Lemierre’s syndrome is an extremely rare condition characterized by initial oropharyngeal infection with development of septic thrombophlebitis and subsequently disseminated septic microemboli. The syndrome remains a disease of considerable morbidity and mortality. The incidence is approximately 3.6 cases per 1 million per year. It is commonly caused by gram-negative <i>Fusobacterium necrophorum</i>. However, less than a third of cases is brought on by other anaerobic bacteria. Here we present a rare case of a Lemierre’s syndrome in a child caused by methicillin-resistant <i>Staphylococcus aureus </i>(MRSA). A 4-year old male presented to emergency department with unremitting fever, progressive painful submandibular swelling concerning for Ludwig’s angina, vesicular lesions on the skin, and decreased level of consciousness. The patient was reported to have fallen onto his chin with resultant lip laceration and tooth avulsion. Fever and neck swelling developed two days later. Computed tomography (CT) of the neck revealed findings in keeping with clinically suspected Ludwig’s angina including: soft tissue gas, and diffuse fat stranding involving the sublingual, perioral, and right submandibular spaces with extension to right sternoclavicular muscle, carotid and jugular vessels. No abscess was identified but a focal non-occlusive thrombus was seen in the right internal jugular vein. Additionally, the lung apices demonstrated multiple patchy densities raising concern for Lemierre’s syndrome and prompting further evaluation with a contrast-enhanced chest CT. Chest CT confirmed the diagnosis demonstrating multiple, variable-sized, randomly distributed lung nodules with cavitation, and multifocal consolidation consistent with septic emboli. Blood culture and skin swab of vesicular lesions were positive for MRSA. On further discussion, it was revealed that the patient’s father was recently treated for MRSA abscess. The patient was placed on intravenous antibiotics (vancomycin, rifampin, meropenem) and anticoagulants (tinazaparin) with improvements in symptoms and imaging findings within six weeks post admission. The learning points include: 1) the need to critically evaluate lung apices and vasculature on neck CT in patients with evidence of soft tissue neck/oropharyngeal infection 2) despite the rarity of Lemierre’s syndrome, multiple cases caused by MRSA have been described. Read More

Meeting name: SPR 2019 Annual Meeting & Postgraduate Course , 2019

Authors: Ibe Donald, Navallas Irujo Maria, Aquino Michael

Keywords: SEPTIC EMBOLI, THROMBOPHLEBITIS, ludwig's angina

Although rare, fibular hemimelia or congenital fibular deficiency (CFD), is the most common congenital long bone deficiency, with an approximate incidence of 7.4- 20 per 1 million live births. The clinical presentation of CFD represents a broad spectrum of manifestations, ranging from mild fibular deficiency with limb length discrepancy to a significantly short limb with multiple associated foot, ankle and knee deformities. Traditional FH classification such as Achterman and Kalamchi described the amount of fibular deficiency, which is today known to be unrelated to length discrepancy and foot deformity. Current classifications are based on the associated deformities of the ankle and subtalar joint, as the foot deformity is the main prognostic factor. Treatment should be tailored for each patient to maximize the lower limb function - this involves predicting the limb length discrepancy and then coming up with a surgical plan to correct these in the fewest number of surgeries spread out as much as possible throughout the child’s growing years, so that by skeletal maturity the child has achieved equal leg length, a functional plantigrade foot, excellent alignment of the hip, knee and ankle and, as needed, a stable knee joint. Multimodal imaging provides detailed evaluation of the osteochondral and extraosseous malformations. In-utero identification can be accomplished with prenatal ultrasonography. After birth, radiographs often show striking bony anomalies. Detailed information regarding associated crucial cartilaginous, articular, soft tissue, and vascular abnormalities required for preoperative planning necessitates the use of magnetic resonance (MR) imaging. The purpose of this poster is to: 1) review the various types of osteochondral and extra-osseous abnormalities of CFD as depicted by different imaging modalities, 2) describe the limitations of each of these modalities, 3) outline the image-based classification of CFD, 4) describe the options for treatment, and 5) discuss the post-operative imaging evaluation of CFD. Read More

Meeting name: SPR 2019 Annual Meeting & Postgraduate Course , 2019

Authors: Marie Eman, Perez Manuela, Aquino Michael, Stimec Jennifer

Keywords: hemimelia, congenital fibular deficiency

<b>Background</b>: Prior studies have shown significant discrepancy between the initial radiologist and pediatric radiologist interpretation of imaging exams performed on pediatric patients. Studies specifically focused on the rate of discrepancy of ultrasound (US) exams for suspected appendicitis and intussusception are deficient. <b>Objective:</b> To determine the agreement and discrepancy rates, and the clinical impact of discrepancies in the diagnosis of appendicitis and ileocolic intussusception between initial US performed at referring community hospitals and second (2^nd) opinion US performed at an academic pediatric tertiary care hospital. Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Alhashmi Ghufran, Yang Joseph, Amirabadi Afsaneh, Aquino Michael

Keywords: Second Opinion, Appendicitis, intussusception