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Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery January 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:
• Swallowed Magnets
• Complex Left Lower Lobe Pneumonia
• Empyema
• Right Middle Lobe Pneumonia
• Pulmonary Hemorrhage
• Multifocal Pneumonia + Influenza
• Pectus Excavatum

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Drs. Potter and Richardson's CMC Pediatric X-Ray Mastery January 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 January 2019
  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. The majority of the cases this month show a step-wise approach to final diagnosis using multiple imaging modalities.
  5. 5. Normal CXR for your reference
  6. 6. HPI: 7-year-old female was attempting to oppose small magnets on either side of her teeth when she accidentally swallowed them.
  7. 7. HPI: 7-year-old female presents to the ED after her mother witnessed her swallow something while playing with a toy. Two adjacent, a round, metallic density objects project over the region of the body of the stomach. Dx: Ingested foreign body.
  8. 8. HPI: On further discussion, that 7-year-old admits to attempting to oppose two magnets on her teeth and accidentally swallowed the magnets. Poison control called and they recommended repeat film 1 hour after initial to evaluate for movement.
  9. 9. HPI: On further discussion, that 7-year-old admits to attempting to oppose two magnets on her teeth and accidentally swallowed the magnets. Poison control called and they recommended repeat film 1 hour after initial to evaluate for movement. Progression of magnets to midline (approx. level of L3). Dx: Ingested magnets.
  10. 10. HPI: Patient transferred to hospital with pediatric GI specialist for endoscopic removal of magnets. No magnets visualized on endoscopy. PACU XR obtained post procedure.
  11. 11. HPI: Patient transferred to hospital with pediatric GI specialist for endoscopic removal of magnets. No magnets visualized on endoscopy. PACU XR obtained post procedure. Progression of magnets to distal small bowel vs descending colon.
  12. 12. HPI: Patient sent home after initial removal attempt with strainer for stool. Did not pass magnets and returned to GI specialist 3 days later. Progression of magnets to midline pelvis. Successful removal in endoscopy suite.
  13. 13. HPI: 4 year old female with no past medical history presents to the ED for evaluation of fever, pain at his belly button and cough for the last 10 days. CT abdomen obtained to rule out appendicitis.
  14. 14. HPI: 4 year old female with no past medical history presents to the ED for evaluation of fever, pain at his belly button and cough for the last 10 days. CT abdomen obtained to rule out appendicitis. Dx: Complex Left Lower Lobe Pneumonia. Airless left lower lung. Left pleural effusion.
  15. 15. Given findings on CT abdomen/pelvis, a CXR was obtained.
  16. 16. Given findings on CT abdomen/pelvis, CXR was obtained. Dx: Complex Left Lower Lobe Pneumonia. Opacification of left lower lobe. Left pleural effusion.
  17. 17. Let’s add one final imaging modality of this patient…Ultrasound!
  18. 18. Lets add one final imaging modality of this patient…Ultrasound! Dx: Empyema requiring VATS procedure. Echogenic fluid in lung base. Septations. Spine sign. Thank you to Dr. Denise Fraga for her assistance in the interpretation of this thoracic US!
  19. 19. Spine Sign on Thoracic Ultrasound • Hyperechoic line of vertebral bodies seen above the diaphragm on thoracic ultrasound. • Suggests presence of a clinically relevant pleural fluid collection. Dickman, E., Terentiev, V., Likourezos, A., Derman, A. and Haines, L., 2015. Extension of the Thoracic Spine Sign: A New Sonographic Marker of Pleural Effusion. Journal of Ultrasound in Medicine, 34(9), pp.1555-1561.
  20. 20. HPI: 5-year-old female presents for fever, chills and nonproductive cough for 5 days. Found to have a hemoglobin of 2.6.
  21. 21. HPI: 5-year-old female presents for fever, chills and nonproductive cough for 5 days. Found to have a hemoglobin of 2.6 Dx: Right Middle Lobe Pneumonia. Patchy opacity.
  22. 22. CT angiography of the chest obtained to further evaluate.
  23. 23. CT angiography of the chest obtained to further evaluate. Ddx: Diffuse pulmonary hemorrhage; pulmonary vasculitis; bilateral pneumonia. Bilateral patchy ground glass opacities. Consolidation VATS lung biopsy performed; results pending.
  24. 24. HPI: 5-year-old with muscular dystrophy presents with 2 days of flu- like symptoms Dx: Multifocal Pneumonia Patchy opacities
  25. 25. Bacterial Pneumonia and Influenza • In a study by Williams et al of over 3,000 children with complicated pneumonia: • In patients with complicated pneumonia AND influenza the most common bacterial pathogens were: • 22.9% Staphylococcus aureus • 66.7% of S aureus was Methicillin- resistant S aureus • 20.0% Streptococcus pneumoniae • If concerned for influenza co-infection or post-influenza bacterial pneumonia add VANCOMYCIN to your antibiotic regimen. • For more about influenza, visit Emergency Medicine Guidewire’s podcast on Pediatric Influenza Williams DJ, Hall M, Brogan TV, et al. Influenza Coinfection and Outcomes in Children With Complicated Pneumonia. Arch Pediatr Adolesc Med. 2011;165(6):506–512. https://www.aafp.org/afp/2012/1001/p661.html
  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. For this diagnosis, no HPI or physical exam findings will be provided. Good luck!
  28. 28. A
  29. 29. B
  30. 30. C
  31. 31. Chest CTs of all 3 cases
  32. 32. So, what’s with these kids??
  33. 33. Pectus Excavatum (PE) • Most common congenital chest wall deformity • Occurs in 1 in 400 to 1 in 1000 live births per year • Male predominance as high as 9:1 • Specific genetic defect is not known however family history present in 43% of cases • Most are isolated; but can be associated with other clinical conditions https://emedicine.medscape.com/article/1004953-overview Brochhausen, Christoph, et al. “Pectus Excavatum: History, Hypothesis, and Treatment Options.” Interactive Cardiovascular and Thoracic Surgery, vol. 14, 2012, pp. 801–806., doi:10.1093/icvts/ivs045. Rhee, Diane, et al. “Incidence of Aortic Root Dilatation in Pectus Excavatum and Its Association With Marfan Syndrome.” Archives of Pediatrics & Adolescent Medicine, vol. 162, no. 9, 2008, p. 882., doi:10.1001/archpedi.162.9.882.
  34. 34. Pectus Excavatum: Associated conditions • Connective tissue disorder (< 1%) • Marfan Syndrome • Ehlers-Danlos Syndrome • Noonan Syndrome • Poland Syndrome • Neurofibromatosis Type I • Homocystinuria • Fetal Alcohol Syndrome • Osteogenesis imperfecta • Socio-psychological problems; especially in adolescents https://step2.medbullets.com/orthopedics/120522/marfan-syndrome https://radiopaedia.org/articles/pectus-excavatum?lang=us Brochhausen, Christoph, et al. “Pectus Excavatum: History, Hypothesis, and Treatment Options.” Interactive Cardiovascular and Thoracic Surgery, vol. 14, 2012, pp. 801–806., doi:10.1093/icvts/ivs045.
  35. 35. Pectus Excavatum: Physiology Considerations • Reduced heart and lung volume • Mitral valve prolapse or regurgitation • Ventricular compression https://www.stanfordchildrens.org/en/service/chest-wall/pectus-excavatum Brochhausen, Christoph, et al. “Pectus Excavatum: History, Hypothesis, and Treatment Options.” Interactive Cardiovascular and Thoracic Surgery, vol. 14, 2012, pp. 801–806., doi:10.1093/icvts/ivs045.
  36. 36. Pectus Excavatum: Clinical Presentation • History • Chest pain • Dyspnea on exertion • Multiple respiratory infections • Asthma-like symptoms • Decreased exercise tolerance • Easy fatigability • Anxiety/depression associated with deformity • OR patient can be asymptomatic • Physical Exam • Sunken chest wall; may be midline or asymmetrical • Thin • Tall • Pot-bellied • Forward hunched shoulders • May have holosystolic murmur at the apex Brochhausen, Christoph, et al. “Pectus Excavatum: History, Hypothesis, and Treatment Options.” Interactive Cardiovascular and Thoracic Surgery, vol. 14, 2012, pp. 801–806., doi:10.1093/icvts/ivs045. Wu, Peter C, et al. “Repair of Pectus Excavatum Deformities in Children: A New Perspective of Treatment Using Minimal Access Surgical Technique .” Arch Surg, vol. 136, 2001, pp. 419–424.
  37. 37. Pectus Excavatum: Evaluation In The ED • Likely to be a physical exam finding in a child presenting to the ED for unrelated complaint • If presenting with cardiac or pulmonary complaints consider obtaining: • POC Cardiac US • Aortic root dilatation is more common in pectus excavatum • If both pectus excavatum AND aortic root dilatation; may require genetics testing • Mitral valve dysfunction • CXR to evaluate for infectious etiology given propensity for pneumonia Rhee, Diane, et al. “Incidence of Aortic Root Dilatation in Pectus Excavatum and Its Association With Marfan Syndrome.” Archives of Pediatrics &amp; Adolescent Medicine, vol. 162, no. 9, 2008, p. 882., doi:10.1001/archpedi.162.9.882.
  38. 38. Pectus Excavatum: CXR findings 1. Poorly defined right heart border on AP 2. Widening of the cardiac silhouette due to compression seen on lateral 3. Leftward displacement of the cardiac silhouette 4. Horizontal orientation of posterior ribs 5. Vertical orientation of anterior ribs 1 2 34 5 https://radiopaedia.org/articles/pectus-excavatum?lang=us
  39. 39. Pectus Excavatum: CXR findings 1. Poorly defined right heart border on AP 2. Widening of the cardiac silhouette due to compression seen on lateral 3. Leftward displacement of the cardiac silhouette 4. Horizontal orientation of posterior ribs 5. Vertical orientation of anterior ribs 1 2 34 5 https://radiopaedia.org/articles/pectus-excavatum?lang=us
  40. 40. Pectus Excavatum: Operative Repairs • Ravitch-type Repair: • Open • Cartilage resection and sternal osteotomy • Internal bracing (Robicsek suspension) • Gold standard • Avoided in young children secondary to potential for restrictive lung disease after repair • Nuss Procedure: • Minimally invasive • No cartilage resection • Transthoracic retrosternal stainless steel bars placed for 2-4 years • More commonly complicated by pneumothorax Wu, Peter C, et al. “Repair of Pectus Excavatum Deformities in Children: A New Perspective of Treatment Using Minimal Access Surgical Technique .” Arch Surg, vol. 136, 2001, pp. 419–424. Photo from Pediatric Cardiovascular Surgery Department at Levine’s Children’s Hospital
  41. 41. Pectus Excavatum: Non-Operative Repair • Vacuum Bell: • Non-operative option • Factors that have shown higher success rates • Mild form of pectus excavatum • Symmetric • Greater chest wall compliance • No costal flaring • Permanence of this technique still not fully known Photo from Pediatric Cardiovascular Surgery Department at Levine’s Children’s Hospital Patel, Akshay J, and Ian Hunt. “Is Vacuum Bell Therapy Effective in the Correction of Pectus Excavatum?” Interactive CardioVascular and Thoracic Surgery, vol. 29, no. 2, 2019, pp. 287–290., doi:10.1093/icvts/ivz082.
  42. 42. Pectus Excavatum: Post-Operative CXRs Ravitch-type Repair with Robicsek mesh suspension Nuss Procedure
  43. 43. Summary Of This Month’s Diagnoses • Swallowed Magnets • Complex Left Lower Lobe Pneumonia • Empyema (Ultrasound) • Right Middle Lobe Pneumonia • Pulmonary Hemorrhage • Multifocal Pneumonia + Influenza • Pectus excavatum

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