Pediatr Radiol (1992) 22:313-314
Pediatric Radiology 9 Springer-Verlag 1992
Sonographic findings in spontaneous renal transplant rupture F. J. A . B e e k ~, N . M . A . B ax 2, R . D o n c k e r w o l c k e 3, a n d M . S. van L e e u w e n l Department of Radiology, 2Department of Surgery, and 3 Department of Nephrology, University Childrens Hospital, Het Wilhelmina Kinderziekenhuis,Nieuwegracht 137, 3512 LK Utrecht, The Netherlands Received: 24 December 1991; accepted: 1 April 1992
Abstract. A post-transplant kidney became acutely swollen during a rejection episode. The hemoglobin level and pulsitility index fell. Sonographic examination demonstrated extrarenal and subcapsular collections due to spontaneous renal transplant rupture.
Non-traumatic rupture of a renal transplant is an infrequent occurrence, with a reported incidence ranging b e t w e e n 0.3 and 8.6% [1]. It has seldom been reported following kidney transplantation in children. In our center two cases occured in 112 tr ansplants. The diagnosis is based on clinical signs and symptoms. Sonography can be helpful in establishing the diagnosis.
Case report A 14-year-old girl received a kidney from a 10year-old donor. Her primary renal disease was familial, steroid resistant nephrotic syndrome. A renal biopsy at the age of 2 years revealed mesangial hypercellularity. By the age of 13 she had progressed to end stage renal failure and was treated with intermittent hemodialysis. One year later she received a renal transplant. Postoperatively she remained anuric and was dialysed on the fourth and sixth day. The renal transplant was imaged with ultrasound (US) on day 1,3, 5, 7 and 9. The Pulsatility Index (PI, maximal systolic velocity maximal diastolic velocity / mean of maximal velocities) was calculated from the average of measurements in segmental arteries in both poles and the midportion of the kidney. The length of the renal transplant increased from 9.4 cm on day 1 to 10.8 cm on day 7. The PI rose from 1.5 on day 1 to 2.8 on day 7. Immunosuppressive therapy consisted initially of prednisone and azothioprine; cyclosporin was started on the 4th day post trans-
plantation. Because rejection was suspected, i.v. methylprednisolone was administered from the 6th to the 9th postoperative day and one dose of OKT3 was given on the 7th day. On the 9th postoperative day a painful, rapidly expanding swelling developed over the transplant. The hemoglobin level fell from 6.0 to 3.8 mmol/1. US showed a massive extrarenal collection of heterogenous echogenicity, displacing the transplant dorsally. A hypoechoic zone was present on the convex edge. It could not be determined whether this hypoechoic area was intrarenal, subcapsular or both (Fig. l). No renal tear could be visualized. The PI fell to 1.6. A moderate amount of clear fluid was present intraperitoneally. The US findings of acute extrarenal and subcapsular/intrarenalcollections in a swollen transplant were suggestive of a spontaneous rupture and in line with the clinical findings. On surgical exploration decapsulation, an extrarenal hematoma, and a rupture on the convex external edge were seen. There were also multiple small tears (Fig. 2). A subcapsular collection was found, corresponding to the hypoechoic area. The main vessels were patent. Because of the absence of kidney func-
tion the transplant was removed. Histopathology showed an acute interstitialrejection and concomittant papillary necrosis. No abnormalities were found in the renal pelvis or ureter.
Discussion The mechanism of spontaneous renal transplant rupture remains the subject of speculation. Rejection, hemodialysis with heparin, renal biopsy, renal vein thrombosis and hydronephrosis may be contributing factors. Since the introduction of cyclosporin it seems to be associated relatively more often with renal vein thrombosis [2]. The clinical course may be typical with an acute onset of abdominal pain. However, a differential diagnosis of acute rejection, acute urinary obstruction, renal vein thrombosis and ovarian torsion should be considered. Therapy consists of nephrectomy in cases with renal vein
Fig. L Longitudinalscan: A massive extrarenal collection of heterogenous echogenicity is displacing the transplant dorsally (whimarrowheads).A hypoechoic zone at the dorsal side represents a subcapsular collection (whimarrows) Fig.2. Peroperative photograph shows a long tear at the convex external edge (black arrow) and a smalltear at the lateral side (whimarrowhead)
314
thrombosis, uncontrollable bleeding and infarction secondary to rejection [2]. In transplants with reversible rejection, suturing or corsettage can be attempted [3]. The use of US in diagnosing a rupture has been mentioned in the literature [4]. In our patient, the sonographic findings consisted of a collection of heterogenous echogenicity around the transplant and free abdominal fluid. The transplant was displaced dorsally by the accumulation of blood on the ventral surface. The tear itself could not be visualized. The image is comparable to a perirenat hematoma after biopsy. The PI-values in our patient showed a remarkable course. They increased for several days, indicating acute rejection or acute tubular necrosis [5]. PImeasurements one hour after the onset of acute abdominal pain showed a sharp drop in PI-value. Theoretically this could be caused by a decrease in
blood pressure or humoral mediated responses but none of these causes was evident in our case. It could merely reflect a decrease of intrarenal pressure after the rupture. Awareness of spontaneous rupture as an infrequent complication following kidney transplantation and knowledge of its sonographic appearance can help in early diagnosis of transplant rupture.
References
3. Chopin DK, A b b o u CC, Lottmann HB, P o p o v Z , L a n g P R , BuissonCL, BelghitiD, Colombel M, Auvert JM (1989) Conservative treatment of renal transplant rupture with polyglactin 910 mesh and gelatin resorcin formaldehyde glue. J Uro1142: 363 4. Ostrovsky PD, Carr L, G o o d m a n JD, Moser F G (1985) Ultrasound findings in renal rupture. J Clin Ultrasound 13:132 5. Genkins SM, Sanfilippo FR Carroll B A (1989) Duplex Doppler sonography of renal transplants: lack of sensitivity and specificity in establishing pathologic diagnosis. A J R 152:535
1. Goldman M, de Pauw L, Kinnaert P e t al. (1981) Renal transplant rupture. Transplantation 32:153 2. Richardson AJ, Higgins RM, Jaskowski AJ, Murie JA, Dunnill MS, Tin A, Morris PJ (1990) Spontaneous rupture of renal transplants: the importance of renal vein thrombosis in the cyclosporin era. Br J Surg 77:558
E J . A . B e e k , M.D. D e p a r t m e n t of Radiology University Childrens Hospital: Het Wilhemina Kinderziekenhuis P. O. Box 18009, 3501 C A Utrecht The Netherlands
Literature in pediatric radiology Pediatric Neurosurgery (Basel)
Delayed posttraumatic intracranial lesions in children. Jaimovich, R., Monges, J.A. (Amenabar 2263, i428 Buenos Aires, Argentina) 17:25 (1992) Hypothalamic hamartoma associated with Laurence-Moon-Biedl syndrome. Diaz, L. L. et al. (Prados, M. D., Dept. ofNeurol. Surg., 1360Ninth Av., Suite 210, San Francisco, CA 94122, USA) 17:30 (1992) Congenital aneurysmal hemorrhage and astrocytoma in an infant. Boop, IF.A. et al. (Children's Hosp., Dept. of Ped. Neurosurg., 800 Marshall St., Little Rock, AR 72202, USA) 17:44 (1992) Magnetic resonance imaging of fourth ventricular choroid plexus neoplasms in childhood. Vazquez, E. et al. (Ball, Jr., W. S., Dept. of Rad., Children's Hosp. Med. Center, Elland and Bethesda Av., Cincinnati, OH 45229-2899, USA) 17:48 (1992) Clival chondroma in a child with Ollier's disease. Ghogawala, Z. et al. (Scott, R. M., Section of Ped. Neurosurg., Children's Hosp., 300 Longwood Av., Boston, MA 02115, USA) 17:53 (1992) Urologia Internationalis (Basel)
Imaging of infantile polycystic kidney disease with some rare association. Patel, P.J. (Rad. Div., King Khalid Univ. Hosp., College of Med., King Sand Univ., R/yadh, Saudi Arabia) 48:87 (1992) Minerva Pediatrica (Torino)
Nuclear magnetic resonance and iron overload in thalassemia. [In Ital.] Schettini, E et al. (Ist. di Ped. Clinica e Prey entiva, I Clinica Ped., Policlinico, Piazza Giulio Cesare, 1-70124 Bari, Italy) 43:777 (1991) Magnetic resonance imaging in diagnosis of aneurysmal bone cyst. [In Ital.] Tom,t, E et al. (Serv. di Rad., Ist. "Giannina Gaslini", Largo G. Gaslini, 5 1-16147 Genova, Italy) 43:789 (1991) Epilepsy with laughing seizures, hypothalamic hamartoma and precocious puberty. Diagnostic value of MRI, computerEEG topography (CET)
[
Continued from p. 312 and ambulatory EEG (A-EEG). [In Ital.] Gaggero, R. et al. (Div. diNeuropsichiatria Infantile, Ist. "G. Gaslini", Largo G. Gaslini, 5,1-16147 Genova, Italy) 43:801 (1991)
Radiologia Medica (Torino) Distal colography in anorectal malformations. [In
Ital.] Maxtucciello, G. et al. (Taccone, A., Serv. di Rad., Ist. "G. Gaslini", Largo Gerolamo Gaslini 5,1-16148 Genova GE, Italy) 82:635 (1991) ComputedtomographyvsInagneticresonanceima~ng in the diagnosis of anorectal anomalies. [In ItaI.] Taccone, A. et al. (Serv. di Rad., Ist. "G. Gaslini', Largo G.Gaslini 5, 1-16148 Genova GE, Italy) 82:638 (1991) Primary myocardial tumors. MRI in two threemonth-old patients. [In Ital.] Foresti, M. et al. (Guidali, A., Radiodiagn. degli 00.RR., Largo Borazzi 1, 1-24100 Bergamo BG, Italy) 82:688 (1991) Lymphatic vessels dysplasiain Noouan's syndrome. Report of a case. [In Ital.] Graziani, M., Fasanelli, S. (Ospedale "Bambino Gesfi", Serv. di Rad., Piazza S. Onofrio 4, 1-00164 Roma RM, Italy) 82:697 (1991) Intestinal intussusception in Henoch-Scli6nlein purpura. Contribution of ultrasonography. [In Ital.] Di Mario, M. et al. (Via M. G. Columba 38, 1-00179 Roma RM, Italy) 82:702 (1991) Hypothesis of diagnostic-prognostic evaluation of enteric intussusception for treatment with USguided pneumatic reduction. [In Ital.] Rabassini, A. et al. (Via Montello 6/E, 1-31100 Treviso TV, Italy) 8a:817 (1991) Mild I-cell disease, or severe pseudo-Hm'ler polydystrophy in three siblings: further evidence for intermediate forms of mucolipidosis II and III. Kozlowski, K. et al. (X-ray Dept., RACH Pyrmont Bridge Rd., Camperdown, NSW 2050, Australia) 82:847 (1991)
Fetal achondrogenesis. A case report. [In ltal.] Fodor, G. et al. (Reparto di Rad., Ospedale Generale Regionale, Via L.B6hler 5, 1-39100 Bolzano BZ, Italy) 82:852 (1991)
Radiologia (Barcelona)
Bronchial atresia: CT and MR findings. [In Span.]. Marti-Bonmati, L. et al. (Serv. de Radiodiagn., Hosp. Doctor Peset, E-46017 Valencia, Espania) 33:705 (1991)
Acta Paediatrica Japonica (Tokyo)
Diagnosis of atlantoaxial subluxation in Morquio's syndrome and spondyloepiphyseal dysplasia congenita. Takeda, E. et al. (Dept. of Ped., Univ. School of Med., 18, 3-chome Kuramoto-cho, Tokushima-shi, Tokushima 770, Japan) 33:633 (1991) Ultrasonography of ovary, uterus and breast in premature thelarche. Nakamura, M. et al. (Dept. of Clinical Pathol., Jichi Med. School, Yakushiji, Minamika-wachi-machi, Kawachi-gun, Tochigi 329-04, Japan) 33:645 (1991) Precocious puberty caused by an hCG-producing tumor of the septum pellucidum. Inamo, Y. et al. (Dept. of Ped., Nihon Univ. School of Med., 30-1 Oyaguchi Kami-machi, Itabashi-ku, Tokyo 173, Japan) 33:68I (1991)
Australian and New Zealand Journal of Surgery
(Victoria) Vertical subluxation of the patella: an unusual feature of multiple epiphyseal dysplasia. Coates, C. J. et al. (Menelaus, M. B., Dept of Orthop., The Royal Children's Hosp., Flemington Rd., Parkville, Vic. 3052, Australia) 62:164 (1992)
I
Pediatric Radiology 9 Springer-Verlag 1992
Sonographic findings in spontaneous renal transplant rupture F. J. A . B e e k ~, N . M . A . B ax 2, R . D o n c k e r w o l c k e 3, a n d M . S. van L e e u w e n l Department of Radiology, 2Department of Surgery, and 3 Department of Nephrology, University Childrens Hospital, Het Wilhelmina Kinderziekenhuis,Nieuwegracht 137, 3512 LK Utrecht, The Netherlands Received: 24 December 1991; accepted: 1 April 1992
Abstract. A post-transplant kidney became acutely swollen during a rejection episode. The hemoglobin level and pulsitility index fell. Sonographic examination demonstrated extrarenal and subcapsular collections due to spontaneous renal transplant rupture.
Non-traumatic rupture of a renal transplant is an infrequent occurrence, with a reported incidence ranging b e t w e e n 0.3 and 8.6% [1]. It has seldom been reported following kidney transplantation in children. In our center two cases occured in 112 tr ansplants. The diagnosis is based on clinical signs and symptoms. Sonography can be helpful in establishing the diagnosis.
Case report A 14-year-old girl received a kidney from a 10year-old donor. Her primary renal disease was familial, steroid resistant nephrotic syndrome. A renal biopsy at the age of 2 years revealed mesangial hypercellularity. By the age of 13 she had progressed to end stage renal failure and was treated with intermittent hemodialysis. One year later she received a renal transplant. Postoperatively she remained anuric and was dialysed on the fourth and sixth day. The renal transplant was imaged with ultrasound (US) on day 1,3, 5, 7 and 9. The Pulsatility Index (PI, maximal systolic velocity maximal diastolic velocity / mean of maximal velocities) was calculated from the average of measurements in segmental arteries in both poles and the midportion of the kidney. The length of the renal transplant increased from 9.4 cm on day 1 to 10.8 cm on day 7. The PI rose from 1.5 on day 1 to 2.8 on day 7. Immunosuppressive therapy consisted initially of prednisone and azothioprine; cyclosporin was started on the 4th day post trans-
plantation. Because rejection was suspected, i.v. methylprednisolone was administered from the 6th to the 9th postoperative day and one dose of OKT3 was given on the 7th day. On the 9th postoperative day a painful, rapidly expanding swelling developed over the transplant. The hemoglobin level fell from 6.0 to 3.8 mmol/1. US showed a massive extrarenal collection of heterogenous echogenicity, displacing the transplant dorsally. A hypoechoic zone was present on the convex edge. It could not be determined whether this hypoechoic area was intrarenal, subcapsular or both (Fig. l). No renal tear could be visualized. The PI fell to 1.6. A moderate amount of clear fluid was present intraperitoneally. The US findings of acute extrarenal and subcapsular/intrarenalcollections in a swollen transplant were suggestive of a spontaneous rupture and in line with the clinical findings. On surgical exploration decapsulation, an extrarenal hematoma, and a rupture on the convex external edge were seen. There were also multiple small tears (Fig. 2). A subcapsular collection was found, corresponding to the hypoechoic area. The main vessels were patent. Because of the absence of kidney func-
tion the transplant was removed. Histopathology showed an acute interstitialrejection and concomittant papillary necrosis. No abnormalities were found in the renal pelvis or ureter.
Discussion The mechanism of spontaneous renal transplant rupture remains the subject of speculation. Rejection, hemodialysis with heparin, renal biopsy, renal vein thrombosis and hydronephrosis may be contributing factors. Since the introduction of cyclosporin it seems to be associated relatively more often with renal vein thrombosis [2]. The clinical course may be typical with an acute onset of abdominal pain. However, a differential diagnosis of acute rejection, acute urinary obstruction, renal vein thrombosis and ovarian torsion should be considered. Therapy consists of nephrectomy in cases with renal vein
Fig. L Longitudinalscan: A massive extrarenal collection of heterogenous echogenicity is displacing the transplant dorsally (whimarrowheads).A hypoechoic zone at the dorsal side represents a subcapsular collection (whimarrows) Fig.2. Peroperative photograph shows a long tear at the convex external edge (black arrow) and a smalltear at the lateral side (whimarrowhead)
314
thrombosis, uncontrollable bleeding and infarction secondary to rejection [2]. In transplants with reversible rejection, suturing or corsettage can be attempted [3]. The use of US in diagnosing a rupture has been mentioned in the literature [4]. In our patient, the sonographic findings consisted of a collection of heterogenous echogenicity around the transplant and free abdominal fluid. The transplant was displaced dorsally by the accumulation of blood on the ventral surface. The tear itself could not be visualized. The image is comparable to a perirenat hematoma after biopsy. The PI-values in our patient showed a remarkable course. They increased for several days, indicating acute rejection or acute tubular necrosis [5]. PImeasurements one hour after the onset of acute abdominal pain showed a sharp drop in PI-value. Theoretically this could be caused by a decrease in
blood pressure or humoral mediated responses but none of these causes was evident in our case. It could merely reflect a decrease of intrarenal pressure after the rupture. Awareness of spontaneous rupture as an infrequent complication following kidney transplantation and knowledge of its sonographic appearance can help in early diagnosis of transplant rupture.
References
3. Chopin DK, A b b o u CC, Lottmann HB, P o p o v Z , L a n g P R , BuissonCL, BelghitiD, Colombel M, Auvert JM (1989) Conservative treatment of renal transplant rupture with polyglactin 910 mesh and gelatin resorcin formaldehyde glue. J Uro1142: 363 4. Ostrovsky PD, Carr L, G o o d m a n JD, Moser F G (1985) Ultrasound findings in renal rupture. J Clin Ultrasound 13:132 5. Genkins SM, Sanfilippo FR Carroll B A (1989) Duplex Doppler sonography of renal transplants: lack of sensitivity and specificity in establishing pathologic diagnosis. A J R 152:535
1. Goldman M, de Pauw L, Kinnaert P e t al. (1981) Renal transplant rupture. Transplantation 32:153 2. Richardson AJ, Higgins RM, Jaskowski AJ, Murie JA, Dunnill MS, Tin A, Morris PJ (1990) Spontaneous rupture of renal transplants: the importance of renal vein thrombosis in the cyclosporin era. Br J Surg 77:558
E J . A . B e e k , M.D. D e p a r t m e n t of Radiology University Childrens Hospital: Het Wilhemina Kinderziekenhuis P. O. Box 18009, 3501 C A Utrecht The Netherlands
Literature in pediatric radiology Pediatric Neurosurgery (Basel)
Delayed posttraumatic intracranial lesions in children. Jaimovich, R., Monges, J.A. (Amenabar 2263, i428 Buenos Aires, Argentina) 17:25 (1992) Hypothalamic hamartoma associated with Laurence-Moon-Biedl syndrome. Diaz, L. L. et al. (Prados, M. D., Dept. ofNeurol. Surg., 1360Ninth Av., Suite 210, San Francisco, CA 94122, USA) 17:30 (1992) Congenital aneurysmal hemorrhage and astrocytoma in an infant. Boop, IF.A. et al. (Children's Hosp., Dept. of Ped. Neurosurg., 800 Marshall St., Little Rock, AR 72202, USA) 17:44 (1992) Magnetic resonance imaging of fourth ventricular choroid plexus neoplasms in childhood. Vazquez, E. et al. (Ball, Jr., W. S., Dept. of Rad., Children's Hosp. Med. Center, Elland and Bethesda Av., Cincinnati, OH 45229-2899, USA) 17:48 (1992) Clival chondroma in a child with Ollier's disease. Ghogawala, Z. et al. (Scott, R. M., Section of Ped. Neurosurg., Children's Hosp., 300 Longwood Av., Boston, MA 02115, USA) 17:53 (1992) Urologia Internationalis (Basel)
Imaging of infantile polycystic kidney disease with some rare association. Patel, P.J. (Rad. Div., King Khalid Univ. Hosp., College of Med., King Sand Univ., R/yadh, Saudi Arabia) 48:87 (1992) Minerva Pediatrica (Torino)
Nuclear magnetic resonance and iron overload in thalassemia. [In Ital.] Schettini, E et al. (Ist. di Ped. Clinica e Prey entiva, I Clinica Ped., Policlinico, Piazza Giulio Cesare, 1-70124 Bari, Italy) 43:777 (1991) Magnetic resonance imaging in diagnosis of aneurysmal bone cyst. [In Ital.] Tom,t, E et al. (Serv. di Rad., Ist. "Giannina Gaslini", Largo G. Gaslini, 5 1-16147 Genova, Italy) 43:789 (1991) Epilepsy with laughing seizures, hypothalamic hamartoma and precocious puberty. Diagnostic value of MRI, computerEEG topography (CET)
[
Continued from p. 312 and ambulatory EEG (A-EEG). [In Ital.] Gaggero, R. et al. (Div. diNeuropsichiatria Infantile, Ist. "G. Gaslini", Largo G. Gaslini, 5,1-16147 Genova, Italy) 43:801 (1991)
Radiologia Medica (Torino) Distal colography in anorectal malformations. [In
Ital.] Maxtucciello, G. et al. (Taccone, A., Serv. di Rad., Ist. "G. Gaslini", Largo Gerolamo Gaslini 5,1-16148 Genova GE, Italy) 82:635 (1991) ComputedtomographyvsInagneticresonanceima~ng in the diagnosis of anorectal anomalies. [In ItaI.] Taccone, A. et al. (Serv. di Rad., Ist. "G. Gaslini', Largo G.Gaslini 5, 1-16148 Genova GE, Italy) 82:638 (1991) Primary myocardial tumors. MRI in two threemonth-old patients. [In Ital.] Foresti, M. et al. (Guidali, A., Radiodiagn. degli 00.RR., Largo Borazzi 1, 1-24100 Bergamo BG, Italy) 82:688 (1991) Lymphatic vessels dysplasiain Noouan's syndrome. Report of a case. [In Ital.] Graziani, M., Fasanelli, S. (Ospedale "Bambino Gesfi", Serv. di Rad., Piazza S. Onofrio 4, 1-00164 Roma RM, Italy) 82:697 (1991) Intestinal intussusception in Henoch-Scli6nlein purpura. Contribution of ultrasonography. [In Ital.] Di Mario, M. et al. (Via M. G. Columba 38, 1-00179 Roma RM, Italy) 82:702 (1991) Hypothesis of diagnostic-prognostic evaluation of enteric intussusception for treatment with USguided pneumatic reduction. [In Ital.] Rabassini, A. et al. (Via Montello 6/E, 1-31100 Treviso TV, Italy) 8a:817 (1991) Mild I-cell disease, or severe pseudo-Hm'ler polydystrophy in three siblings: further evidence for intermediate forms of mucolipidosis II and III. Kozlowski, K. et al. (X-ray Dept., RACH Pyrmont Bridge Rd., Camperdown, NSW 2050, Australia) 82:847 (1991)
Fetal achondrogenesis. A case report. [In ltal.] Fodor, G. et al. (Reparto di Rad., Ospedale Generale Regionale, Via L.B6hler 5, 1-39100 Bolzano BZ, Italy) 82:852 (1991)
Radiologia (Barcelona)
Bronchial atresia: CT and MR findings. [In Span.]. Marti-Bonmati, L. et al. (Serv. de Radiodiagn., Hosp. Doctor Peset, E-46017 Valencia, Espania) 33:705 (1991)
Acta Paediatrica Japonica (Tokyo)
Diagnosis of atlantoaxial subluxation in Morquio's syndrome and spondyloepiphyseal dysplasia congenita. Takeda, E. et al. (Dept. of Ped., Univ. School of Med., 18, 3-chome Kuramoto-cho, Tokushima-shi, Tokushima 770, Japan) 33:633 (1991) Ultrasonography of ovary, uterus and breast in premature thelarche. Nakamura, M. et al. (Dept. of Clinical Pathol., Jichi Med. School, Yakushiji, Minamika-wachi-machi, Kawachi-gun, Tochigi 329-04, Japan) 33:645 (1991) Precocious puberty caused by an hCG-producing tumor of the septum pellucidum. Inamo, Y. et al. (Dept. of Ped., Nihon Univ. School of Med., 30-1 Oyaguchi Kami-machi, Itabashi-ku, Tokyo 173, Japan) 33:68I (1991)
Australian and New Zealand Journal of Surgery
(Victoria) Vertical subluxation of the patella: an unusual feature of multiple epiphyseal dysplasia. Coates, C. J. et al. (Menelaus, M. B., Dept of Orthop., The Royal Children's Hosp., Flemington Rd., Parkville, Vic. 3052, Australia) 62:164 (1992)
I
