Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

School ager with juvenile idiopathic arthritis with neck pain and torticollis for 6 weeks

CT of atlanto-axial rotatory subluxation due to juvenile idiopathic arthritis — Axial images from a CT without contrast of the cervical spine shows the C1 vertebral body rotated to the left approximately 45 degrees (top) in relation to the C2 vertebral body (middle). A MIP image (bottom) better demonstrates the rotation of C1 on C2.

The diagnosis was atlanto-axial rotatory subluxation due to juvenile idiopathic arthritis.

Preschooler with fever and torticollis

CT of atlanto-axial rotatory subluxation due to retropharyngeal abscess — Axial images with bone windows from a CT with contrast of the neck shows the C1 vertebral body (above left) rotated approximately 30 degrees to the right in relation to the C2 vertebral body (above right). Axial image with soft tissue windows (below) from the same CT shows a low density fluid collection with an enhancing rim to the left of midline in the retropharyngeal space.

The diagnosis was atlanto-axial rotatory subluxation due to a retropharyngeal abscess.

Preschooler who developed torticollis after watching a video on their tablet with their neck flexed for 8 hours without moving

CT of atlanto-axial rotatory subluxation — 3D CT without contrast of the cervical spine shows the C1 vertebral body rotated to the left approximately 30 degrees in relation to the C2 vertebral body.

The diagnosis was atlanto-axial rotatory subluxation due to muscle spasm.

Infant with torticollis since birth and a left neck mass

US of fibromatosis coli — Transverse US of the neck shows a normal sized hypoechoic right sternocleidomastoid muscle lying above the jugular vein and carotid artery. The left sternocleidomastoid muscle has a heterogenous echotexture and is 5-6 times larger in size than the right.

The diagnosis was fibromatosis coli.

Infant with torticollis since birth and a right neck mass

US of fibromatosis coli — Transverse US of the neck shows a normal sized hyopechoic left sternocleidomastoid muscle lying above the jugular vein and carotid artery. The right sternocleidomastoid muscle is more heterogenous in echotexture and is 3-4 times larger in size than the left.

The diagnosis was fibromatosis coli.

Infant with torticollis since birth

CT of atlanto-axial rotatory subluxation — Axial CT without contrast of the cervical spine shows the C1 vertebral body rotated to the left approximately 45 degrees in relation to the C2 vertebral body.

The diagnosis was atlanto-axial rotatory subluxation without a demonstrated etiology.

School ager with torticollis since birth

Radiograph of Klippel-Feil syndrome — AP radiograph of the cervical spine shows multiple segmentation anomalies including vertebral body fusion and hemivertebrae of the cervical spine and upper thoracic spine.

The diagnosis was Klippel-Feil syndrome.

Our DDX For This Week Is

Teenager with a chest wall deformity

Clinical image of pectus excavatum — Clinical image shows a marked concavity of the chest wall.

The diagnosis was pectus excavatum.

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

Toddler who was seen ingesting gasoline

CXR of lipoid pneumonia — CXR AP obtained 1 week after the ingestion of gasoline shows bilateral perihilar confluent infiltrates. No pneumatocele is seen.

The diagnosis was lipoid pneumonia.

Toddler who was seen ingesting kerosene

CXR of lipoid pneumonia — CXR obtained at 1 hour (upper left), at 10 hours (upper right), and 72 hours (bottom) after the ingestion of kerosene shows initially an unremarkable CXR that at 10 hours has developed bilateral fine interstitial infiltrates which have become more confluent at 72 hours.

The diagnosis was lipoid pneumonia.

Toddler with respiratory distress after a surgical procedure that utilized general anesthesia

CXR of aspiration pneumonia — CXR AP shows a dense infiltrate in the apical aspect of the right upper lobe. The stomach is air-filled and distended.

The diagnosis was aspiration pneumonia.

Infant who is often noted to gag and choke with feedings

CXR of aspiration pneumonia — CXR AP shows a dense infiltrate in the lateral aspect of the right upper lobe.

The diagnosis was aspiration pneumonia.

Newborn with meconium stained amniotic fluid and meconium noted beneath the vocal cords during intubation

CXR of meconium aspiration syndrome — CXR AP shows a hyperinflated chest with coarse interstitial infiltrates.

The diagnosis was meconium aspiration syndrome.

Our DDX For This Week Is

Newborn with prenatal ultrasound that showed marked bilateral hydroureteronephrosis

Clinical image of prune belly syndrome / Eagle Barrett syndrome — Clinical image shows a small thorax, a bulging abdomen due to hypoplastic abdominal wall musculature, and bilateral undescended testicles.

The diagnosis was Prune Belly Syndrome.

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

Premature newborn after PICC placement

CXR of a lower extremity peripherally inserted central catheter / PICC in the right atrium — CXR AP shows a lower extremity PICC tip projecting within the right atrium

The diagnosis was high malposition of the PICC.

Premature newborn after PICC placement

AXR of a peripherally inserted central catheter / PICC in a superficial epigastric vein — AXR AP and lateral shows a right lower extremity PICC tip projecting over a superficial epigastric vein in the anterior abdominal wall.

The diagnosis was malposition of the PICC.

Premature newborn after PICC placement

AXR of a peripherally inserted central catheter / PICC in a superficial epigastric vein — AXR AP and lateral shows a right lower extremity PICC tip projecting over a superficial epigastric vein in the anterior abdominal wall.

The diagnosis was malposition of the PICC.

Premature newborn after PICC placement

AXR of lower extremity peripherally inserted central catheter / PICC in a thoracoepigastric vein — AXR AP and lateral shows a left lower extremity PICC coursing along in a thoracoepigastric vein along the left lateral abdominal wall. The umbilical arterial catheter tip projects at T10.

The diagnosis was malposition of the PICC and appropriate position of the umbilical arterial catheter.

Premature newborn after PICC placement

AXR of peripherally inserted central catheter / PICC in the left hepatic vein — AXR AP shows a left lower extremity PICC whose tip projects over the left hepatic vein.

The diagnosis was malposition of the PICC.

Newborn with abnormal prenatal echocardiogram after PICC placement

AXR of lower extremity peripherally inserted central catheter / PICC in a left-sided inferior vena cava in a patient with situs inversus — AXR AP shows a left lower extremity PICC and a right femoral venous catheter both of whose tips project over a left-sided inferior vena cava. An umbilical venous catheter tip projects over the ductus venosus. An umbilical arterial catheter tip projects at the level of T9. Nasogastric tube tip projects over the stomach in the right upper quadrant. Feeding tube tip projects transpylorically over the duodenal bulb. The cardiac apex is in the right chest.

The diagnosis was appropriate position of the PICC and low malposition of the umbilical venous catheter in a patient with situs inversus.