Captopril-enhanced renal scintigraphy in the diagnosis of pediatric hypertension

Hypertension in childhood is no longer a rare condition mainly secondary to renal, or renovascular diseases, as a growing proportion of children are obese and hypertensive, with the phenotype of metabolic syndrome. Thus, we need to reconsider our practice in the examination of the hypertensive child and redefine the place of non-invasive methods for screening of renovascular hypertension, and specifically, to evaluate the value of captopril-enhanced renal scintigraphy at the two ends of the palette: the obese child with hypertension and the severely hypertensive prepubertal child. Renal artery stenosis in children is mainly due to fibromuscular dysplasia and stenoses associated with syndromes involving single or multiple smaller branch vessels. This explains the low specificity and sensitivity of the color-Doppler ultrasound method and captopril renal scintigraphy. Even the more sophisticated computed tomography (CT) and magnetic resonance imaging (MRI) angiographic techniques are, at present, not sensitive enough to exclude stenoses of the small branches definitely. Thus, children in whom there is a strong suggestion of renovascular hypertension should undergo angiography with a view to endovascular treatment, as non-invasive imaging has no significant benefit and might lead to a delay in treatment. In the cases when the probability of renovascular disease is moderate a basic assessment of renal function and structure is sufficient. In the neonate, catheter-associated thromboembolic disease is among the most common causes hypertension. It should be controlled medically until the patient is old enough to undergo angiography and angioplasty successfully. Thus, in this age group, there is a place for functional imaging with renal sonography and angiotensin-converting enzyme inhibitor (ACEI) renography to detect hemodynamically significant renovascular disease, with the limitations mentioned above. However, the rapid technical evolution of non-invasive methods requires periodic re-consideration of the actual standpoints.     

Pyoderma gangrenosum--an unusual differential diagnosis for acute infection

Pyoderma gangrenosum rarely occurs in the breast and has only previously been reported in the literature in response to trauma. We describe a case occurring spontaneously in the breast that was initially mistaken for an infection.     

Solitary eosinophilic granuloma of the radius. An unusual differential diagnosis

A case of an 11-year-old patient with a lesion in the proximal metaphyseo-diaphyseal region of the right radius is presented. The clinico-radiological suspicion was either infection or tumour of the proximal radius. Subsequently, a biopsy proved the lesion to be an eosinophilic granuloma of bone. Following curettage and after a follow-up of two years, there was complete resolution of the lesion with restitution of the cortex.     

An unusual case of clitoral enlargement: its differential diagnosis and surgical management

Clitoromegaly can be either congenital or acquired. The congenital forms are caused by hormonal disturbances or intersex states. Usually they are obvious at birth. When the clitoromegaly develops later the underlying aetiology should be explored and acquired causes should also be considered. These acquired forms of clitoromegaly are either hormonal or non-hormonal. In the hormonal causes, an androgen excess is the main contributing factor of the clitoral enlargement. Three groups should be distinguished: endocrinopathies, masculizing tumours, or self-injection of long-acting synthetic androgens. The most important endocrinopathies are non-polycystic ovarian hypertenstosteronism and polycystic ovarian syndrome. The only reported non-hormonal cause has been neurofibromatosis. We present a case in which the clitoromegaly developed during puberty. As no hormonal disturbances or other abnormalities had been found, and no signs of neurofibromatosis seen, temporary use of steroids was suspected. To our surprise a large sebaceous cyst was found.     

Echinococcal lump: An unusual differential diagnosis for a right iliac fossa lump

Aim

To report the rare case of a primary peritoneal hydatid cyst in a 65-year-old lady.

Case Report

A 65-year-old female presented with a 3-month history of a painless progressive swelling in the right lower abdomen. The lump was 10 cm × 8 cm in size, non-tender, cystic in consistency, and was located in the right iliac fossa and part of the right lumbar region; mobility was restricted in all directions. CECT showed a large septated cystic lesion 14 × 9 × 8 cm in size with enhancement, and sharp regular outline in the right lower abdomen along the anterior aspect of the right psoas muscle. The liver and spleen were not affected.

Result

During surgery, a cystic swelling was exposed. Aspiration revealed a clear fluid with some floating material. The cyst wall was incised and fluid along with daughter cysts were removed keeping the pericyst in situ. Histopathological examination confirmed hydatid disease.

Conclusion

Primary peritoneal hydatid cysts, though very rare, should be kept in mind in the differential diagnosis of a right iliac fossa lump in areas where hydatid disease is endemic.

     

Pathomechanisms and the diagnosis of arterial hypertension in pediatric renal allograft recipients

Arterial hypertension is common in pediatric renal allograft recipients. While the causes are multifactorial, including chronic graft rejection, immunosuppressive therapy, and renal vascular disorders, the effect of hypertension on renal allograft function is detrimental. As in adults, if not treated early and aggressively, hypertension may lead to cardiovascular damage and graft failure. Pathophysiological changes in the arteries and kidney after renal transplantation and the impact of receptor regulation have not been studied extensively in children. For identifying children with hypertension following renal transplantation casual blood pressure measurements do not accurately reflect average arterial blood pressure and circadian blood pressure rhythm. Ambulatory 24-h blood pressure monitoring should regularly be applied in transplant patients. The purpose of this review is to analyze pathophysiological aspects of risk factors for arterial hypertension and underline the importance of regular blood pressure monitoring and early therapeutic intervention.     

Obstructive pancreatitis: unusual causes of chronic pancreatitis

Fifty-eight consecutive surgical pancreatic resections for chronic pancreatitis were examined. Eight cases were identified with obstructive pancreatopathy; all underwent pancreato-duodenectomy. Histological examination revealed that obstruction in three cases was due to duodenal wall cysts, and in two patients it was associated with pancreas divisum (the accessory papilla was obstructed by a neuroendocrine tumour in one case and by ectopic pancreatic tissue in the other). One case each was due to obstruction of an anomalous duct by vegetable matter, to segmental pancreatitis, and to an intraductal carcinoma. Obstructive pancreatitis has many causes and diligent pre-operative assessment is required as surgical resection may be beneficial. Special efforts should be made to identify ductal anomalies, duodenal cysts, ectopic pancreatic tissue, and small ampullary tumours of exocrine and endocrine origin in order to define the aetiology of pancreatitis.     

Leg ulcers of unusual causes

In this review, unusual causes of leg ulcers are examined with an emphasis on pathophysiology, clinical presentation, and epidemiology. Cutaneous ulcers due to malignancy of unusual leg ulcers with hematologic disorders, vasculitis, sarcoidosis, calciphylaxis, Buerger's disease, and pyoderma gangrenosum are discussed.     

Distinguishing the causes of post-transplantation hypertension

The purpose of this article is to elucidate the causes of hypertension following kidney transplantation. In the months and years that follow their operation, most recipients of renal transplants develop or maintain blood pressures that are high. This complication has become more prominent since the widespread use of cyclosporine for immunosuppression. Children seem especially prone to hypertension after kidney transplantation. Absence of hypertension is a favorable long-term prognostic sign. It's presence suggests that allograft function is impaired. Impaired allograft function may be due to either lesions intrinsic to the allograft, or lesions that are extrinsic to the allograft but alter its function. Many transplant patients have more than one possible explanation for hypertension. This multifactorial nature of hypertension after transplantation complicates the management of patients.     

Nonunion of radial neck fracture: An unusual differential diagnosis of tennis elbow,a case report

A 67-year-old woman was referred because of persistent pain in her dominant right elbow. She had been treated for lateral epicondylitis and nonspecific wrist pain by intraarticular corticosteroid injection in the wrist and by physiotherapy for 2 years. The pain occurred during straining and with pro- and supination movements and had started after a fall on the right hand. Radiographs of the wrist were normal. There was full flexion and extension in the elbow joint and normal pro- and supination. There was tenderness on palpation of the lateral epicondyle. Resisted extension of the wrist was slightly painful, but grip strength was normal. Radiographs of the elbow showed an atrophic pseudarthrosis of the radial neck (Figure 1).     

Pheochromocytoma in the pediatric age group: the prostate--an unusual location

Pheochromocytomas of the prostate are rare, with only 3 cases in adults reported in the literature. We present the case of an 8-year-old boy with a pheochromocytoma of the prostate and a second tumor in the region of the left internal iliac artery.     

Other causes of pediatric deformity

Pediatric spine deformity can result from a variety of conditions. The etiologies include idiopathic, congenital, neuromuscular, traumatic, iatrogenic, and radiation-induced spine deformities. The spine deformity may manifest as scoliosis, kyphosis, lordosis, or a mixed deformity. In this article, the authors discuss the classification, natural history, and management of congenital scoliosis. They conclude with a discussion of the various etiologies for neuromuscular scoliosis.