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The aim of this study was to evaluate the outcome of children undergoing treatment for malignancy and immunodeficiency syndromes in whom invasive pulmonary aspergillosis (IPA) developed.The authors reviewed the medical records of all patients treated at their institution from January 1990 to August 1999 for culture-proven pulmonary aspergillus infection.Among the 43 patients studied, the median age at the time of diagnosis of IPA was 13.1 years. The most common primary diagnoses were acute myelogenous leukemia (n = 18) and acute lymphoblastic leukemia (n = 14); 27 patients (63%) had received a bone marrow transplant (BMT). Of the 18 patients who underwent surgical intervention for IPA, 14 (78%) had one operation, whereas the remaining 4 patients had 2. The 4 patients alive at the time this report was written had undergone surgical intervention 2, 10, 23, and 44 months previously respectively. Surgical resection of the involved lung parenchyma was significantly prognostic for survival (P.001). Other factors that influenced outcome were the extent of pulmonary invasion, steroid use, and the timing of bone marrow transplantation (BMT) in regard to the diagnosis of IPA.The overall mortality rate of children treated for malignancies and immunodeficiency syndromes in who IPA develops remains high, and antifungal therapy alone may not be curative. Surgical resection may provide a small but possibly the only chance for survival. Therefore, we would advocate for resection of all involved tissue, even if it requires reoperation.

To compare the accuracies of computed tomography (CT), magnetic resonance (MR) imaging, and bone scintigraphy in staging disease in patients with neuroblastoma.Ninety-six children with newly diagnosed neuroblastoma were enrolled in a multicenter prospective cohort study. CT, MR, and bone scintigraphy were used to evaluate tumor stage. Sensitivity and specificity values and receiver operating characteristic (ROC) curve analyses were used to compare the accuracy of CT, MR, and scintigraphy for tumor staging.Eighty-eight patients were eligible for staging analysis, and 45 patients who underwent surgery at initial diagnosis were eligible for analysis of local tumor extent. CT and MR had sensitivities of 43% and 83%, respectively (P.01), and specificities of 97% and 88%, respectively (P.05), for detection of stage 4 disease. Areas under the ROC curves for CT and MR were 0.81 and 0.85, respectively (P =.06); that for scintigraphy was 0.83. Addition of scintigraphy to both CT and MR increased the areas under the ROC curves to 0.90 and 0.88, respectively. Accuracy of CT and MR for staging disease confined to the chest or abdomen (stages 1, 2, and 3) was poor.MR alone and CT and MR combined with bone scintigraphy enable the accurate detection of stage 4 disease. Both CT and MR perform poorly for local tumor staging.

Contrast-enhanced 3D MR angiography can be used for imaging of children. This technique can improve the delineation of the vasculature that is more anatomically familiar to surgeons. Here we illustrate the usefulness of contrast-enhanced 3D MR angiography in the diagnosis and follow-up of pediatric oncology patients.

The diagnostic, developmental, and surgical aspects of left pulmonary artery sling associated with right lung agenesis in 3 patients are described. Cardiac catheterization may be avoided by the combined use of echocardiography and magnetic resonance imaging and/or computed tomography.

Contrast angiography can demonstrate the vascular components of a vascular malformation, but can be technically challenging in small patients with complex venous anomalies. We reviewed the role of magnetic resonance venography (MRV) in the evaluation of children with predominantly low-flow, vascular malformations of the extremities. MRV (2D time-of-flight technique) and magnetic resonance (MR) imaging examinations were performed in ten young patients with congenital predominantly low-flow vascular malformations of the extremities. MR imaging was used to characterize and determine the extent of the malformations, and MRV to evaluate the deep and superficial venous channels. In all patients, MRV studies were reviewed in conjunction with contrast angiograms, considered the gold standard, to confirm the findings. All significant channel anomalies seen with contrast angiography were identified with MRV. In addition, MRV demonstrated some veins that were not intentionally opacified during contrast studies. MRV demonstrates both the superficial and deep conducting veins, whereas contrast angiography is a more directed study, evaluating only those channels intentionally opacified. Together, MR imaging and MRV data can non-invasively form the basis for determining the prognosis and choosing the individual treatment of congenital vascular malformations of the extremities.

Treatment for children with congenital deformities of the lower extremities may vary, depending on the state of the unossified skeletal structures and surrounding soft tissues. The purpose of our study was to demonstrate the spectrum of the osteochondral and extrasosseous abnormalities as depicted with MR imaging. We retrospectively reviewed MR examinations of 13 limbs of ten children (aged 1 month-9 years, mean 2.1 years) with longitudinal and transverse deformities of the lower extremities. The lesions imaged were fibular hemimelia (n = 5), tibial hemimelia (n = 5), and congenital constriction bands (n = 3). Each examination was assessed for abnormalities in the osteocartilaginous and extraosseous (articular or periarticular components such as ligaments, tendons, and menisci; the muscles and the arteries) structures. Abnormalities were seen in all patients. Osteocartilaginous abnormalities in the patients with longitudinal deformities included abnormal distal femoral epiphyses, abnormal proximal tibial physes, hypertrophied and dislocated proximal fibular epiphyses, unsuspected fibular and tibial remnants, and absence or coalition of the tarsal bones. No osteocartilaginous abnormalities were seen in the patients with congenital constriction bands. Articular abnormalities about the knee in patients with either form of hemimelia included absent cruciate ligaments and menisci, dislocated or absent cartilaginous patellae, absent patellar tendons, and abnormal collateral ligaments. All but one limb imaged had absent or attenuated muscle groups. Of the nine MR arteriograms performed at the level of the knee, eight were abnormal. The normal popliteal trifurcation was absent or in an abnormal location. We conclude that MR imaging of children with congenital lower extremity deformities shows many osteochondral and extraosseous abnormalities that are not depicted by conventional radiography. This information can help to plan early surgical intervention and prosthetic rehabilitation.

We reviewed the diastolic blood flow (DBF), pulsatility index (PI), and resistive index (RI) in 211 duplex Doppler ultrasound examinations of 63 pediatric renal transplant recipients. We correlated our findings with the clinical diagnosis, independently determined at the time of ultrasound examination. DBF, evaluated in 202 examinations, was found to be decreased, absent, or reversed in acute rejection (kappa = 0.4, p0.01) and acute tubular necrosis (ATN) (kappa = 0.3, p0.01). The PI and RI were evaluated in 87 and 78 ultrasound examinations respectively. The range of normal PI and RI values in recipients between six and 18 years of age were similar to those reported in adults. However, normal PI and RI values were somewhat higher in recipients less than six years of age who had received adult donor allografts. Overall, the PI was greater than 1.5 in acute rejection (kappa = 0.3, p0.05) and ATN (kappa = 0.3, p0.01), but not in chronic rejection (kappa0, p = NS). The RI was greater than 0.7 in chronic rejection (kappa = 0.3, p0.05) and ATN (kappa = 0.3, p0.05), but not in acute rejection (kappa = 0.03, p = NS). We conclude that the PI and RI vary in pediatric recipients of renal allografts and are not associated with a specific clinical diagnosis.

Transcatheter closure of intracardiac defects is an investigational procedure that is in use at a number of centers in North America and Europe. A radiologist should be able to recognize these devices on a chest radiograph, understand their actual physical appearance, and be able to recognize their expected location. This essay summarizes the indications for, technical aspects of, and radiologic appearance of these devices.

The cartilaginous structures at the ends of growing bones constitute the "growth mechanism." These structures are not visible on radiographs, but they can be seen with MR imaging. Improved definition of cartilaginous abnormalities by MR imaging may permit earlier detection and treatment of these disorders and thus prevent bone deformity. This pictorial essay contains examples of normal and abnormal growth cartilage as seen with MR imaging. The indications for MR imaging in the evaluation of certain growth disorders are discussed, and the usefulness of MR imaging in certain clinical situations in which the role of this technique is still evolving is illustrated.

Fifteen pediatric patients with biopsy- or culture-proved nonspinal osteomyelitis were studied with magnetic resonance (MR) imaging. Osteomyelitis was acute in seven patients, subacute in three, and chronic in five. Four patients had subperiosteal abscesses, one had a large associated soft-tissue abscess, and one had an intraosseous (Brodie) abscess. Areas of active inflammation had decreased marrow signal intensity on T1-weighted images, increased signal intensity on T2-weighted images, and enhancement on T1-weighted images obtained after gadopentetate dimeglumine administration (n = 10). Abscesses were rim enhancing (n = 3) or not (n = 2) with gadolinium-enhanced MR imaging. Nonenhancing areas presumably represented necrotic material. Gadolinium-enhanced MR imaging assisted in definition of the presence and extent of nonvascularized fluid collections within the bone and/or adjacent soft tissues and the extent of bone involvement in patients with chronic osteomyelitis. It also helped guide surgical debridement of intraosseous disease (n = 7) and open or percutaneous drainage of subperiosteal or soft-tissue fluid collections (n = 5).

Hemangioendotheliomas and arteriovenous malformations (AVMs) of the liver often cause congestive heart failure in babies, but embolization of the hepatic artery is not always effective. Six newborns and infants (four with hemangioendotheliomas and two with AVMs) underwent abdominal aortography, hepatomesenteric arteriography, and angiography of arterial and portal collateral vessels prior to embolization of the hepatic artery for heart failure (n = 5) and portal hypertension (n = 1). In addition, extrahepatic arteries were embolized in one patient and a portal vein branch in another. Extrahepatic arterial collaterals from the superior mesenteric, intercostal, phrenic, and adrenal arteries were seen in five patients; portal vein connections, in two patients. Embolization was therapeutically most effective in the baby with the least collateral supply and in the two patients in whom arterial collaterals or portal venous connections were embolized. Angiographic documentation and possibly embolization of collateral flow is required to improve treatment planning and success in these severely ill patients.

MR imaging has proved useful for delineating the extent of vascular anomalies when applied to artemiovenous malfommations (AVM5) [1] on lymphatic malformations [2]. However, the term hemangioma is often used generically, and in the past has been used to describe a combination of infantile hemangiomata and venous malformations with confusing radiologic findings [3]. The biological classification of vascular anomalies proposed by Mulliken et al. [4, 5] is based on cellular turnover, histology, natural history, and physical findings. It cleanly separates hemangiomas of infancy (tumors with an early proliferative and later involuting stage) from vascular malformations: capillary, lymphatic, venous, arterial, on combined (e.g., capillary venous, lymphaticovenous, AVM). This classification has been useful clinically [5], has been correlated with angiogmaphy [6], and recently has been adopted for interventional radiology [7]. It is the official nomenclature for the International Workshop for the Study of Vascular Anomalies [5]. Materials and Methods

The formation of a bony bridge across the growth plate was studied with magnetic resonance (MR) imaging, tomography, and histologic examination in 12 rabbits. Histologic studies performed 0-8 weeks after the creation of a defect in the physis demonstrated transphyseal bone formation with no evidence of cartilage repair. Gadolinium enhancement indicated the development of vascularity through the plate, which preceded the formation of a bony bridge. Enhancement was faint at 4 days after surgery, was inhomogeneous at 1 week, was maximal at 2 weeks, and decreased at 3 weeks and beyond as the lesion was replaced by bone. A dark rim representing bone deposition at the periphery of the lesion was seen at 2 weeks. At 4 weeks and beyond, the bridge was seen as a dark band of dense bone or as a wider area that was isointense with adjacent fatty marrow. Abnormality in the cartilage and development of transphyseal vascularity, which precede the formation of a bony bridge after trauma, can be detected with MR imaging.

Our review of pediatric urinary tract ultrasonograms over a period of two and one-half years resulted in a catalog of pitfalls. Cases included normal scans mistaken for abnormal and vice versa. These erroneous diagnoses stemmed from the inappropriate selection of the primary imaging test, improper timing of the ultrasonogram, errors of commission or omission in performance of the scans, and improper interpretation of the findings. For ease of reference, the pitfalls are grouped under bladder, ureters, and kidney with emphasis on the first two which are common sources of error.

Approximately 5-10% of patients with rhabdomyosarcomas (RMS) are diagnosed during the first year of life, and their clinical characteristics have been well documented. However, because RMS rarely occurs during the neonatal period, little is known about neonatal RMS.Four patients with neonatal RMS were treated at St. Jude Children's Research Hospital between 1962 and 1999. The authors report the results of a review of these patients and of cases described in the literature. Clinical, radiologic, and pathologic features of these patients and their outcomes were evaluated.One patient with embryonal RMS was treated successfully with a combination of systemic chemotherapy and local control measures. The other three patients had alveolar RMS. Two of them had multiple skin and subcutaneous metastatic nodules at the time of diagnosis and developed brain metastases early in their course. In one of these patients, the PAX3-FKHR fusion transcript was detected. Three other similar cases of neonatal alveolar RMS with metastases to the skin and brain have been reported in the literature.A distinct syndrome of neonatal RMS is described. This syndrome is characterized by alveolar histology, multiple skin and subcutaneous metastases, and fatal outcome as the result of early brain metastasis.

Over a two-and-one-half year period, 50 children underwent placements of jejunal tubes through a nasal route (NJ, n = 47) or through an existing gastrostomy site (GJ, n = 119). There were four attempted placements (98% success rate). The NJ tubes remained in place an average of 13 days, and the GJ tubes remained in place an average of 37 days. Fluoroscopic time for placement of an NJ tube averaged 6 min (29 cases), and for a GJ tube 8 minutes (91 cases). In spite of the limited retention time, fluoroscopic time, and availability of alternative methods, fluoroscopically placed jejunal feeding tubes are still playing an active role in this institution.

Background. Small pediatric tumors may be difficult to biopsy or resect. Objective. To examine the benefits of needle localization of a variety of small pediatric tumors before surgical biopsy or excision. Materials and methods. Seven patients aged 1–19 years underwent 12 procedures for needle localization of suspected tumor. Two patients had undergone previous biopsies without needle localization with negative results. Computed tomography (four patients) or ultrasonography (three patients) guided needle placement. Each patient had suspected tumor(s) in 1–3 anatomical sites, including thigh (7), lung (2), parasacral region (2), and iliac bone (1). Results. All 12 lesions (9 less than 1 cm3 in volume) were successfully localized for excision or biopsy. Three small (

Objective. To assess and contrast the role of interventional therapy for two types of cavitating pneumonias: lung abscess and necrotizing pneumonia. Materials and methods. We retrospectively reviewed the imaging, interventional therapy, and outcome of 14 children seen between February 1987 and January 1996 with lung abscess and 9 with necrotizing pneumonia. All children were treated with antibiotics prior to intervention. Pulmonary parenchymal fluid was percutaneously aspirated from ten lung abscesses and three necrotizing pneumonias. Percutaneous catheters drained five lung abscesses. Pleural drainage was performed for three lung abscesses and eight necrotizing pneumonias. Results. All 14 children with lung abscesses had positive Gram stains of the pulmonary fluid; 13 cultures were positive. All 14 defervesced within 48 h of intervention. None developed a bronchopleural fistula. All nine necrotizing pneumonias were presumed to be sequelae of prior pneumonia. Streptococcus pneumoniae was the only organism as documented by pleural fluid latex fixation in three patients, gram stain in two, and culture in only one. Seven of these children developed pneumatoceles, five developed bronchopleural fistulae, and three required long-term chest tubes for persistent pneumothoraces. Conclusion. Aggressive interventional therapy can be diagnostic and therapeutic in the infected lung abscess. Interventional therapy can be harmful in postinfectious necrotizing pneumonia.

This article addresses the most common types of interventional procedures performed in the pediatric abdomen. Nonvascular interventions are stressed because they are more common than vascular interventions.

Intravenous antibiotics and surgical drainage are the accepted methods of treating osteomyelitis complicated by abscess formation. The objective of this study was to determine whether percutaneous drainage of subperiosteal abscess is a potential treatment for osteomyelitis.Three pediatric patients with subperiosteal abscesses from acute osteomyelitis had percutaneous drainage with sonographic and fluoroscopic guidance using a Seldinger technique and an 8-F catheter.Two patients required no further intervention and had the drainage catheter removed after 72 h. After completing a course of antibiotics they healed completely. One patient, after a week of purulent drainage, required open drainage including a bone debridement of an area of septic necrosis.Percutaneous drainage of subperiosteal abscess may be an alternative to surgical drainage when medical therapy alone is inadequate. Development of intraosseous abscess, necrosis or persistent drainage suggests further intervention may be necessary.

The authors review their experience with transrectal drainage of pelvic abscesses in seven children and adolescents (6–16 years old). Initial access was guided by transrectal ultrasound with an endovaginal transducer followed by fluoroscopy for placement of self-retaining catheters (8.5–10 F) using the Seldinger technique. All abscesses were successfully drained without complications. A transrectal catheter was well tolerated by most patients without spontaneous dislodgment. Catheters were removed after an average of 4 days (range 3–7 days). Transrectal drainage of pelvic abscess with transrectal sonographic and fluoroscopic guidance seems to be a safe and effective procedure in children.

Ninety-six children with an irritable hip possibly representing septic arthritis underwent clinical and laboratory evaluation, radiography, and ultrasonography (US). Forty had normal US scans; none were later shown to have septic arthritis, although three had osteomyelitis. Fifty-six children had effusion at US. Thirty-one of these underwent US-guided aspiration, two unsuccessfully. On the basis of results of aspirate analysis, 15 of these 31 patients underwent surgical drainage, and septic arthritis was diagnosed in all 15. The mean peripheral white blood cell (WBC) count was not significantly higher in patients with septic arthritis (n = 21) than in patients with toxic synovitis (n = 24) (P = .44). However, the erythrocyte sedimentation rate and synovial fluid WBC count were significantly greater in those with septic arthritis than in those with toxic synovitis (P = .002 and P < .0001, respectively). Clinical evaluation, radiographs, and sonograms together determined the need for US-guided aspiration. US-guided aspiration allowed selection of only those with septic arthritis for operative drainage and shortened that procedure. Negative sonograms allow exclusion of septic arthritis but not osteomyelitis.

In order to assess whether MR imaging could be used to evaluate posttraumatic abnormalities of the growth plate cartilage, 28 MR imaging examinations of 26 physeal fractures were performed from 4 days to 2 years after injury. Twelve patients were studied within 6 months of the fracture. MR imaging changed the Salter-Harris classification in six. Interruption of the growth plate detected on T2-weighted images was associated with subsequent growth anomaly in six of eight patients. Horizontal fracture of the physis without interruption was associated with growth disturbance in only one of four patients. Sixteen growth plates were studied beyond 6 months after injury. Twelve had physeal bars and abnormal growth. Of four patients without physeal abnormality on MR imaging, two had normal growth and two had mild deformity. Our results show that MR imaging defects abnormalities in the cartilage that are associated with subsequent growth disturbances and provides accurate mapping of physeal bridging and associated growth abnormalities that have already occurred.

B.M. is a previously healthy 18-year-old man referred for a second opinion on an abnormal echocardiogram. He had been followed in the first year of life for a nonspecific murmur. He presented again to medical attention secondary to Navy prequalification requirements and was referred to a local cardiologist. His physical examination, chest radiograph, and ECG were normal. On transthoracic and transesophageal echocardiograms performed in the referring institution, “the aorta did not connect to the left ventricle” and the superior aspect of the ventricular septum was “prominent.” Cardiac MRI …

Obstruction at the ureteropelvic junction (UPJ) is usually intrinsic. Recently, however, 13 (11%) of approximately 120 children with UPJ obstruction were found to have extrinsic obstruction caused by a lower-pole renal vessel. In each case, the obstruction was confirmed at the time of surgery. Most of these patients had intermittent pain. Excretory urograms did not show obstruction between episodes of pain, but when a urogram was obtained during an episode, marked obstruction was noted. Contrast agent trapped in a segment of proximal ureter suggests the presence of an extrinsic obstruction. Properly timed renal imaging, therefore, can identify the urinary tract as the source of the symptoms.

31P NMR spectroscopy was used to analyzed the in vivo metabolism of reticulum cell sarcoma of mice. The ratio of high- to low-energy phosphates ATPB/(Pi + PME) was measured to reflect the relative metabolic state in the tumor. Of the 34 mice studied, 26 were treated with an antiangiogenesis regimen of heparin and cortisone. Eighty-two percent of the tumors treated eventually decreased in volume (P less than 0.01). Volumes and spectroscopic information of 20 tumors were analyzed. Although the average untreated volume was similar to the volume after 3 days of treatment, the average ATPB/(Pi + PME) ratio rose from 0.34 +/- 0.10 to 0.47 +/- 0.07 (P = 0.02). However, after 6 days of treatment, the volume significantly decreased (P less than 0.0001) but the ratio did not significantly rise further (P = 0.06). The rise in the high-energy phosphate preceded a significant decrease in volume of the tumors. In addition, the replenishment of high-energy stores with tumor regression coincided with the histologic findings of a decrease in the number of tumor cells, a decrease of the mitotic index, and a decrease of the number of necrotic cells present with ongoing treatment. Our data suggest that noninvasive methods of assessing early biochemical response of tumor regression may be possible.

The patency of vascular access shunts and fistulae has been prolonged by a combined surgical and radiological approach that includes percutaneous transluminal angioplasty (PTA), surgical revision, thrombectomy, and thrombolysis. Over the last 3 years, 35 vascular accesses in 27 patients were found to have angiographic abnormality. PTA was performed 32 times on 19 accesses and 7 PTAs resulted in patent accesses by the end of the study. Surgical revision was performed 9 times on 8 accesses and 2 of the surgical revisions resulted in a patent access by the end of the study. Concerning Thomas femoral shunts, PTA prolonged the patency by 2.2 months and surgical revision by 3.8 months per procedure. Concerning arteriovenous (AV) fistulae, PTA prolonged the patency by 4.3 months and surgical revision by 3.5 months per procedure. A combination of procedures effectively doubles the duration of patency of Thomas femoral shunts and almost triples the duration of patency of AV fistulae in children. Forty-one percent of these accesses remain open 1 year following the initiation of these procedures.

Nine patients, 6 weeks to 17 years of age with esophageal atresia (EA), developed esophageal strictures and were treated with 26 balloon catheter dilatations over a period of 3 years; 6 are now asymptomatic. Five of the 9 patients had suspected reflux esophagitis, confirmed in 3 by biopsy and treated medically prior to dilatation. Seven of the 9 patients had a primary anastomosis, 1 a gastric tube, and 1 a colonic interposition. Most dilatations in the group of 7 were performed with balloon (B) greater than or equal to the diameter of the distal esophagus (E) (B/E greater than or equal to 1). The 3 residually symptomatic patients include an infant dilated conservatively (B/E less than 1) to facilitate later bouginage, 1 patient with a recurrent stricture after stopping medical therapy and home bouginage, and 1 infant who had a persistent anastomotic stricture, suspected but untreated reflux esophagitis, and a perforation during the second balloon dilatation. Balloon catheter esophageal dilatation, as an alternative to bouginage, is usually a safe and effective procedure when reflux esophagitis is diagnosed and treated prior to dilatation.

The American Board of Pediatrics In-Training Examination or "Pre-Test" is not in widespread use as a means of evaluating the cognitive knowledge and problem-solving skills of hourse officers. The examination is modeled after the certifying examination of the American Board of Pediatrics. The 1977 Pre-Test was analyzed in an attempt to determine whether awareness of recent medical knowledge was required to pass this examination. The 7th through 10th editions of the Nelson Textbook of Pediatrics were used as a reference source. These editions represent information that is from 5 to at least 20 years of age. Analysis of the 190 items revealed that the correct answer was known for 148 or 78% of the questions at least 20 years ago. These results suggest that the Pre-Test, and presumably the American Board of Pediatrics certifying exam, measures the candidates' knowledge of long-standing core information.

In four women pelvic peritoneal inclusion cysts were diagnosed with ultrasound or computed tomography. Three patients had a history of multiple surgical procedures, whereas the fourth had prior severe abdominal trauma. Imaging studies showed large cystic structures contiguous with the adnexa. The normal ovarian appearance was distorted in two women. Pathologic confirmation was obtained in all cases. When large adnexal cystic structures are identified in young women with a history of surgery or trauma, the diagnosis of peritoneal inclusion cysts should be entertained. Recognition should result in conservative therapy rather than salpingo-oophorectomy.

The classical effects of lateral orthopedic stress on the midpalatal suture were confirmed in this study conducted on ten female Macaca mulatta monkeys in the mixed dentitional period. The suture was opened with consequent expansion of the maxillary arch, of the intranasal space, and of the palatal vault. There was marked buccal displacement of the upper posterior teeth together with a definite broadening of the entire midface. Modest relapse of maxillary expansion and of palatal depth occurred when retention was terminated after four months. Normal angulation of the upper first molars at the end of the experimental period is indicative of a predominantly translatory expansion of the arch or of a rapid restoration of normal tooth alignment and inclination. Subsidiary expansion of the mandibular arch and reclosure of the midpalatal suture also occurred. Of particular importance to this study was confirmation of changes in the bony configuration of the midface manifested by prominence of the canine eminence and the general pug-nosed appearance of treated animals althrough this could not be attributed to retrusion of the premaxilla.

The initial renal sonograms of 15 patients, aged 8 months to 5 years, with hemolytic uremic syndrome (HUS) were reviewed. Ultrasound studies were graded according to cortical echogenicity relative to the liver, they were compared to the severity of the clinical syndrome at admission and to the ultimate outcome of the disease. The degree of cortical echogenicity correlated with the clinical outcome of HUS in 12 of the patients, whereas clinical assessment alone predicted outcome in 13 patients. Sonography overestimated severity in three patients with mild disease correctly assessed clinically, whereas clinical assessment overestimated severity in two patients with moderate disease in whom the sonographic assessment proved correct. The sonographic changes are most likely multifactorial. They appear to reflect a combination of platelet-thrombus deposition in the renal cortex, as well as the general fluid status of the patient. Ultrasound is useful in ruling out other causes of acute renal failure such as obstruction or congenital diseases. It cannot replace laboratory tests and clinical judgement, but nevertheless provides another index of severity in patients with HUS.