Pediatric Chest Imaging - part 9 pot

Although recurrent pneumonias and pulmonary abscesses are common, other thoracic manifestations include lymphadenitis, osteomyelitis, and chest wall abscesses.. Imaging Evaluation of Che

occurs more commonly than other fungal infections,

such as Candida[24] Chest radiographs or chest CT

typically demonstrate lymphadenopathy, recurrent

pneumonia, and pleural thickening (Fig 5) [25]

The radiographic manifestations of Aspergillus vary

but segmental or lobar infiltrates, nodular opacities,

and cavitation are typical [24] Although recurrent

pneumonias and pulmonary abscesses are common,

other thoracic manifestations include lymphadenitis,

osteomyelitis, and chest wall abscesses Esophageal

strictures can also be a complication of chronic

granulomatous disease

Leukocyte adhesion deficiency results from a

defect in the gene encoding CD18, a component of

three different types of leukocyte adhesion

mole-cules required for effective cell adhesion and

migra-tion [2] This defect results in faulty phagocyte

migration and ultimately increased host susceptibility

to pyogenic infections Severity of symptoms varies

greatly, but these patients typically present with recurrent bacterial pneumonias and other severe and repetitive bacterial infections

Other primary immunodeficiencies Hyperimmunoglobulinemia E syndrome typically

is associated with widespread staphylococcal ab-scesses of the skin, lungs, viscera, and other sites Onset of symptoms characteristically occurs in in-fancy in association with markedly elevated serum IgE levels [26] Pulmonary sequellae include recur-rent staphylococcal pneumonias, which typically result in pneumatocele formation (Fig 6) The most striking radiographic manifestation of this disease is persistent single or multiple, often large, pneumato-celes These pulmonary air cysts may persist, expand,

or become superinfected Not infrequently, surgical

Fig 5 An 8-month-old boy with chronic granulomatous disease (A) The initial frontal and lateral chest radiographs demonstrates pulmonary hyperinflation with diffuse nodular opacities and lymphadenopathy Axial images from an intravenous contrast-enhanced chest scan better delineate the extensive adenopathy (B) and pulmonary nodules (C) from an unusual species

of gram-negative bacteria.

thoracic disorders: immunocompromised child 439

Imaging Evaluation of Chest Wall Disorders in Children

Nancy R Fefferman, MD*, Lynne P Pinkney, MD

Division of Pediatric Radiology, Department of Radiology, New York University School of Medicine, 560 First Avenue,

RIRM 234, New York, NY 10016, USA

The chest wall encases and protects the vital

structures within the thoracic cavity The chest wall

comprises multiple layers, including skin,

subcuta-neous fat, muscle, bone, cartilage, and pleura Chest

wall disorders may be congenital, developmental, or

acquired and typically involve one or more of these

layers Acquired pathologic processes may be

infec-tious, neoplastic, or traumatic Imaging often plays an

integral role in the evaluation of symptomatic and

asymptomatic chest wall abnormalities Symptomatic

chest wall pathology usually requires imaging

evalua-tion to assist in localizaevalua-tion and characterizaevalua-tion

of lesions Although asymptomatic palpable chest

wall lesions tend to be benign or reflect normal

developmental variations, imaging is still often

re-quested[1,2]

Imaging modalities and techniques

Radiography

Conventional radiography of the chest or osseous

structures is often the primary screening modality

for palpable, symptomatic, or asymptomatic chest

wall disorders as well as for symptomatic

nonpalpa-ble processes Palpanonpalpa-ble but otherwise asymptomatic

osseous abnormalities, including congenital and

developmental variants involving the ribs and ster-num, can sometimes be recognized on chest radio-graphs or on dedicated radioradio-graphs, avoiding further imaging evaluation Chest or rib radiographs may

be the only imaging study necessary for definitive diagnosis of benign osseous lesions Additionally, chest radiography can be useful in the preliminary assessment of suspected malignant osseous lesions and can help direct the imaging work-up

Cross-sectional imaging CT

CT has a pivotal role in the evaluation of chest wall pathology Recent technological advances in CT allowing improved spatial resolution, multiplanar ca-pabilities, and faster examination times minimizing respiratory artifact have increased the appeal of this imaging modality in children Additionally, the rapid scan time with multidetector helical CT (MDCT) has helped to overcome the need for sedation in younger children [3] Concerns regarding the radiation dose associated with CT in children and the potential car-cinogenic effects [4,5] remain important considera-tions when using CT CT may be indicated for further evaluation when plain radiographs are normal or in-conclusive In particular, CT is excellent for defin-ing lesion extent, includdefin-ing involvement of adjacent structures, for providing information that can be im-portant for determining the nature of the disorder, or for narrowing the range of differential considerations Examinations for chest wall pathology can be performed using single-detector or multidetector CT The smallest possible field of view should be used

to maximize spatial resolution When diagnostic

0033-8389/05/$ – see front matter D 2005 Elsevier Inc All rights reserved.

doi:10.1016/j.rcl.2004.11.002 radiologic.theclinics.com

* Corresponding author.

E-mail address: nancy.fefferman@nyumc.org

(N.R Fefferman).

Radiol Clin N Am 43 (2005) 355 – 370