumor • Endotracheal tube in right mainstem bronchus • Vascular ring

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