Pediatr Radiol DOI 10.1007/s00247-014-3025-x
PICTORIAL ESSAY
Imaging of pediatric pathology during the Iraq and Afghanistan conflicts David M. Biko & Brian F. McQuillan & Robert A. Jesinger & Paul M. Sherman & Bryson D. Borg & John P. Lichtenberger III
Received: 30 January 2014 / Revised: 14 April 2014 / Accepted: 1 May 2014 # Springer-Verlag Berlin Heidelberg (outside the USA) 2014
Abstract United States Armed Forces radiologists deployed to Afghanistan and Iraq in modern military conflicts may encounter pediatric patients as a casualty of war or when providing humanitarian assistance to the indigenous population. Pediatric patients account for 4–7% of admissions at U.S. military hospitals during the Iraq and Afghanistan conflicts. It is pertinent for radiologists in the humanitarian care team to be familiar with imaging pediatric trauma patients, the pathology endemic to the local population, and delayed presentations of congenital and developmental disorders to adequately care for these patients. The radiological manifestations of various pediatric disorders seen in the setting of the Iraq and Afghanistan conflicts will be explored. Keywords Pediatric imaging . Humanitarian . Trauma . Infection . Neoplasm
Introduction A United States Armed Forces radiologist’s primary objective during a conflict is to support combat casualty care of service members; however, medical personnel are also often called on D. M. Biko (*) : B. F. McQuillan : R. A. Jesinger : B. D. Borg : J. P. Lichtenberger III Department of Radiology, David Grant USAF Medical Center, 101 Bodin Circle, Travis AFB, CA 94535, USA e-mail: [email protected] D. M. Biko : R. A. Jesinger : P. M. Sherman : J. P. Lichtenberger III Department of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences, Bethesda, MD, USA P. M. Sherman Department of Radiology, San Antonio Military Medical Center, Wilford Hall Ambulatory Surgical Center, San Antonio, TX, USA
to provide humanitarian services to the local population, making pediatric imaging more necessary during a conflict than one would expect. Pediatric patients account for 4% to 7% of admissions at U.S. hospitals during deployment in Iraq and Afghanistan [1]. Pediatric patients in a conflict zone also consume more resources than adults in both operating room time and hospital beds. Twenty-five percent of hospital bed days at U.S. military hospitals in Afghanistan and 10–12% of hospital bed days at U.S. military hospitals in Iraq are occupied by children [1, 2]. In spite of limited pediatric supplies and trained personnel in military hospitals, the mortality rate for children admitted was 6.2% in Afghanistan and 3.9% in Iraq [3, 4]. Pediatric pathology encountered in the deployed environment includes trauma, both blunt and penetrating, and infection. Similar to a tertiary facility in the United States that receives patients from abroad, due to lack of access to health care, medical staff in the deployed environment commonly see delayed presentations of congenital and acquired diseases [5]. Additionally, radiologists serving as humanitarians in underserved populations may also encounter pediatric pathology similar to the disorders described.
Trauma Seventy-five percent of pediatric hospital admissions to military hospitals during the Iraq and Afghanistan conflicts were secondary to traumatic injuries, compared to only 17% in the United States [5, 6]. Children presenting to these military hospitals suffer considerably more penetrating injuries (75%) than blunt injuries, whereas blunt injury is more common in the civilian experience [5, 7]. More than half of children admitted with trauma in these conflict zones required two or more invasive procedures [5]. Overall, penetrating trauma has higher mortality and morbidity in children than in adults [7].
Pediatr Radiol Fig. 1 Anatomical distribution of traumatic injuries to children in both Iraq and Afghanistan
Additionally, in a wartime environment, injuries to children younger than 8 are more severe than those in older children and adults [8]. Most injuries involve the extremities (38%),
followed by the brain and skull (Fig. 1) [1]. Most injuries are due to gunshot wounds (39% of cases) (Fig. 2) and explosives (32% of cases) (Fig. 3) [4]. Additionally, wartime pediatric
Fig. 2 A 10-year-old boy injured with a gunshot wound to the head. a Frontal scout view from a non-contrast CT of the head demonstrates a bullet overlying the right maxillary sinus. b Multiple axial images from
the same non-contrast CT show edema and hemorrhage within the brain parenchyma adjacent to the trajectory of bullet (arrows)
Pediatr Radiol Fig. 3 A 14-year-old boy injured following blast injury. a Lateral scout image from a non-contrast axial CT of the head demonstrates the radiopaque foreign piercing in the orbit. b Axial image from the same non-contrast CT of the head image shows the shrapnel extending into the right frontal lobe with an adjacent hemorrhagic right frontal lobe contusion and orbital wall fragments (circle)
trauma patients have a higher rate of vascular injury (3.5%) than those outside a war zone (0.6%) (Fig. 4) [9]. Mechanisms of blunt trauma in the conflict zone include blast injuries, motor vehicle accidents and falls (Fig. 5) [4]. In the civilian sector, children with blunt trauma have a significantly better outcome in a designated pediatric trauma center, likely due to successful nonoperative treatment [10]. A specialized pediatric trauma center is not available in Iraq and Afghanistan.
Infection Endemic infectious disease in Iraq and Afghanistan— most commonly gastrointestinal illness—affects troops, Fig. 4 A 10-year-old girl with prior gunshot wound. a Frontal scout image from a contrastenhanced CT of the lower extremity demonstrates apex medial bowing of the left femur (arrow) with an adjacent metallic fragment. b Axial image from the same CT shows an adjacent posttraumatic pseudoaneurysm (arrowhead)
humanitarian personnel, and local adults and children alike. In Iraq, gastrointestinal illness is caused by viral illness in up to 49% of cases but can also be secondary to Salmonella, Escherichia coli, Campylobacter jejuni and Vibrio cholerae [11]. In Afghanistan, bacterial etiologies of gastrointestinal illness include Salmonella, Shigella and Vibrio strains. In most cases, no definite etiology is established [12]. Other endemic infectious illnesses that often affect children include malaria, typhoid fever, viral hepatitis, leishmaniasis, CrimeanCongo hemorrhagic fever, anthrax, Rickettsial disease, Ascaris, Echinococcus and tuberculosis [11–13]. In one study, 12,850 children were treated for infection such as pneumonia and tuberculosis during a 4-year period at two refugee camps in Pakistan [14].
Pediatr Radiol
capillaries entering the lungs or other organs [19]. The liver, specifically the right lobe, is the most common site of involvement followed by the lungs [16, 19]. The imaging findings of Echinoccocus granulosus depend on the stage of cyst growth. There are four types of hydatid cyst. Type 1 cysts resemble simple cysts on imaging studies (Fig. 6). Sonographically, a double-line sign can be seen in unruptured cysts [16]. On CT or MRI, the cyst walls or septa may enhance helping to distinguish them from a simple cyst. Additionally, on MRI a characteristic low-intensity rim, most evident on T2-weighted images, has been described in hydatid disease [16, 19]. Type 2 cysts contain daughter cysts inside the mother cyst. Sonographically, floating membranes may be seen within the cyst. There may be multiple cysts or echogenic foci arranged together in a single capsule creating a “wheel spoke” appearance. Hyperechoic solid lesions within the mother cyst may be created by a conglomeration of daughter cysts. On CT, peripheral daughter cysts (type 2A), larger irregularly shaped daughter cysts (type 2B), or scattered calcifications within the mother cyst after degeneration of daughter cysts (type 2C) are characteristic. Daughter cysts may appear hypointense or hyperintense relative to the mother cyst on T1- and T2-weighted images. Type 3 cysts are calcified cysts, demonstrating posterior acoustic shadowing on sonography. They are hyperdense on CT and hypointense on MR. Finally, type 4 cysts are complicated cysts, usually due to rupture. Ruptures may be contained with an undulating membrane seen on US or cross-sectional imaging. Ruptures may also be communicating or direct where cysts rupture into the biliary system, pleural or peritoneal cavities [19]. Fig. 5 An 18-year-old who fell from a roof. Sagittal image from a noncontrast CT of the lumbar spine demonstrates a burst fracture of L1 with retropulsion of posterior element of vertebral body (arrow). There is an adjacent compression fracture of the superior end plate of L3 (arrowhead)
Echinococcus Echinococcus, a parasitic infection caused by the tapeworm Echinococcus in its larval form, is prevalent in both Iraq and Afghanistan [15, 16]. In Northern Iraq, it has been reported that 49.5-80% of dogs are infected with Echinococcus granulosa [17, 18]. There are two main forms of echinococcal disease: the more common unilocular cystic form caused by Echinococcus granulosus and the multilocular alveolar form caused by Echinococcus multilocularis [16]. Humans are exposed via the ingestion of contaminated feces. The ingested egg breaks down and a freed embryo passes through the duodenal mucosa into the portal vein. Most embryos embed in the hepatic capillaries forming hydatid cysts, but others pass through
Ascariasis Ascaris lumbricoides is the most common helminth infection with a prevalence of 25%. The incidence is greater in children, especially those living in warm, humid overpopulated climates, and can have a profound effect on their mental development [20–22]. The overall morbidity from this infection is 7.2%, with a mortality of 1.8% in a 10-year retrospective study in western Iran [21]. As in Echinococcal disease, ascariasis is acquired by ingesting contaminated food, water or soil. After ingestion, the eggs hatch and migrate through the duodenal wall, eventually into the pulmonary circulation. They enter the bronchi and trachea where they are again swallowed. The helminth matures in the small intestine, laying eggs to complete the cycle [20]. Ascaris causes pneumonia, manifesting as alveolar opacities, normally clearing within 10 days. Intestinal ascarids may
Pediatr Radiol Fig. 6 Echinoccal infection in a 5-year-old. a Axial non-contrast CT image shows an hydatid cyst within the left lower lobe (arrow). b Coronal image from the same CT demonstrates hydatid cysts in both the left lower lobe (arrow) and liver (arrowhead)
cause luminal obstruction. Radiographs may be normal with few ascarids, but large aggregations of ascarids appear as a tangled group of cords within the bowel (Fig. 7). Sonographically, the appearance of intestinal ascariasis is two parallel echogenic lines separated by the anechoic fluidfilled alimentary canal. On higher-resolution sonography, four parallel echogenic lines can be seen. The two outer lines represent the outside of the worm and the two inner lines represent the gut. Real-time movements of the worm can also be seen including swallowing [23]. CT demonstrates elongated or rounded filling defects within the intestinal lumen (Fig. 7). On fluid-sensitive MRI, the worm is a hypointense tubular structure surrounded by hyperintense intestinal fluid [20]. Biliary ascariasis mostly occurs when the worm migrates into the common bile duct, the intrahepatic ducts, gallbladder or pancreatic duct. This may result in cholecystitis, cholangitis, pancreatitis or hepatic abscesses. Worms typically migrate back into the duodenum between 2 days and 2 weeks [20]. Ultrasound is the preferred method of imaging biliary ascariasis identifying greater than 85% of cases. Sonography
Fig. 7 Ascariasis in a 2-year-old with abdominal distention. a Frontal scout image from a contrast-enhanced CT shows multiple tubular lucencies in the right hemi-abdomen consistent with ascarids. b Axial image from the same CT demonstrates ascarids in the right colon
enables direct visualization of the worm. Complications include enlargement of the bile duct, gallbladder edema or sludge, liver abscesses or pancreatic edema [24].
Cutaneous anthrax Bacillus anthracis, the gram-positive bacillus causing anthrax, is endemic to Afghanistan [12, 25]. Most natural anthrax infection is cutaneous from contamination of open wounds. Other forms of anthrax include gastrointestinal anthrax from ingestion and inhalation anthrax, the latter of which has the greatest potential for bioterroism [12, 26]. In cutaneous anthrax, a painless pruritic papule initially appears. This is followed by enlargement of the papule, ultimately erupting and undergoing necrosis forming an ulcer with a black-colored eschar (Fig. 8). Imaging is not frequently used for the diagnosis but correlates to the clinical findings of adjacent edema along with regional lymphadenopathy (Fig. 8) [26].
Pediatr Radiol Fig. 8 Cutaneous anthrax in an Afghan boy with acute respiratory distress (age unknown). a Photograph shows an ulcerated papule with peripheral vesicles and characteristic black eschar. b Axial contrast-enhanced CT image demonstrates subcutaneous edema along with enhancing level III lymphadenapathy (arrow) and laryngeal edema (arrowhead)
Tuberculosis Tuberculosis is a common endemic infection worldwide caused by the bacteria Mycobacterium tuberculosis. The scope of imaging findings of both pulmonary and extrapulmonary tuberculosis is substantial and too broad for this article, but its frequence is widespread, particularly in Afghanistan. In 1997, the prevelance of tuberculosis in Afghanistan was 753 cases per 100,000 [12, 27]. In Iraq in 2012, the prevalance of tuberculosis was 73 per 100,000 [28]. Children account for a large majority of cases of tuberculosis, particularly in endemic areas [29]. The most common form of pulmonary tuberculosis in children is the primary form as opposed to the post-primary form in adults [30, 31]. The most common radiographic finding of primary tuberculosis in children is lympahadenopathy, present in 92%, and typically involving the hilar and paratracheal regions [30]. The radiographic findings in pediatric post-primary tuberculosis are upper lobe consolidation and cavitation, multifocal ill-defined airspace opacities and apical pleural thickening [31]. Extrapulmonary Fig. 9 Tuberculous spondylitis in a 14-year-old with back pain. a Axial image of a contrastenhanced CT demonstrates compression of the L3 vertebral body with an adjacent rim enhancing psoas abscess (arrowhead). b Sagittal image from the same CT better demonstrates the L3 vertebral body compression fracture (arrow)
manifestations of tuberculosis include musculoskeletal manifestations such as osteomyelitis and spondylitis (Fig. 9), central nervous system manifestations such as meningitis and parenchymal disease, and both gastrointestinal and genitourinary manifestations [32, 33].
Delayed presentation of congenital or acquired disease Due to limited access to health care, those providing humanitarian services to the local populations of Iraq and Afghanistan may encounter children with advanced congenital or acquired disease, so it is important for radiologists and medical teams to recognize and diagnose these diseases by reviewing pertinent imaging findings. Macrodystrophia lipomatosa Macrodystrophia lipomatosa (MDL) is a term describing macrodactyly with lipomatosis of a nerve, which most often occurs in the upper extremity and has been described using
Pediatr Radiol
Fig. 10 Macrodystrophia lipomatosa in a child (age unknown). a Frontal scout image from a non-contrast-enhanced CT demonstrates localized overgrowth of the subcutaneous tissues of the right upper extremity, most severely involving the hand. b Radiograph of the same child again reveals
overgrowth of the subcutaneous tissues of the right upper extremity along with bony overgrowth of the 1st, 2nd and 3rd digits. c Coronal image from a non-contrast-enhanced CT further demonstrates the enlarged subcutaneous tissues and digits of the right upper extremity
multiple terms including neural fibrolipoma, intraneural lipoma, fatty infiltration of the nerve, perineural lipoma and fibrolipomatous hamartoma. Macrodactyly or MDL occurs in 27-67% of cases [34]. The hallmark of MDL is progressive overgrowth of the mesenchymal elements with disproportionate enlargement of the fibrous and adipose tissue. The disease is usually recognized as a neonate. Complications present during growth due to degenerative changes in the small joints and compression of neurovascular structures [35, 36]. The abnormal overgrowth halts at puberty [37, 38]. The abnormality in MDL occurs in the distribution of the sclerotome of the nerve involved. The lower extremity is more commonly involved than the upper extremity. Most cases involve the territory supplied by the median nerve [38, 39]. Plain radiography demonstrates hypertrophied tissue, most severe on the volar surface. CT demonstrates excessive fatty proliferation involving the soft tissues and muscles (Fig. 10). On MRI, the affected limb has unencapsulated fatty tissue with linear TI hypointense bands corresponding to fibrous strands [35, 40, 41]. Neural enlargement in the region of the overgrowth can also be seen on MRI [40, 41]. Bony overgrowth and cortical thickening of the involved digits can be demonstrated on both CT and MRI [35].
[42–44]. This aganglionic segment begins at the anal sphincter and extends a variable distance proximally within the colon and small bowel. There are three types of HD described: 1) classical, involving the rectum and rectosigmoid, and extending to the splenic flexure; 2) ultrashort, involving only 2–3 cm of the rectum, and 3) ultra-long, where greater than half of the colon is involved [43]. Ninety percent of cases of HD are symptomatic in the newborn period [44]. Neonates present with failure to pass meconium (90-94%) and abdominal distention (55-87%) [43]. Imaging findings of HD on a neonatal contrast enema include an abrupt caliber change between the dilated proximal ganglionic bowel and the distal small or normal in caliber aganglionic bowel [45]. Late presentation of HD presents with complications rather than the classic findings of abdominal distention. These include acute enterocolitis or toxic megacolon, anemia, fecal impaction and failure to thrive [44]. Late presentation of the disease may be evaluated with CT, which demonstrates similar findings to the contrast enema (Fig. 11) [46].
Hirschsprung disease Hirschprung disease (HD) is a congenital enteric nervous system disorder characterized by the lack of ganglion cells in the submucosal and myenteric plexuses of the bowel
Retinoblastoma Retinoblastoma is the most common intraocular pediatric tumor. The tumor arises from immature retina. Ninety to ninety-five percent of children are diagnosed before the age of 5 years old [47]. Clinical symptoms of retinoblastoma are leukocoria (56-72% of cases) and strabismus or lack of binocular vision (22-24% of cases). The diagnosis of retinoblastoma is made with ophthalmoscopy followed by imaging [47, 48].
Pediatr Radiol Fig. 11 Hirschprung disease in a 3-year-old. a Frontal scout from a contrast-enhanced CT of the abdomen and pelvis demonstrates abdominal distention and dilated loops of bowel. b Axial image from the same CT further demonstrates the distended abdomen and markedly dilated loops of colon
Calcification is a key finding that distinguishes retinoblastoma from other intraocular lesions on imaging (Fig. 12). Orbital sonography demonstrates an irregular heterogeneous solid mass with calcifications in up to 75%. CT findings include a dense mass within the posterior aspect of the globe with calcifications in 95% and enhancement in 28% of the cases (Fig. 12) [47]. MRI is the modality of choice to evaluate intracranial spread of disease [47, 48]. Extraocular extension through the optic nerve and/or sclera is the most important risk factor for metastatic disease [47]. Metastases most commonly involve the central nervous system, regional lymph nodes, and the bone and bone marrow [49]. Ewing sarcoma Ewing sarcoma is the second most common musculoskeletal neoplasm in the pediatric population accounting for 3% of all pediatric cancers [50, 51]. In up to 86% of cases, Ewing sarcoma involves the pelvis, extremities and ribs. In the long bones, the
Fig. 12 Retinoblastoma in an 11year-old boy with a chronically growing left eye mass. a Photograph shows a large softtissue mass extending from the left orbit. b Axial image from a contrast-enhanced CT of the same child demonstrates the large heterogenous mass with internal calcifications (arrow) extending from the left globe
tumor is most commonly metadiaphyseal and more common proximally. Clinically, most patients present with pain and a mass or swelling. Although Ewing sarcoma can be encountered between the ages of 4 and 25 years, the peak prevalence is 10–15 years old [50]. At presentation, 20-30% of patients have lung or skeletal metastases [51]. Prognosis is worse if tumor size is greater than 8 cm and with metastatic disease [52]. The radiographic appearance of Ewing sarcoma is a poorly marginated, intramedullary lytic lesion with aggressive lamellated periosteal reaction and a large soft-tissue mass (Fig. 13). CT demonstrates similar findings but is more sensitive for the soft-tissue component and provides better bony detail [51]. MRI is the modality of choice for local tumor staging given its superb contrast resolution. MRI can demonstrate the degree of extension of the lesion and its relationship with the neurovascular bundle [51, 53]. The signal on MRI is homogenous and intermediate in signal intensity on T1weighted images and low to intermediate signal intensity on T2-weighted images [50].
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Fig. 13 Ewing sarcoma in a 10-year-old boy with a chronically enlarging left upper extremity mass. a Photograph shows a large soft-tissue mass involving the proximal upper extremity. b Radiograph of the left upper extremity in the same patient demonstrates a large soft-tissue mass with
near complete disruption of the humerus. c Sagittal image from a contrastenhanced CT image of the left upper extremity in the same patient demonstrate a heterogeneous mass within internal necrosis
Conclusion
3. Gawande A (2004) Casualties of war: military care for the wounded from Iraq and Afghanistan. N Engl J Med 351:2471–2475 4. Creamer KM, Edwards MJ, Shields CH et al (2009) Pediatric wartime admissions to U.S. military combat support hospitals in Afghanistan and Iraq: Learning from the first 2,000 admissions. J Trauma 67:762–768 5. Semerad D, Statler J, Harcke HT et al (2007) Disease and nonbattle injury in the combat zone. Emerg Radiol 14:205–209 6. White JRM, Dalton HJ (2002) Pediatric trauma: post injury care in the pediatric intensive care unit. Crit Care Med 30: S478–S488 7. Boleken ME, Cevik M, Yagiz B et al (2013) The characteristics and outcomes of penetrating thoracic and abdominal trauma among children. Pediatr Surg Int 29:795–800 8. Matos RI, Holcomb JB, Callahan C et al (2008) Increased mortality rates of young children with traumatic injuries at a U.S. army combat support hospital in Baghdad, Iraq, 2004. Pediatrics 122:e959–e966 9. Villamaria CY, Morrison JJ, Fitzpatrick CM et al (2014) Wartime vascular injuries in the pediatric population of Iraq and Afghanistan: 2002–2011. J Pediatr Surg 49:428–432 10. Hall JR, Reyes HM, Meller JL et al (1996) The outcome for children with blunt trauma is best at a pediatric trauma center. J Pediatr Surg 31:72–77 11. Gasser RA, Magill AJ, Oster CN et al (1991) The threat of infectious disease in Americans returning from Operation Desert Storm. N Eng J Med 324:859–863 12. Wallace MR, Hale BR, Utz GC et al (2002) Endemic infectious diseases of Afghanistan. Clin Infect Dis 34:S171–S207 13. Rajabali A, Moin O, Ansari AS et al (2009) Communicable disease among displaced Afghans: refuge without shelter. Nat Rev Microbiol 7:609–614 14. Oldfield EC, Wallace MR, Hyams KC et al (1991) Endemic infectious diseases of the Middle East. Rev Infect Dis 13: S199–S217 15. Moro P, Chantz PM (2006) Cystic echinococcosis in the Americas. Parasitol Int 55:S181–S186 16. Czermak BV, Unsinn KM, Gotwald T et al (2001) Echinococcus granulosus revisited. AJR Am J Roentgenol 177:1051–1056
The humanitarian mission in a region of conflict involves the radiological diagnosis of several categories of disorders. These conditions include blunt and penetrating trauma, infection, and congenital and developmental disorders. It is pertinent for radiologists on a humanitarian care team to be familiar with many of these disorders, including the advanced stages of the infectious diseases and congenital and acquired disorders. Acknowledgments illustration.
Special thanks to Gilbert Gardner for the
Disclaimer The opinions and views expressed herein belong solely to the authors. They are not nor should they be implied as being endorsed by the United States Uniformed Services University of the Health Sciences, Department of the Army, Department of the Navy, Department of the Air Force, Department of Defense or any other branch of the federal government. Conflicts of interest Dr. J. P. Lichtenberger is an author for Amirsys. Drs. Biko, McQuillan, Jesinger, Sherman and Borg have no conflicts to declare.
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PICTORIAL ESSAY
Imaging of pediatric pathology during the Iraq and Afghanistan conflicts David M. Biko & Brian F. McQuillan & Robert A. Jesinger & Paul M. Sherman & Bryson D. Borg & John P. Lichtenberger III
Received: 30 January 2014 / Revised: 14 April 2014 / Accepted: 1 May 2014 # Springer-Verlag Berlin Heidelberg (outside the USA) 2014
Abstract United States Armed Forces radiologists deployed to Afghanistan and Iraq in modern military conflicts may encounter pediatric patients as a casualty of war or when providing humanitarian assistance to the indigenous population. Pediatric patients account for 4–7% of admissions at U.S. military hospitals during the Iraq and Afghanistan conflicts. It is pertinent for radiologists in the humanitarian care team to be familiar with imaging pediatric trauma patients, the pathology endemic to the local population, and delayed presentations of congenital and developmental disorders to adequately care for these patients. The radiological manifestations of various pediatric disorders seen in the setting of the Iraq and Afghanistan conflicts will be explored. Keywords Pediatric imaging . Humanitarian . Trauma . Infection . Neoplasm
Introduction A United States Armed Forces radiologist’s primary objective during a conflict is to support combat casualty care of service members; however, medical personnel are also often called on D. M. Biko (*) : B. F. McQuillan : R. A. Jesinger : B. D. Borg : J. P. Lichtenberger III Department of Radiology, David Grant USAF Medical Center, 101 Bodin Circle, Travis AFB, CA 94535, USA e-mail: [email protected] D. M. Biko : R. A. Jesinger : P. M. Sherman : J. P. Lichtenberger III Department of Radiology and Radiological Sciences, Uniformed Services University of the Health Sciences, Bethesda, MD, USA P. M. Sherman Department of Radiology, San Antonio Military Medical Center, Wilford Hall Ambulatory Surgical Center, San Antonio, TX, USA
to provide humanitarian services to the local population, making pediatric imaging more necessary during a conflict than one would expect. Pediatric patients account for 4% to 7% of admissions at U.S. hospitals during deployment in Iraq and Afghanistan [1]. Pediatric patients in a conflict zone also consume more resources than adults in both operating room time and hospital beds. Twenty-five percent of hospital bed days at U.S. military hospitals in Afghanistan and 10–12% of hospital bed days at U.S. military hospitals in Iraq are occupied by children [1, 2]. In spite of limited pediatric supplies and trained personnel in military hospitals, the mortality rate for children admitted was 6.2% in Afghanistan and 3.9% in Iraq [3, 4]. Pediatric pathology encountered in the deployed environment includes trauma, both blunt and penetrating, and infection. Similar to a tertiary facility in the United States that receives patients from abroad, due to lack of access to health care, medical staff in the deployed environment commonly see delayed presentations of congenital and acquired diseases [5]. Additionally, radiologists serving as humanitarians in underserved populations may also encounter pediatric pathology similar to the disorders described.
Trauma Seventy-five percent of pediatric hospital admissions to military hospitals during the Iraq and Afghanistan conflicts were secondary to traumatic injuries, compared to only 17% in the United States [5, 6]. Children presenting to these military hospitals suffer considerably more penetrating injuries (75%) than blunt injuries, whereas blunt injury is more common in the civilian experience [5, 7]. More than half of children admitted with trauma in these conflict zones required two or more invasive procedures [5]. Overall, penetrating trauma has higher mortality and morbidity in children than in adults [7].
Pediatr Radiol Fig. 1 Anatomical distribution of traumatic injuries to children in both Iraq and Afghanistan
Additionally, in a wartime environment, injuries to children younger than 8 are more severe than those in older children and adults [8]. Most injuries involve the extremities (38%),
followed by the brain and skull (Fig. 1) [1]. Most injuries are due to gunshot wounds (39% of cases) (Fig. 2) and explosives (32% of cases) (Fig. 3) [4]. Additionally, wartime pediatric
Fig. 2 A 10-year-old boy injured with a gunshot wound to the head. a Frontal scout view from a non-contrast CT of the head demonstrates a bullet overlying the right maxillary sinus. b Multiple axial images from
the same non-contrast CT show edema and hemorrhage within the brain parenchyma adjacent to the trajectory of bullet (arrows)
Pediatr Radiol Fig. 3 A 14-year-old boy injured following blast injury. a Lateral scout image from a non-contrast axial CT of the head demonstrates the radiopaque foreign piercing in the orbit. b Axial image from the same non-contrast CT of the head image shows the shrapnel extending into the right frontal lobe with an adjacent hemorrhagic right frontal lobe contusion and orbital wall fragments (circle)
trauma patients have a higher rate of vascular injury (3.5%) than those outside a war zone (0.6%) (Fig. 4) [9]. Mechanisms of blunt trauma in the conflict zone include blast injuries, motor vehicle accidents and falls (Fig. 5) [4]. In the civilian sector, children with blunt trauma have a significantly better outcome in a designated pediatric trauma center, likely due to successful nonoperative treatment [10]. A specialized pediatric trauma center is not available in Iraq and Afghanistan.
Infection Endemic infectious disease in Iraq and Afghanistan— most commonly gastrointestinal illness—affects troops, Fig. 4 A 10-year-old girl with prior gunshot wound. a Frontal scout image from a contrastenhanced CT of the lower extremity demonstrates apex medial bowing of the left femur (arrow) with an adjacent metallic fragment. b Axial image from the same CT shows an adjacent posttraumatic pseudoaneurysm (arrowhead)
humanitarian personnel, and local adults and children alike. In Iraq, gastrointestinal illness is caused by viral illness in up to 49% of cases but can also be secondary to Salmonella, Escherichia coli, Campylobacter jejuni and Vibrio cholerae [11]. In Afghanistan, bacterial etiologies of gastrointestinal illness include Salmonella, Shigella and Vibrio strains. In most cases, no definite etiology is established [12]. Other endemic infectious illnesses that often affect children include malaria, typhoid fever, viral hepatitis, leishmaniasis, CrimeanCongo hemorrhagic fever, anthrax, Rickettsial disease, Ascaris, Echinococcus and tuberculosis [11–13]. In one study, 12,850 children were treated for infection such as pneumonia and tuberculosis during a 4-year period at two refugee camps in Pakistan [14].
Pediatr Radiol
capillaries entering the lungs or other organs [19]. The liver, specifically the right lobe, is the most common site of involvement followed by the lungs [16, 19]. The imaging findings of Echinoccocus granulosus depend on the stage of cyst growth. There are four types of hydatid cyst. Type 1 cysts resemble simple cysts on imaging studies (Fig. 6). Sonographically, a double-line sign can be seen in unruptured cysts [16]. On CT or MRI, the cyst walls or septa may enhance helping to distinguish them from a simple cyst. Additionally, on MRI a characteristic low-intensity rim, most evident on T2-weighted images, has been described in hydatid disease [16, 19]. Type 2 cysts contain daughter cysts inside the mother cyst. Sonographically, floating membranes may be seen within the cyst. There may be multiple cysts or echogenic foci arranged together in a single capsule creating a “wheel spoke” appearance. Hyperechoic solid lesions within the mother cyst may be created by a conglomeration of daughter cysts. On CT, peripheral daughter cysts (type 2A), larger irregularly shaped daughter cysts (type 2B), or scattered calcifications within the mother cyst after degeneration of daughter cysts (type 2C) are characteristic. Daughter cysts may appear hypointense or hyperintense relative to the mother cyst on T1- and T2-weighted images. Type 3 cysts are calcified cysts, demonstrating posterior acoustic shadowing on sonography. They are hyperdense on CT and hypointense on MR. Finally, type 4 cysts are complicated cysts, usually due to rupture. Ruptures may be contained with an undulating membrane seen on US or cross-sectional imaging. Ruptures may also be communicating or direct where cysts rupture into the biliary system, pleural or peritoneal cavities [19]. Fig. 5 An 18-year-old who fell from a roof. Sagittal image from a noncontrast CT of the lumbar spine demonstrates a burst fracture of L1 with retropulsion of posterior element of vertebral body (arrow). There is an adjacent compression fracture of the superior end plate of L3 (arrowhead)
Echinococcus Echinococcus, a parasitic infection caused by the tapeworm Echinococcus in its larval form, is prevalent in both Iraq and Afghanistan [15, 16]. In Northern Iraq, it has been reported that 49.5-80% of dogs are infected with Echinococcus granulosa [17, 18]. There are two main forms of echinococcal disease: the more common unilocular cystic form caused by Echinococcus granulosus and the multilocular alveolar form caused by Echinococcus multilocularis [16]. Humans are exposed via the ingestion of contaminated feces. The ingested egg breaks down and a freed embryo passes through the duodenal mucosa into the portal vein. Most embryos embed in the hepatic capillaries forming hydatid cysts, but others pass through
Ascariasis Ascaris lumbricoides is the most common helminth infection with a prevalence of 25%. The incidence is greater in children, especially those living in warm, humid overpopulated climates, and can have a profound effect on their mental development [20–22]. The overall morbidity from this infection is 7.2%, with a mortality of 1.8% in a 10-year retrospective study in western Iran [21]. As in Echinococcal disease, ascariasis is acquired by ingesting contaminated food, water or soil. After ingestion, the eggs hatch and migrate through the duodenal wall, eventually into the pulmonary circulation. They enter the bronchi and trachea where they are again swallowed. The helminth matures in the small intestine, laying eggs to complete the cycle [20]. Ascaris causes pneumonia, manifesting as alveolar opacities, normally clearing within 10 days. Intestinal ascarids may
Pediatr Radiol Fig. 6 Echinoccal infection in a 5-year-old. a Axial non-contrast CT image shows an hydatid cyst within the left lower lobe (arrow). b Coronal image from the same CT demonstrates hydatid cysts in both the left lower lobe (arrow) and liver (arrowhead)
cause luminal obstruction. Radiographs may be normal with few ascarids, but large aggregations of ascarids appear as a tangled group of cords within the bowel (Fig. 7). Sonographically, the appearance of intestinal ascariasis is two parallel echogenic lines separated by the anechoic fluidfilled alimentary canal. On higher-resolution sonography, four parallel echogenic lines can be seen. The two outer lines represent the outside of the worm and the two inner lines represent the gut. Real-time movements of the worm can also be seen including swallowing [23]. CT demonstrates elongated or rounded filling defects within the intestinal lumen (Fig. 7). On fluid-sensitive MRI, the worm is a hypointense tubular structure surrounded by hyperintense intestinal fluid [20]. Biliary ascariasis mostly occurs when the worm migrates into the common bile duct, the intrahepatic ducts, gallbladder or pancreatic duct. This may result in cholecystitis, cholangitis, pancreatitis or hepatic abscesses. Worms typically migrate back into the duodenum between 2 days and 2 weeks [20]. Ultrasound is the preferred method of imaging biliary ascariasis identifying greater than 85% of cases. Sonography
Fig. 7 Ascariasis in a 2-year-old with abdominal distention. a Frontal scout image from a contrast-enhanced CT shows multiple tubular lucencies in the right hemi-abdomen consistent with ascarids. b Axial image from the same CT demonstrates ascarids in the right colon
enables direct visualization of the worm. Complications include enlargement of the bile duct, gallbladder edema or sludge, liver abscesses or pancreatic edema [24].
Cutaneous anthrax Bacillus anthracis, the gram-positive bacillus causing anthrax, is endemic to Afghanistan [12, 25]. Most natural anthrax infection is cutaneous from contamination of open wounds. Other forms of anthrax include gastrointestinal anthrax from ingestion and inhalation anthrax, the latter of which has the greatest potential for bioterroism [12, 26]. In cutaneous anthrax, a painless pruritic papule initially appears. This is followed by enlargement of the papule, ultimately erupting and undergoing necrosis forming an ulcer with a black-colored eschar (Fig. 8). Imaging is not frequently used for the diagnosis but correlates to the clinical findings of adjacent edema along with regional lymphadenopathy (Fig. 8) [26].
Pediatr Radiol Fig. 8 Cutaneous anthrax in an Afghan boy with acute respiratory distress (age unknown). a Photograph shows an ulcerated papule with peripheral vesicles and characteristic black eschar. b Axial contrast-enhanced CT image demonstrates subcutaneous edema along with enhancing level III lymphadenapathy (arrow) and laryngeal edema (arrowhead)
Tuberculosis Tuberculosis is a common endemic infection worldwide caused by the bacteria Mycobacterium tuberculosis. The scope of imaging findings of both pulmonary and extrapulmonary tuberculosis is substantial and too broad for this article, but its frequence is widespread, particularly in Afghanistan. In 1997, the prevelance of tuberculosis in Afghanistan was 753 cases per 100,000 [12, 27]. In Iraq in 2012, the prevalance of tuberculosis was 73 per 100,000 [28]. Children account for a large majority of cases of tuberculosis, particularly in endemic areas [29]. The most common form of pulmonary tuberculosis in children is the primary form as opposed to the post-primary form in adults [30, 31]. The most common radiographic finding of primary tuberculosis in children is lympahadenopathy, present in 92%, and typically involving the hilar and paratracheal regions [30]. The radiographic findings in pediatric post-primary tuberculosis are upper lobe consolidation and cavitation, multifocal ill-defined airspace opacities and apical pleural thickening [31]. Extrapulmonary Fig. 9 Tuberculous spondylitis in a 14-year-old with back pain. a Axial image of a contrastenhanced CT demonstrates compression of the L3 vertebral body with an adjacent rim enhancing psoas abscess (arrowhead). b Sagittal image from the same CT better demonstrates the L3 vertebral body compression fracture (arrow)
manifestations of tuberculosis include musculoskeletal manifestations such as osteomyelitis and spondylitis (Fig. 9), central nervous system manifestations such as meningitis and parenchymal disease, and both gastrointestinal and genitourinary manifestations [32, 33].
Delayed presentation of congenital or acquired disease Due to limited access to health care, those providing humanitarian services to the local populations of Iraq and Afghanistan may encounter children with advanced congenital or acquired disease, so it is important for radiologists and medical teams to recognize and diagnose these diseases by reviewing pertinent imaging findings. Macrodystrophia lipomatosa Macrodystrophia lipomatosa (MDL) is a term describing macrodactyly with lipomatosis of a nerve, which most often occurs in the upper extremity and has been described using
Pediatr Radiol
Fig. 10 Macrodystrophia lipomatosa in a child (age unknown). a Frontal scout image from a non-contrast-enhanced CT demonstrates localized overgrowth of the subcutaneous tissues of the right upper extremity, most severely involving the hand. b Radiograph of the same child again reveals
overgrowth of the subcutaneous tissues of the right upper extremity along with bony overgrowth of the 1st, 2nd and 3rd digits. c Coronal image from a non-contrast-enhanced CT further demonstrates the enlarged subcutaneous tissues and digits of the right upper extremity
multiple terms including neural fibrolipoma, intraneural lipoma, fatty infiltration of the nerve, perineural lipoma and fibrolipomatous hamartoma. Macrodactyly or MDL occurs in 27-67% of cases [34]. The hallmark of MDL is progressive overgrowth of the mesenchymal elements with disproportionate enlargement of the fibrous and adipose tissue. The disease is usually recognized as a neonate. Complications present during growth due to degenerative changes in the small joints and compression of neurovascular structures [35, 36]. The abnormal overgrowth halts at puberty [37, 38]. The abnormality in MDL occurs in the distribution of the sclerotome of the nerve involved. The lower extremity is more commonly involved than the upper extremity. Most cases involve the territory supplied by the median nerve [38, 39]. Plain radiography demonstrates hypertrophied tissue, most severe on the volar surface. CT demonstrates excessive fatty proliferation involving the soft tissues and muscles (Fig. 10). On MRI, the affected limb has unencapsulated fatty tissue with linear TI hypointense bands corresponding to fibrous strands [35, 40, 41]. Neural enlargement in the region of the overgrowth can also be seen on MRI [40, 41]. Bony overgrowth and cortical thickening of the involved digits can be demonstrated on both CT and MRI [35].
[42–44]. This aganglionic segment begins at the anal sphincter and extends a variable distance proximally within the colon and small bowel. There are three types of HD described: 1) classical, involving the rectum and rectosigmoid, and extending to the splenic flexure; 2) ultrashort, involving only 2–3 cm of the rectum, and 3) ultra-long, where greater than half of the colon is involved [43]. Ninety percent of cases of HD are symptomatic in the newborn period [44]. Neonates present with failure to pass meconium (90-94%) and abdominal distention (55-87%) [43]. Imaging findings of HD on a neonatal contrast enema include an abrupt caliber change between the dilated proximal ganglionic bowel and the distal small or normal in caliber aganglionic bowel [45]. Late presentation of HD presents with complications rather than the classic findings of abdominal distention. These include acute enterocolitis or toxic megacolon, anemia, fecal impaction and failure to thrive [44]. Late presentation of the disease may be evaluated with CT, which demonstrates similar findings to the contrast enema (Fig. 11) [46].
Hirschsprung disease Hirschprung disease (HD) is a congenital enteric nervous system disorder characterized by the lack of ganglion cells in the submucosal and myenteric plexuses of the bowel
Retinoblastoma Retinoblastoma is the most common intraocular pediatric tumor. The tumor arises from immature retina. Ninety to ninety-five percent of children are diagnosed before the age of 5 years old [47]. Clinical symptoms of retinoblastoma are leukocoria (56-72% of cases) and strabismus or lack of binocular vision (22-24% of cases). The diagnosis of retinoblastoma is made with ophthalmoscopy followed by imaging [47, 48].
Pediatr Radiol Fig. 11 Hirschprung disease in a 3-year-old. a Frontal scout from a contrast-enhanced CT of the abdomen and pelvis demonstrates abdominal distention and dilated loops of bowel. b Axial image from the same CT further demonstrates the distended abdomen and markedly dilated loops of colon
Calcification is a key finding that distinguishes retinoblastoma from other intraocular lesions on imaging (Fig. 12). Orbital sonography demonstrates an irregular heterogeneous solid mass with calcifications in up to 75%. CT findings include a dense mass within the posterior aspect of the globe with calcifications in 95% and enhancement in 28% of the cases (Fig. 12) [47]. MRI is the modality of choice to evaluate intracranial spread of disease [47, 48]. Extraocular extension through the optic nerve and/or sclera is the most important risk factor for metastatic disease [47]. Metastases most commonly involve the central nervous system, regional lymph nodes, and the bone and bone marrow [49]. Ewing sarcoma Ewing sarcoma is the second most common musculoskeletal neoplasm in the pediatric population accounting for 3% of all pediatric cancers [50, 51]. In up to 86% of cases, Ewing sarcoma involves the pelvis, extremities and ribs. In the long bones, the
Fig. 12 Retinoblastoma in an 11year-old boy with a chronically growing left eye mass. a Photograph shows a large softtissue mass extending from the left orbit. b Axial image from a contrast-enhanced CT of the same child demonstrates the large heterogenous mass with internal calcifications (arrow) extending from the left globe
tumor is most commonly metadiaphyseal and more common proximally. Clinically, most patients present with pain and a mass or swelling. Although Ewing sarcoma can be encountered between the ages of 4 and 25 years, the peak prevalence is 10–15 years old [50]. At presentation, 20-30% of patients have lung or skeletal metastases [51]. Prognosis is worse if tumor size is greater than 8 cm and with metastatic disease [52]. The radiographic appearance of Ewing sarcoma is a poorly marginated, intramedullary lytic lesion with aggressive lamellated periosteal reaction and a large soft-tissue mass (Fig. 13). CT demonstrates similar findings but is more sensitive for the soft-tissue component and provides better bony detail [51]. MRI is the modality of choice for local tumor staging given its superb contrast resolution. MRI can demonstrate the degree of extension of the lesion and its relationship with the neurovascular bundle [51, 53]. The signal on MRI is homogenous and intermediate in signal intensity on T1weighted images and low to intermediate signal intensity on T2-weighted images [50].
Pediatr Radiol
Fig. 13 Ewing sarcoma in a 10-year-old boy with a chronically enlarging left upper extremity mass. a Photograph shows a large soft-tissue mass involving the proximal upper extremity. b Radiograph of the left upper extremity in the same patient demonstrates a large soft-tissue mass with
near complete disruption of the humerus. c Sagittal image from a contrastenhanced CT image of the left upper extremity in the same patient demonstrate a heterogeneous mass within internal necrosis
Conclusion
3. Gawande A (2004) Casualties of war: military care for the wounded from Iraq and Afghanistan. N Engl J Med 351:2471–2475 4. Creamer KM, Edwards MJ, Shields CH et al (2009) Pediatric wartime admissions to U.S. military combat support hospitals in Afghanistan and Iraq: Learning from the first 2,000 admissions. J Trauma 67:762–768 5. Semerad D, Statler J, Harcke HT et al (2007) Disease and nonbattle injury in the combat zone. Emerg Radiol 14:205–209 6. White JRM, Dalton HJ (2002) Pediatric trauma: post injury care in the pediatric intensive care unit. Crit Care Med 30: S478–S488 7. Boleken ME, Cevik M, Yagiz B et al (2013) The characteristics and outcomes of penetrating thoracic and abdominal trauma among children. Pediatr Surg Int 29:795–800 8. Matos RI, Holcomb JB, Callahan C et al (2008) Increased mortality rates of young children with traumatic injuries at a U.S. army combat support hospital in Baghdad, Iraq, 2004. Pediatrics 122:e959–e966 9. Villamaria CY, Morrison JJ, Fitzpatrick CM et al (2014) Wartime vascular injuries in the pediatric population of Iraq and Afghanistan: 2002–2011. J Pediatr Surg 49:428–432 10. Hall JR, Reyes HM, Meller JL et al (1996) The outcome for children with blunt trauma is best at a pediatric trauma center. J Pediatr Surg 31:72–77 11. Gasser RA, Magill AJ, Oster CN et al (1991) The threat of infectious disease in Americans returning from Operation Desert Storm. N Eng J Med 324:859–863 12. Wallace MR, Hale BR, Utz GC et al (2002) Endemic infectious diseases of Afghanistan. Clin Infect Dis 34:S171–S207 13. Rajabali A, Moin O, Ansari AS et al (2009) Communicable disease among displaced Afghans: refuge without shelter. Nat Rev Microbiol 7:609–614 14. Oldfield EC, Wallace MR, Hyams KC et al (1991) Endemic infectious diseases of the Middle East. Rev Infect Dis 13: S199–S217 15. Moro P, Chantz PM (2006) Cystic echinococcosis in the Americas. Parasitol Int 55:S181–S186 16. Czermak BV, Unsinn KM, Gotwald T et al (2001) Echinococcus granulosus revisited. AJR Am J Roentgenol 177:1051–1056
The humanitarian mission in a region of conflict involves the radiological diagnosis of several categories of disorders. These conditions include blunt and penetrating trauma, infection, and congenital and developmental disorders. It is pertinent for radiologists on a humanitarian care team to be familiar with many of these disorders, including the advanced stages of the infectious diseases and congenital and acquired disorders. Acknowledgments illustration.
Special thanks to Gilbert Gardner for the
Disclaimer The opinions and views expressed herein belong solely to the authors. They are not nor should they be implied as being endorsed by the United States Uniformed Services University of the Health Sciences, Department of the Army, Department of the Navy, Department of the Air Force, Department of Defense or any other branch of the federal government. Conflicts of interest Dr. J. P. Lichtenberger is an author for Amirsys. Drs. Biko, McQuillan, Jesinger, Sherman and Borg have no conflicts to declare.
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