Venous thromboembolism (VTE) is a major complication in hospitalised children and adolescents secondary to its association with increased morbidity and mortality.1, 2 Historically, the standard of care for secondary VTE prophylaxis in children and adolescents with primary VTE is the use of either warfarin or low molecular weight heparin (LMWH).2, 3 Each of these approaches has significant limitations in the paediatric population including the need for frequent laboratory testing, erratic oral absorption or frequent subcutaneous injections leading to decreased compliance and treatment failure.4 Direct oral anticoagulants (DOACs), direct factor Xa inhibitors, such as apixaban, are approved in adults with established efficacy and safety. In the randomised, double blind AMPLIFY trial, apixaban was found to be noninferior to conventional therapy in rates of secondary symptomatic VTE or death related to secondary VTE.5 However, there is a paucity of information related to safety, feasibility and efficacy of apixaban as secondary VTE prophylaxis in children and adolescents with a history of a primary VTE.6 We conducted a phase II pilot open label study of apixaban as secondary VTE prophylaxis in children and adolescents. The study was reviewed and approved by the institutional review board. Written consent was obtained from patients and/or legal guardians, and assent was obtained in age appropriate patients. The study was registered on clinicaltrials.gov (NCT04041843). Children and adolescents through age 21.99 years, in compliance with the adolescent definition in our hospital, weighing >40 kg diagnosed with a primary VTE were eligible for study entry. Treatment began within 72 h of diagnosis of a primary VTE and transition from other anticoagulants was permitted. Consented patients received apixaban 10 mg twice daily orally for 7 days followed by 5 mg twice daily until day 90, based on the AMPLIFY trial in adults (NCT04041843). Participants had a chest computed tomography angiogram and Doppler ultrasound of affected areas on day 1, between days 8 and 15, day 30 (if not resolved), and day 90. Anti-Xa level was obtained prior to dose administration on days 8 and 30, and 4 h after dose administration on days 1, 15 and 90. If indicated, a thrombophilia workup was performed including, but not limited to, Factor V Leiden, Protein C and S, antithrombin III, and prothrombin gene mutation to rule out a primary or hereditary thrombotic disorder. Any Grade III–V haemorrhage probably or definitely related to apixaban therapy was considered a dose-limiting toxicity. Stopping criterion was not reached so there was no dose modification made to the protocol (Table S1). In total, 26 patients were enrolled with a median age of 16 years (12–21 years) and 61.5% were females (16 females and 10 males). In all, 14 patients had isolated new onset deep venous thrombosis (DVT), eight patients had isolated pulmonary emboli (PE) and 4 patients had both DVT and PE upon study entry (Table 1). Evaluable thrombi (Table S2) on imaging at day 30 revealed 40.9% showed complete response (CR), 40.9% showed a partial response (PR), 9.1% showed stable disease and 9.1% showed progressive disease (Figure 1). For the two patients with an increase in clot burden, one patient was taken off study for noncompliance. The remaining patient suffered from autoimmune encephalitis unrelated to study drug and was taken off study. At the completion of 3 months of therapy, 63.6% (14 of 22) had a CR and 36.4% (8 of 22) had a PR with no patients having stable disease (Figure 1). Importantly, there were no patients who experienced a new VTE, which equates to 100% successful VTE secondary prophylaxis. Some patients did not have a second timepoint due to study removal (2), COVID-19 (2), contrast allergy (1) and lost to follow-up (1). The average anti-Xa level was 1.02 iu/mL 4 h after apixaban treatment while the average trough level was 0.78 iu/mL. There were no episodes of bleeding, classified as Grade I–IV haemorrhage (CTCAE 4.0), or other adverse events and no patients required dose modifications. Our preliminary results demonstrate that apixaban administered in children and adolescents with a primary VTE for secondary prophylaxis is feasible, safe and effective. Apixaban is an oral therapy that does not require daily injections or frequent laboratory monitoring, potentially leading to improved compliance of children and adolescents with their therapy. It is important to note that this study was initiated prior to the suggestion that DOACs should not be used in patients with anti-phospholipid antibody (APLA) syndrome. This is based on publications of APLA patients who received DOACs and developed new thrombi on therapy.7 Four patients were diagnosed with APLA on our study—two had decrease in their thrombus and one had complete resolution at the end of 3 months of therapy with no untoward event in the study period with the final patient taken off study once diagnosed. One limitation of our study is the use of repeat imaging as a secondary outcome rather than symptomatic or recurrent VTE especially when considering cost, radiation exposure, variation on imaging interpretation and burden on families. The KIDS-DOTT study suggests 6 weeks of therapy may be sufficient if a thrombus is nonocclusive in some paediatric patients with VTE.8 This provides guidance regarding timing of follow-up imaging and characterisation of occlusion in future studies. National trials are currently underway to further investigate the use of apixaban in specific populations of children, adolescent and young adults. The SAXOPHONE study is a multi-national trial prospective, randomised trial of using apixaban in children with congenital and acquired cardiac disease.9 The Children's Oncology Group PREVAPIX-ALL trial is a randomised trial exploring the use of apixaban to prevent VTE in patients with B- and T-cell acute lymphoblastic leukaemia and lymphoma who receive asparaginase during induction chemotherapy and have the presence of a central venous line.10 Results of these studies will help to determine the optimal use of apixaban in specific paediatric populations. There are no published randomised studies to date comparing DOACs, to oral warfarin or LMWH prophylaxis in paediatric patients with primary VTEs. A meta-analysis looking to compare apixaban, dabigatran, edoxaban and rivaroxaban found that apixaban had the most favourable safety profile.11 There is an ongoing randomised phase IV clinical trial looking at the use of apixaban compared to standard of care in paediatric patients less than 18 years of age (NCT02464969). In summary, our study demonstrates that apixaban administered for secondary VTE prophylaxis was feasible, safe and effective in children and adolescents weighing more than 40 kg in the prevention of recurrent VTEs. In addition, stable anti-Xa levels were demonstrated. Larger studies are warranted to validate these findings and apply these principles to neonates and younger children. Ashley Pinchinat, Oya Levendoglu-Tugal, Yara Perez, Liana Klejmont and Mitchell S. Cairo wrote and revised the research protocol. Emily Thatcher, Neida Otero, Arvind Budhram, Harshini Mahanti and Erin Morris provided excellent research and patient support throughout the trial. Adele Brudnicki, Deborah Friedman and Simon Li provided expertise in their respective fields during protocol creation. Ashley Pinchinat, Oya Levendoglu-Tugal, Yara Perez, Erin Morris and Mitchell S. Cairo wrote and revised the paper. The authors would like to thank Ginny Davenport, RN for her assistance in the submission of this manuscript and the patients and families who participated in this study. This study was supported in part by the Paediatric Cancer Research Foundation (PCRF). Mitchell S. Cairo has served as a consultant for Jazz Pharmaceuticals, Omeros Pharmaceuticals, Servier Pharmaceuticals, NEKTAR and Novartis Pharmaceuticals; Speakers Bureau for Jazz Pharmaceuticals, Servier Pharmaceuticals, Amgen, Inc., Sanofi and Sobi; Advisory Board for Astra Zeneca; and research funding from Celularity, Merck, Miltenyi Biotec, Servier, Omeros and Jazz. All other authors declare no conflict of interest. Requests for secondary use of the dataset can be made by emailing Dr. Mitchell S. Cairo at [email protected]. Table S1. Table S2. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Background: Sickle cell disease (SCD) is a vasculopathy resulting in recurrent vaso-occlusive crises leading to endothelial dysfunction, chronic end-organ damage, poor quality of life, early mortality and the major curative therapy to date is allogeneic stem cell transplantation (AlloSCT) (Talano/Cairo, EJH, 2015). Acute chest syndrome (ACS) can result in pulmonary hypertension and is the leading cause of morbidity and mortality in patients with SCD (Gladwin et al, NEJM, 2008). ACS accounts for 25% of deaths (Vichinsky et al, Blood, 1997). Clinical definition of ACS is chest pain, fever, cough, dyspnea, and new pulmonary infiltrate on chest radiography. Defibrotide was approved in the US for the treatment of severe sinusoidal obstructive syndrome (SOS) with renal or pulmonary dysfunction following HSCT (Cairo et al, BJH, 2020). Defibrotide primarily targets endothelium in microvascular beds and has anti-inflammatory and anti-coagulant activity, which can treat the underlying pathophysiology of ACS (Falanga et al, Leukemia, 2003 and Scallia et al, Clin Pharm, 1996 and Pescador et al, Vasc Pharm, 2013). Objective: To determine the safety and toxicity of defibrotide in children, adolescents, and young adults with SCD-associated ACS. Design/Methods: Patients with SCD aged 2 to 40 years meeting ACS criteria (at least two of the following: fever, chest pain, cough, dyspnea, tachypnea, pulmonary infiltrate on chest imaging, decreased oxygen saturation with or without supplemental oxygen requirements) and eligibility were enrolled within 72 hours of diagnosis after consent was obtained (NCT03805581). Baseline studies comprised of chest radiograph, CT chest angiogram, echocardiography with TRJ velocity and brachial artery reactivity, pulmonary function tests, and biomarkers (IFN-a and -g, TNF-a, IL-6, 8, and 10, sCD163, TSP-1, secretory phospholipase A(2), sVCAM-1, sTNFR1, Ang2, sTei-2, PAI-1, sICAM-1, sP-and sE-selectin, sPECAM-1, VEGF-A, C, D and sVEGFR1 and 2). Defibrotide was administered at 6.25mg/kg IV q6 hours and continued for 7 days or until time of discharge, whichever occurred earlier and patients were followed until day +30 following defibrotide. Dose limiting toxicities include Grade III/IV infusion/allergic reaction or hemorrhage probably or directly related to defibrotide. Results: We have enrolled thirteen patients aged 3 to 18 years with a gender ratio (M/F) of 4/9. Patients' genotypes are as follows: hemoglobin SS disease in nine patients, hemoglobin SC disease in two patients, and hemoglobin Sb0/+ thalassemia in two patients. Presenting symptoms included fever, chest pain, cough, dyspnea, tachypnea, pulmonary infiltrate on imaging, and hypoxia.Eight patients completed seven days of treatment, one patient received 6 days of treatment, three patients were discharged after three days of treatment, and one patient withdrew due to recurrent fevers unrelated to defibrotide. All but one patient had resolution of fevers prior to end of treatment. Patients required an average of 1.15 days of oxygen support, with one patient requiring high flow nasal cannula, and no patients required mechanical ventilation. There were no adverse events possibly, probably, or directly related to defibrotide. There was no evidence of hemorrhage in any patient despite four patients receiving concomitant ketorolac or ibuprofen. Of the eleven patients who had pulmonary infiltrates on imaging, eight were evaluated on day +30, two had complete resolution of infiltrate, five had improvements, and one had no change. Seven patients did not follow-up for echocardiography or pulmonary function testing and two of those patients were unable to be evaluated at day +30 due to COVID-19. Discussion: The preliminary data suggest defibrotide is safe and well tolerated in patients with SCD-related ACS. All patients at diagnosis have had baseline studies, which included biomarkers; however, only eight of the thirteen patients have completed all required observations due to poor compliance. After four patients were enrolled and three failed to follow-up, changes to appointment schedules were made with detailed information on all follow-ups. Efforts at improving compliance post therapy are ongoing. Further accrual is needed to determine clinical significance of improvements in cardiac and/or pulmonary function. This study was funded in part by a grant from Jazz Pharmaceuticals. Disclosures Cooke: Jazz Pharmaceuticals: Consultancy, Honoraria, Research Funding, Speakers Bureau. Cairo:Nektar Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees, Research Funding; Technology Inc/Miltenyi Biotec: Research Funding; Jazz Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Miltenyi: Research Funding. OffLabel Disclosure: Defibrotide is utilized in patients with acute chest syndrome to decrease the amount of time they are hospitalized and to assist in alleviating symptoms. Defibrotide is approved in the US for sinusoidal obstructive syndrome with renal or pulmonary dysfunction.

Background: Venous thromboembolism (VTE) is a major complication in children and adolescents because of its association with significant morbidity and mortality (Raffini, Pediatrics 2009). Neonates represent the largest group at risk in the pediatric population, however, adolescents account for approximately 25% of pediatric patients who develop primary VTEs. This may in part be related to the similar risk factors between adults and adolescents such as obesity, smoking, and use of oral contraceptives (Kuhle, Thromb Haemost 2004). Fan et al, PBC, 2017 reported on the safety and efficacy of enoxaparin administered by subcutaneous injection in pediatric patients with primary VTEs in which 38% of patients had complete resolution of their VTE on imaging after 3 months of therapy and 39% had partial resolution. Novel oral anticoagulants, direct factor Xa (FXa) inhibitors, are approved in adults for secondary VTE prophylaxis with established efficacy and safety and without the need of subcutaneous injection or frequent blood monitoring compared to oral warfarin (Male et al, Thromb Res 2019). Apixaban, a selective inhibitor of FXa, compared to vitamin K antagonists, has a rapid onset of action, few drug-drug interactions and a predictable anticoagulant response that enables fixed dosing. In addition, they have less variability in pharmacokinetic and pharmacodynamic responses than warfarin, and have a wider therapeutic index (Garcia, J Thromb Haemost 2013). Similarly, compared to subcutaneous heparin, no injections are required and no pharmacodynamic monitoring is needed. Hypothesis: Secondary prophylaxis with Apixaban (Eliquis®) will be safe, well tolerated and prevent secondary VTEs in children and adolescents with a newly diagnosed primary VTE. Methods: Children weighing > 40 kg and having experienced a primary VTE were eligible to receive apixaban within 72 hrs of VTE diagnosis. A thrombophilia workup was performed including, but not limited to, Factor V Leiden, Protein C and S, and prothrombin gene mutation. Eligible consented patients were administered apixaban 10 mg twice daily P.O. for 7 days followed by 5 mg twice daily until day 90, similar to that used in the AMPLIFY trial in adults (Agnelli, J Thromb Haemost 2015). Treatment began within 72 hours of diagnosis of VTE and transition from other anticoagulants was permitted. Patients unable to tolerate oral medications, with personal or family history of bleeding disorder, history of significant head injury and/or history of intracranial hemorrhage, were excluded from this study. Results: Fifteen patients have been enrolled to date with a median age of 16 yrs (12 - 21 years) and were seventy three percent females (11 females, 4 males). Forty percent of patients were enrolled with primary pulmonary emboli, the remaining with new onset deep venous thrombosis. Line associated clots were included in the study. There were no episodes of bleeding, classified as Grade I-IV hemorrhage (CTCAE), or other adverse events and no patients required dose modifications. There were also no significant changes in creatinine or liver function throughout the course of apixaban administration. Of the 11 patients that completed the day 30 evaluations, 55% showed resolution of their primary thrombus at 30 days with the remainder showing significant decrease in the size of the thrombus (Fig. 1). Fig. 2 illustrates the change from baseline to Day 30 in a child with a pulmonary embolus. There were no patients that experienced increase of their thrombus or any new VTE, which equates to 100% successful VTE secondary prophylaxis. The average INR range was 1.04 (0.92-1.19). The average anti-Xa level was 1.05 four hours after apixaban treatment while the average trough level was 0.88. Conclusions: Our preliminary results suggest that apixaban is safe and well tolerated in children and adolescents for the secondary prophylaxis of patients with a newly diagnosed primary VTE. Additionally, all patients had a decrease in the size of their thrombus with 50% experiencing complete resolution as early as 30 days. There was no evidence of toxicity secondary to apixaban and no requirement to monitor anticoagulant activity. We plan to continue to enroll patients on this study to further validate the safety and efficacy of apixaban. Future directions will include investigating apixaban in children < 40 kg and in neonates with primary VTEs as secondary prophylaxis. Disclosures Friedman: MedImmune: Speakers Bureau; Astra Zeneca: Speakers Bureau. Cairo:Osuka: Research Funding; Miltenyi: Other: MTA; Jazz Pharmaceuticals: Other: Advisory Board, Research Funding, Speakers Bureau.

Central venous catheters are routinely used for resuscitation, chemotherapy and nutrition but are not without risk. Central lines are the most common extrinsic cause of venous thrombosis in neonates and infants. We present an ex-36 week 1800g infant baby girl recovering after a staged repair of gastroschisis with ileostomy and mucous fistula formation. The patient was receiving parenteral nutrition through an indwelling saphenous vein tunneled catheter, with its tip in the inferior vena cava. The patient developed polyuria, with a characteristic odor of the parenteral nutrition and a urine analysis showed glucose and triglyceride levels consistent with the composition of the parenteral nutrition fluid. A fluoroscopic cysto-urogram and an inferior vena-cavogram showed a catheter-associated inferior vena cava thrombosis leading to backpressure changes, diverting all intravenous contrast into the right renal vein and to renal collecting system, thus elucidating the route of the parenteral nutrition fluid reaching the bladder. Our case represents an extreme case of complicated central venous thrombosis. We emphasize the importance of practicing a high index of suspicion for thrombotic complications in severely ill neonates with central venous access. An early diagnosis and aggressive management may prevent progression of the disease towards an overwhelming complication.

OBJECTIVE:To determine the epidemiology of lower extremity deep venous thrombosis (DVT) in critically ill adolescents, which currently is unclear.STUDY DESIGN:We performed a multicenter, prospective, cohort study. Adolescents aged 13-17 years who were admitted to 6 pediatric intensive care units and were anticipated to receive cardiopulmonary support for at least 48 hours were eligible, unless they were admitted with DVT or pulmonary embolism or were receiving or anticipated to receive therapeutic anticoagulation. While patients were in the unit, serial sonograms of the lower extremities were performed, then centrally adjudicated. Bayesian statistics were used to leverage the similarities between adults and adolescents.RESULTS:A total of 88 adolescents were enrolled, from whom 184 lower extremity sonograms were performed. Of these, 9 adolescents developed DVT, with 1 having bilateral DVT. The frequency of DVT was 12.4% (95% credible interval: 6.1%, 20.1%), which ranged from 6.3% to 19.8% with a variability of 41.0% across units. All cases of DVT occurred in adolescents who received invasive mechanical ventilation (frequency: 16.5%; 95% credible interval 8.1%, 26.6%). DVT was associated with femoral central venous catheterization (OR 15.44; 95% credible interval 1.62, 69.05) and severe illness (OR for every 0.1 increase in risk of mortality 3.11; 95% credible interval 1.19, 6.85). DVT appears to be associated with prolonged days on support.CONCLUSIONS:Our findings highlight the similarities and differences in the epidemiology of DVT between adults and adolescents. They support the conduct and inform the design of a trial of pharmacologic prophylaxis in critically ill adolescents.

Compared with consultative US performed by the radiology department, point-of-care US performed by non-radiology physicians can accurately diagnose deep venous thrombosis in adults. In preparation for a multicenter randomized controlled trial, we determined the accuracy of point-of-care US in diagnosing central venous catheter-related thrombosis in critically ill children. Children <18 years old with a central venous catheter who were admitted to the intensive care unit were enrolled. Consultative and point-of-care compression ultrasounds with Doppler were done on the vein where the catheter was inserted within 24 h after insertion. Repeat US was obtained within 24 h of removal of the catheter. All images were centrally, blindly and independently adjudicated for thrombosis by a team of pediatric radiologists. Chance-corrected agreement between readings was calculated. From 84 children, 152 pairs of consultative and point-of-care ultrasounds were analyzed. A total of 38 (25.0%) consultative and 17 (11.2%) point-of-care ultrasounds were positive for thrombosis. The chance-corrected agreement between consultative and point-of-care ultrasounds was 0.17 (standard error: 0.07; P = 0.008). With consultative US as a reference, the sensitivity of point-of-care US was 28.1% (95% confidence interval: 13.7%-46.7%) with a specificity of 91.8% (95% confidence interval: 84.4%-96.4%). A catheter in the subclavian vein was associated with discordant readings (adjusted odds ratio: 4.00; 95% confidence interval: 1.45-13.94). Point-of-care US, when performed by non-radiology physicians and centrally adjudicated by pediatric radiologists in the setting of a multicenter randomized controlled trial, may not accurately diagnose catheter-related thrombosis in critically ill children.

Lead poisoning caused by a foreign body is rare. Foreign bodies that are ingested typically pass without consequence or awareness by the patient [1]. There are few documented cases of lead poisoning from an ingested foreign body lodged in the appendix. Screening for lead poisoning is mandated by New York State at annual well person exams for children ages 6 months to 6 years [2]. We present a case of a 2-year-old male who was found to have elevated lead levels during a routine well-child visit. An abdominal X-ray was obtained as part of routine follow up for elevated lead levels and a foreign body was found in the right lower quadrant. After unsuccessful attempt to flush the foreign body out with golytely, a CT abdomen/ pelvis was obtained. The foreign body was localized in the appendix. The patient was subsequently taken to surgery for an appendectomy to remove the foreign body. This case is a demonstration of the positive effects of the lead screening guidelines of New York.

Recurrent pneumonias in children may be from an unrecognized aspirated foreign body. Our patient was a 10-year-old neurologically impaired child with an aspirated tooth in the right lower lobe segmental bronchus that was inaccessible to extraction using flexible bronchoscopy because of its extremely distal location. We used intraoperative ultrasound during thoracoscopy to locate the foreign body, a tooth, and to facilitate a wedge resection of the involved lung. This combined approach with ultrasound and thoracoscopy can be useful in managing an aspirated foreign body that cannot be extracted from the airway using conventional rigid or flexible bronchoscopy.

1241 Learning Objectives In the daily interpretation of nuclear medicine studies, the nuclear medicine physician must be familiar with a variety of surgical procedures to accurately interpret nuclear examinations. In a pictorial review, we demonstrate a variety of surgical procedures utilizing simple 3 dimensional balloon models and compare these with actual nuclear medicine studies. The nuclear medicine physician and resident will have a better understanding of normal and abnormal patterns of uptake on studies where surgical procedures were performed. To adequately perform and interpret daily nuclear medicine studies, the nuclear medicine physician must be aware of the various common and uncommon surgical procedures which can affect the appearance of studies. In many cases, the appropriate clinical history is not conveyed, leading to potential problems with interpretation. We use simple balloon models which are 3 dimensional to demonstrate, simplify and understand the various procedures and appearances of the surgical procedures. In a pictorial review poster, we discuss various common and uncommon surgical procedures which can affect the appearance and dynamics of the nuclear medicine study interpretation and compare the surgical procedure with an example of an actual nuclear medicine studies. We will show cases of post cholecystectomy with leaks, post renal transplant with leaks, various gastric and bowel surgeries and effects on gastric emptying, various biliary surgeries and Kasai procedures, and several others. Upon review of this exhibit, the nuclear physician will have a better of understanding of various surgical procedures leading to improved understanding and interpretation of various nuclear studies.

BACKGROUND/PURPOSE:The purpose of this study was to determine whether a correlation exists between the finding of complex ascites on ultrasound (US) and the presence of intestinal perforation or gangrene in neonates with complicated necrotizing enterocolitis (NEC). METHODS:Charts of neonates with NEC (n = 76) whose care involved consultations with the pediatric surgery service between 2005 and 2008 were reviewed. Twenty-three babies with NEC without free air had a bedside abdominal US. Neonates with pneumoperitoneum were excluded from the study because this was an absolute indication for surgical intervention. RESULTS:Twelve of the 23 neonates who had a bedside abdominal US were found to have ascites with debris or complex ascites. One of these 12 patients improved with medical management, and the ascites resolved. One infant with complex ascites had an initial laparotomy that revealed extensive bowel necrosis and gangrene that required intestinal resection and ostomy creation. This infant survived and is currently doing well. Ten patients were critically ill and were managed with bedside peritoneal drainage. Of those, 7 had drainage of intestinal contents after placement of the drain. Two of the babies who had a drain placed for complex ascites subsequently died of progressive disease. Five neonates with ascites with debris improved after peritoneal drainage and were subsequently subjected to laparotomy. All had gangrene with intestinal perforation. Three infants with complex ascites and intestinal contents were not observed during the initial peritoneal drainage. They improved after peritoneal drainage and had laparotomy. Free intestinal perforation was not demonstrated. The 3 infants in this group survived. CONCLUSIONS:The presence of complex ascites with debris correlated well with intestinal gangrene or perforation. This correlation may also be a predictor of mortality. Neonates with complicated NEC without clear indication for surgical intervention would benefit from bedside abdominal US evaluation.

Rhabdomyolysis has been described as a rare sequela of severe infections by group A streptococcus related to toxic shock syndrome in adults. Streptococcal pharyngitis, on the other hand, has never been reported to cause rhabdomyolysis. We report a case of rhabdomyolysis in a child after an uncomplicated course of group A streptococcal pharyngitis. Although MRI of rhabdomyolysis from other causes has been described in a few case reports, this is a unique MRI description of its occurrence with streptococcal pharyngitis.

Sex-cord tumors with annular tubules (SCTAT) have been extensively reported in the literature with great emphasis on the cytologic and histologic appearance. The association of Peutz-Jeghers syndrome (PJS) with bilateral benign, typically multifocal, small, and sometimes calcified SCTAT has also been reported. We present and describe the sonographic findings of bilateral SCTAT in a patient with PJS.

Appendiceal intussusception is a rare entity. The majority of cases reported in the literature address surgical and colonoscopic approaches to treatment of the condition. The existing radiologic literature largely describes the sonographic and double-contrast enema findings of appendiceal intussusception. We present a case of appendiceal intussusception and describe the air-contrast enema, sonographic and CT findings.

An unusual case of cavitary Rhodococcus equi pneumonia with endobronchial granulomas in congenital HIV infection is presented. The clinical features and radiological manifestations of pulmonary R. equi infection are discussed.

Seven infants with ductal dependent cyanotic congenital heart disease are reported. All were on prostaglandin E1 therapy to maintain ductus patency. All showed chest radiographic evidence of multiple masses indenting the stomach lumen (gastric thumbprinting). Other than feeding intolerance in two patients, the findings were incidental and disappeared with cessation of PGE1 therapy. "Gastric thumbprinting" appears to be a more common consequence of PGE1 therapy than actual obstructing antral masses (antral foveolar hyperplasia).

The spleen is the most frequently injured organ in blunt abdominal trauma (BAT). Contrast-enhanced computed tomography (CT) is approximately 95% sensitive and specific for detection of splenic injury. In children, nonoperative treatment is well-established. The basic tenet of such management is an obligatory period of rest to prevent recurrent bleeding and allow splenic healing. Splenic preservation prevents post-splenectomy sepsis. At our level I trauma center, pediatric patients (N = 54) with BAT between 1993 and 1998 were retrospectively studied. Two (3.7%) died of associated injuries; 2 underwent splenectomy before transfer to our hospital. All had been diagnosed with splenic injury by CT. The mean age was 11.3 years. The mechanisms of injury were motor vehicle accidents (66%), bicycle accidents (26%), and falls (8%). All 50 remaining patients were followed by ultrasound (US) after the initial diagnosis by CT. The mean hospital stay was 6 days. One patient developed the rare complication of an arterio venous (AV) fistula within the damaged spleen; 47 (94%) had normal, homogeneous parenchymal echogenicity at healing (including the patient with the AV fistula). The remaining 3 demonstrated a visible echogenic scar. Imaging documentation of healing blunt splenic trauma should ideally minimize cost and relative risk. Our results add further evidence that US is well-suited to the task. No delayed complications with this approach were recorded in this series.

An unusual case of a juxtabronchial lymphoepithelial cyst in an HIV-positive child with post-obstructive pneumonia is presented. The pathogenesis and similarity with parotid lymphoepithelial cysts is discussed.