Introduction Hepatic visceral larva migrans (VLM) is an increasingly recognized parasitic manifestation wherein migratory nematode larvae get lodged in hepatic parenchyma leading to inflammatory granuloma or abscess formation. In this report, we describe a case of VLM presenting with upper gastrointestinal (GI) bleed secondary to a rare complication, a hepatic artery pseudoaneurysm. On literature search, only one such case is reported. Case Report A 13-year-old girl presented with abdominal pain and progressively increasing jaundice for the last 2 weeks. The patient had multiple episodes of hematemesis and melaena requiring 2 units of blood transfusion during this time. Ultrasound (USG) abdomen showed multiple ill-defined hyperechoic lesions in the right lobe of liver with presence of anechoic cystic areas within. A dual phase Computed Tomography (CT) scan of the abdomen revealed multiple confluent and discrete hypodense lesions in the right lobe of liver more apparent on portal venous phase, along with presence of a 1.5 cm pseudoaneurysm arising from posterior branch of right hepatic artery. A differential diagnosis of pyogenic liver abscesses, hepatic VLM, disseminated tuberculosis and immunodeficiency with invasive fungal infection was kept along with hepatic artery pseudoaneurysm leading to hemobilia. Lab investigations revealed peripheral eosinophilia (54%) and raised serum IgE (1600 IU/mL). Hydatid serology was negative. Based on these findings, a diagnosis of hepatic VLM was made and the patient was started on Albendazole (400 mg BD). The patient underwent Digital Subtraction Angiography and managed with successful embolization of the pseudoaneurysm using microcoils. There was significant improvement in jaundice and no recurrence of hematemesis over the next ten days along with rapid drop in peripheral eosinophilia. The patient subsequently remained asymptomatic over a follow-up period of 18 months. The inflammation caused by cytotoxic eosinophil-derived proteins associated with helminthic parasites may lead to vascular complications. Conclusion Hepatic VLM can be rarely associated with hepatic artery pseudoaneurysm presenting in the form of acute upper GI bleed in the background of progressive abdominal symptoms secondary to hepatic lesions. Prompt diagnosis and management with percutaneous angio-embolization for the aneurysm and anti-helminthic therapy for the underlying parasitic infestation is of paramount importance for a good clinical outcome. Read More

Meeting name: SPR 2022 Annual Meeting & Postgraduate Course , 2022

Authors: Gupta Amit, Naranje Priyanka, Kandasamy Devasenathipathy, Jana Manisha

Keywords: Visceral larva migrans, Pseudoaneurysm, GI bleed

Children with ambiguous genitalia form a major subset of children with Disorders of sexual differentiation (DSD). Genital ambiguity invariably results in significant parental anxiety and social issues. Management requires involvement of multiple medical specialties. Accurate delineation of anatomy on imaging is a very important step in clinical decision making. The imaging tools consist of conventional genitogram, pelvic ultrasound and magnetic resonance imaging (MRI). Drawback of MRI lies in the lengthy acquisition process; whereas conventional fluoroscopic genitogram is an invasive procedure, and bears the hazards of ionizing radiation. Pelvic ultrasound is good for visualization of the gonads, and internal genital organs. However, the details of lower genital tract anatomy can not be well evaluated in a pelvic ultrasound. Trans-Perineal ultrasound (TPUS) is a technique where high resolution transducers are placed on the perineum of the child; and detailed imaging of the lower genital tract and anorectum can be performed. It has the advantages of easy availability and portability, lack of radiation exposure and avoidance of general anesthesia/ sedation. This educational exhibit will describe normal male and female lower genital tract anatomy. Various anomalies, namely, urogenital sinus, hypospadias, hypertrophied clitoris, aphallia, will be described. Technique and pitfalls will also be discussed. Normal ossification of the pubic symphysis is variable, depending on the age of the child. Selection of suitable acoustic windows in subpubic and perineal positioning of transducers is crucial. Performed by trained radiologist, TPUS can be useful adjunct imaging modality, both useful and acceptable. Read More

Meeting name: SPR 2022 Annual Meeting & Postgraduate Course , 2022

Authors: Jana Manisha, Jain Rupali, Gupta Amit, Kandasamy Devasenathipathy

Keywords: DSD, Ultrasound

Congenital urethral anomalies comprise a wide spectrum of developmental disorders. Conventional imaging such as contrast voiding cystourethrography (VCUG) and retrograde urethrography (RGU) are still the first radiological investigations for diagnosis, pre-operative planning based on visualization of urogenital anatomy, and postoperative follow-up. An understanding of the embryological origin of the urogenital tract is essential for the radiologist to correctly diagnose urethral anomalies. Urogenital sinus is the precursor of bladder, female urethra and posterior urethra in males, which is separated from the hindgut by the urorectal septum. A defect in this septum can give rise to a myriad of anorectal malformations. The anterior urethra in males is derived from fusion of the ventral urethral folds. Any abnormality in proliferation, fusion or canalisation of these embryological structures leads to various congenital anomalies. Sterile technique and periprocedural antibiotics are essential to avoid introducing or exacerbating urinary tract infection, which can be catastrophic in a child with reflux or bladder outlet obstruction. RGU is typically performed prior to a VCUG.The urethra is cannulated and an iodinated contrast agent such as urografin is injected under fluoroscopic guidance for the evaluation of anterior urethra. The bladder is then catheterised and filled to age-appropriate capacity. The child is allowed to micturate after removal of the catheter to obtain voiding films for evaluation of posterior urethra, and vesicoureteral reflux. A post-void film to look for residual contrast in the bladder completes the study. In this exhibit, after a review of the embryology and anatomy of the urogenital system, we describe the technique, indications and contraindications of conventional urethrography. This will be followed by a discussion of clinicoradiological features of urethral pathologies in children, including urethral valves, diverticula, megalourethra, Mullerian remnants, persistent cloaca, and syndromic conditions such as Prune belly syndrome. Normal variants and imaging pitfalls will also be discussed. Conventional urethrography is an age-old, yet simple and useful technique for the evaluation of the pediatric urogenital tract. We revisit this technique and describe its utility in diagnosis and follow-up of urethral anomalies in children. Read More

Meeting name: SPR 2022 Annual Meeting & Postgraduate Course , 2022

Authors: Baijal Neha, Gupta Amit, D S Dheeksha, Singh Shivani, Jana Manisha

Keywords: retrograde urethrogram, voiding cystourethrogram, conventional urethrography

Chest radiograph (CXR) is a valuable tool, especially in children owing to its low cost, availability, portability and easy disinfection along with less radiation as compared to Computed Tomography (CT). In this study, we evaluate the spectrum of CXR findings and patterns in pediatric COVID-19 patients. Read More

Meeting name: SPR 2022 Annual Meeting & Postgraduate Course , 2022

Authors: Gupta Amit, Bansal Abhinav, Naranje Priyanka, Jana Manisha, Bhalla Ashu, Kabra Sushil, Kandasamy Devasenathipathy

Keywords: COVID, Radiograph