In treating cases of malignancy, the use of chemotherapy carries a high risk of lower respiratory tract infections, especially fungal pneumonopathy. This complication is a major cause of mortality and is often difficult to diagnose because of non-specific clinical or radiological changes, but the early recognition of invasive fungal disease is imperative. CT is an important non-invasive method for the detection and evaluation of opportunistic fungal infections. In these patients an improved survival rate can be achieved when early detection by CT leads to the prompt institution of high-dose antifungal therapy. We illustrate the spectrum of CT findings of invasive pulmonary aspergillosis encountered in children with cancer. These patients had previously been treated with high-dose chemotherapy with or without bone marrow rescue, and underwent radiological examinations because of clinical evidence of pneumonopathy. Representative cases demonstrate the clinical applications of CT in the evaluation and management of invasive fungal disease.

A 13-year-old girl treated for Hodgkin's disease developed asymptomatic pulmonary infiltrates at an early phase of a chemotherapy protocol combining COOP and ABV. The histological diagnosis was of bronchiolitis obliterans organizing pneumonia (BOOP). In the two weeks following surgery the infiltrates disappeared spontaneously. The patient restarted and completed the chemotherapy regimen with dacarbazine substituted for bleomycin. No further complications occurred and she is presently disease-free 27 months from diagnosis. The possible relations between the underlying malignant disease, side effects of cytotoxic drugs and unidentified infectious agents are discussed.

OBJECTIVE:Gut inflammation is a common feature shared by inflammatory bowel diseases (IBD) and the spondyloarthropathies (SpA). The aim of the present study was to compare the reliability of a number of non-invasive investigations for the detection of an inflammatory process of the intestine. METHODS:Forty-two children were studied: (i) patients with a previous diagnosis of IBD (group A); (ii) patients with suspected IBD (group B); and (iii) patients with predominantly rheumatological manifestations associated with gastrointestinal symptoms (group C). All the patients were studied using 99mTechnetium-HMPAO labelled white cell scanning (99mTc-WCS), and abdominal ultrasound (US). In addition the ESR, serum class A immunoglobulins, faecal occult blood (OB) and faecal alpha 1-antitripsin level (F alpha 1-AT) were determined. Colonoscopy plus multiple biopsies and radiological study of the intestine were used as gold standards. RESULTS:99mTc-WCS showed the highest sensitivity (85%) and specificity (100%) in detecting the presence of gut inflammation. This was followed by ESR and faecal occult blood (63% sensitivity, 44% specificity), F alpha 1-AT (43% sensitivity, 44% specificity) and IgA (42% sensitivity, 88% specificity). Ultrasound was informative in 28% of the active/affected patients, with a specificity of 75%. CONCLUSION:Although ileo-pancolonscopy remains the gold standard for the histological characterisation of gut inflammation, 99mTc-WCS represents the most reliable non-invasive test for its detection.

Chronic inflammatory bowel disease (CIBD) in children is represented mainly by ulcerative colitis (UC) and Crohn's disease (CD). Infectious forms, Behçet's disease and eosinophilic gastroenteritis are not included in this study. UC and CD are difficult to diagnose and to treat, and require a multispecialistic approach including pediatric gastroenterologists, surgeons, radiologists, endoscopists and pathologists. Progress in diagnostic techniques--i.e., nuclear medicine procedures, conventional, duplex and color-Doppler US, and endoscopy--has increased our knowledge of these diseases and it has made their diagnosis easier, opening new therapeutic perspectives. In our paper, after mentioning the major clinical and radiologic features of CIBD, we report on the patients hospitalized in the Gaslini Institute from 1984 to 1994. Thirty-six patients (age range: 3,9 to 14 years) were examined with several imaging techniques--i.e., plain radiography, US, contrast studies and CT--according to the clinical presentation and behavior of the disease. X-ray studies played the leading role in imaging mucosal disease spread (double contrast studies) and monitoring "surgical" complications (plain radiography). These techniques, which were always combined with US and, in some cases, CT, are also a major tool to study extraluminal CIBD spread--i.e., fistulas, pseudotumors, lymph nodes, abscesses and mesenteric changes. Color-Doppler US may play a critical role in the differential diagnosis of these and other small and large bowel pathologic conditions. The most typical CD patterns in bowel disease are listed in the paper, to give a contribution to the differential diagnosis of the chronic abdominal pain syndrome which is a very common condition in children.

We report a 2 years old girl affected with scurvy. The clinical onset was characterized by lower limb pain so severe that she was enable to walk, and by mucous-cutaneous haemorrhage. These data firstly addressed the diagnosis toward rheumatological or malignant diseases. Subsequently the peculiar eating habits of the girl together with the radiologic findings led us to the correct diagnosis. The nearly undetectable ascorbic acid plasma concentration definitively confirmed the diagnosis. The reported case allows us to discuss the differential diagnosis of scurvy.

We retrospectively reviewed T1-weighted MR images of 381 patients aged from 7 days to 24 years to evaluate the bone marrow change in thoracic wall and shoulder, pelvis and proximal femur and upper and lower extremities. The patients included in the study were without history of bone marrow disease, A grade of from 1 to 4 was assigned to the marrow signal intensity of the examined anatomic segments, The signal intensity of all anatomic segments was as low as or lower than that of muscle in all patients younger than 2 months, reflecting underlying hematopoietic marrow, The first segments to become hyperintense were the epiphyseal/round bone ossification centers, followed by the phalanges, diaphysis, flat bones and metaphysis. Marrow signal intensity increased in all regions with age, While in the epiphyseal/round bones and diaphysis bone marrow shows a diffuse and homogeneous increased signal intensity with age, in the sternum, ribs, scapulae, posterior ilium and metaphysis varying percentages of intermediate signal intensity are maintained. An orderly progression of red to yellow marrow was established.

We retrospectively reviewed 733 cranial and 250 spinal T1-weighted MR images of patients younger than 24 years to evaluate the bone marrow changes. The signal intensity of the bone marrow on short-TR/TE images was compared with that of fat and normal muscles in the contiguous region and graded. The signal intensity of all anatomic segments was as low as that of muscle, or inferior, in all patients younger than 3 months because of hematopoietic tissue and probably greater amounts of trabecular bone. The first anatomic segments of cranial bone to become hyperintense were the zygomatic bone and mandibular symphysis, followed by the presphenoid bone, basisphenoid, basiocciput, calvaria, and the petrous apex. After 3 years of age, most patients demonstrated pneumatization of the sphenoid sinus. We describe the most interesting changes in the developing spien, which occur in the first 2 years of life. The morphology of the vertebral bodies was evaluated. The variability of the signal and the morphology of the disks were also evaluated. Regional patterns of bone marrow signal intensity and age-related differences should not be misinterpreted as a pathologic condition.

We describe a child with Wilms' tumor (WT) which occurred in an unequivocal multicystic dysplastic kidney (MDK). We indicate a current nonsurgical approach to MDK, but stress the probable malignant degeneration of blastemal cells, the need to search carefully for the WT in the MDK, and the necessity on 3-monthly follow-up US studies.

The authors, after reviewing the main features of the so called "leukemic osteopathy", remark how the natural history of leukoses has changed thanks to progress in both diagnosis and treatment. Indeed, the condition is now diagnosed early and its remission is quick. Thus, the cases with X-ray-evident bone involvement are quite uncommon: hence the need to use, at AL onset, imaging techniques which are more sensitive to bone marrow changes. To this purpose, MR imaging has proved a valuable technique which can demonstrate even the early stages of pathologic conditions affecting bone marrow.

Cranial CT and/or MRI examinations were performed in 8 patients affected with mucopolysaccharidosis. Two patients were affected with mucopolysaccharidosis IH,1 had mucopolysaccharidosis IS, 1 had mucopolysaccharidosis IV A and 4 presented mucopolysaccharidosis VI. CT and MRI showed white matter changes consisting of symmetric and diffuse hypodense areas on CT, large areas and multiple spots of prolonged T1 and T2 value on MRI. Reduced gray/white matter contrast was demonstrated on T2-weighted sequences. Furthermore, CT and MRI showed thickening of the dura mater at the cranio-cervical junction, which caused subarachnoid space narrowing in all patients. Spinal cord compression was detected in 4 patients. Additional findings were mild to severe hydrocephalus, skull dysplasia and odontoid dysplasia. Owing to the progressive clinical course of all mucopolysaccharidosis, the authors stress the importance of a careful study of the cranio-cervical junction in all the patients with mucopolysaccharidosis examined by CT or MRI in order to demonstrate essential thickening of the dura mater. In the patients with symptomatic cord compression, surgery should be considered.