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Case report: The sonographic appearances of neonatal herpes simplex encephalitis
574
CLINICAL RADIOLOGY
Similar focal echogenic lesions were seen in the splenic substance in this patient (Fig. 1). The unusual appearance of a complex subcapsular fluid collection associated with the infarcted spleen, as seen in this patient, has not, to the best of our knowledge, been reported before. We suggest that the focal echogenic lesions seen in the spleen were old infarcts. On this admission the patient probably had atraumatic splenic rupture associated with a subcapsular haematoma, followed by infarction and necrosis of the spleen, accounting for this complex fluid collection, mimicking the appearance of a splenic abscess. We conclude that in this case the ultrasound scan showed important splenic abnormalities, which were not as clearly demonstrated on the CT scan. Furthermore, other diagnoses apart from splenic abscess should be considered if a subcapsular splenic fluid collection is seen on ultrasound examination in patients with sickle
cell disease. We therefore reiterate that an ultrasound scan of the spleen is a useful investigation in the management of sickle cell patients with abdominal pain, and may reveal important and treatable disorders. REFERENCES
1 Sarr MG, Zvidema GD. Splenic abscess, presentation, diagnosis and treatment. Surgery 1982;92/3:480-485. 2 Delaitre B, Zerbib M, Chapuis Y e t al. Splenic abscess, 3 cases. Journal of Chit (Paris) 1982;119:237-240. 3 Iko B. Splenic abscess on ultrasonography. European Journal of Radiology 1986;6:6-120. 4 Mathieson J, Cooperberg P. The spleen. Diagnostic ultrasound. Rumack CM, Wilson SR & Charboneau JW, eds. Vol. 1. St Louis, Mosby, 1991: 97-98. 5 Maresca P, Mirk A, De-Gaetano B e t al. Sonographic patterns in splenic infarct. Journal of Clinical Ultrasound 1986; 14:23-28. 6 Walker TM, Serjeant GR. Focal echogenic lesions in the spleen in sickle cell disease. Clinical Radiology 1993;47:114-116.
Clinical Radiology (1995) 50, 574-576
Case Report: The Sonographic Appearances of Neonatal Herpes Simplex Encephalitis W. H. RAMSDEN and D. A. SAPHERSON
Department of Diagnostic Imaging, BradfordRoyal Infirmary, Bradford This case report describes the sonographic appearances in a proven case of neonatal Herpes Simplex encephalitis. Both early and late phase appearances are discussed, and are compared with other reports of imaging in similar disease processes. A role for sonography in the management of neonatal Herpes Simplex encephalitis is suggested.
CASE REPORT A male infant born at 32 weeks gestation was delivered by Caesarean section and weighed 1.34kg at birth. The maternal membranes ruptured 6 d prior to delivery, resulting in amniotis. Despite initial good progress the infant's respiratory drive decreased over the first week of life, leading to intubation after 9 d, and subsequent prolonged ventilator dependence. Bullous skin lesions were noted on the eighth day of life, and swabs from these areas revealed Herpes Simplex type II. A lumbar puncture performed at 11 d of age demonstrated the same organism, as did material from a throat swab. Subsequently abnormal jittery movements were observed. At a later stage there were few spontaneous movements, and eventually the only responses were to painful stimuli. Despite three courses of intravenous Acyclovir, the infant's condition steadily deteriorated, and he died following the withdrawal of intensive therapy at 45 d of age. A postmortem was refused. There was no evidence of an acquired cause of infection and the illness was presumed to be congenital, despite the absence of maternal symptoms or signs. The patient's poor condition meant that sonography was the optimal means of examining the brain during the illness. Cranial sonography was
Correspondence to: Dr W. H. Ramsden, X-Ray Department, Clarendon Wing, The Leeds General Infirmary, Belmont Grove, Leeds LS2 9NS.
performed on six occasions, the last five being performed at weekly intervals after the diagnosis was established. An initial examination performed at 2 d of age was normal. Two weeks later, and 5 d after Herpes Simplex encephafitis had first been diagnosed, cranial sonography revealed a right-sided subependymal bleed and a normal size ventricular system. Several well-defined echogenic areas were demonstrated in the brain parenchyma, within the right frontal and both parietal lobes (Fig. la,b). The largest of these measured 1 era in diameter. Sonography at 23d of age was preceded by a 10d course of Acyclovir. The echogenic areas had become less prominent, and some had developed hypoechoic centres (Figs 2a,b). The subependymal bleed and ventricular size were unchanged. Dramatic changes were noted 1 week later, there being extensive cyst formation concentrated upon the previously echogenic areas. In addition, the third and lateral ventricles had become dilated. These appearances extended throughout the brain parenchyma over the next 2 weeks (Fig. 3a,b) despite two further courses of Acyclovir, and the infant died the day after the final examination.
DISCUSSION The sonographic appearances of Herpes encephalitis have previously been described in an infant aged 11 months [1]. Similar findings to our case were described as regions of increased echogenicity developed within the brain parenchyma, followed by cystic changes in the 9 1995 BlackwellScience Ltd, ClinicalRadiology,50, 574-576.
CASE REPORTS
575
(a)
( i~ )
Fig i i~r cchogcnic t'oci zuad right >ubcpcnd}real bleed.
16d,~l',l,_.'c.,hox~/n~
same areas. The report detailed an indistinct appe~rancc of the brain parenchyma consistent ~vitln focal cerebral oedema, a finding not seen in our case. It has previously been suggested that the echodensities which precede cystic change are haemorrhagic in nature [1]. Both computed tomography and magnetic resonance have been used to image viral encephalitis [2]. The former technique has revealed abnormal hypodense areas in the midbrain, basal ganglia and cerebral white matter. It has been postulated that these changes may be ischaemic in nature. Although unproven, we suggest that the cystic areas demonstrated sonographically may also be due to ischaemia or infarction. These findings would be consistent with the necrotizing nature of Herpes Simplex encephalitis [3]. Previously brain biopsy has been advo:~, 1995 Blackwell Science Ltd, Clinical Radiology, 50, 574 576,
it', ~)Ov]C:l,C LI:Cd- ,~, I[hlI1 I}l< CCllO$CIII~ [OCI
cared ~ t h c ' G o l d Stundard" in the diagnosis of Herpcs Simplex encephalitis [4], but this max be inappropriate in the sick neonate. Analxsis of cerebrospinal fluid for Herpes Simplex antibod\ synthesis is less invasixe and has a high degree of accuracy [5]. This may be supported b} demonstrating changes in the brain parenchyma sonographically, and allows appropriate therapy' to be commenced without moving the patient from the intensive care unit. Sonography will also allow changes within the brain to be monitored as the disease progresses. without undue disturbance of an ill neonate.
AcknoMedgements. The authors thank Dr S. L. Chatfield. Consultant Neonatologist. for permission to report this case.
576
CLINICAL RADIOLOGY
(a) Fig. 3
(b)
(a, b) Saggital and coronal views taken at 44 d of age, showing extensive cystic changes and ventricular dilatation.
REFERENCES 1 Riccabona M, Grubbauer HM. Ultrasonography findings in a case with infantile herpes encephalitis. (German) Klinische Padiatrie 1991;203(5):403 405. 2 Protheroe SM, Mellor DH. Imaging in influenza A encephalitis. Archives of Disease in Childhood 1991;66:702-705.
3 Kohl S. Herpes simplex virus encephalitis in children. Pediatric Clinics o f North America 1988;35:465-482. 4 Kohl S, James AR. Herpes simplex virus encephalitis during childhood: Importance of brain biopsy diagnosis. Journal of Pediatrics 1985;107:212-215. 5 Klapper PE, Laing I, Longson M. Rapid non-invasive diagnosis of Herpes encephalitis. Lancet 1981; (ii):607-609.
Clinical Radiology (1995) 50, 576-578
Case Report: Ultrasound and MRI Findings in a Scrotal Epidermoid Cyst R. A. KOENIGSBERG, D. KELSEY* and A. C. FRIEDMAN
Department of Radiology, Medical College of PA, Philadelphia, PA and "361 Lankenau Medical Building, E Wynnewood, PA, USA lntrascrotal masses in the adult are worrisome due to their possible malignancy. Most intratesticular masses are malignant whereas most extratesticular masses are benign. The differential diagnosis of intrascrotal cysts usually includes simple testicular cysts, intratesticular epidermoid and dermoid cysts, tunica albuginea cysts, epididymai cysts and spermatoceles [1-7]. This case report describes a large epidermoid cyst of the scrotum presenting as an enlarging scrotal turnout.
CASE REPORT A 69-year-old male presented with a tender scrotal mass. Although the mass was enlarging, it had been present for about 30 years. The Correspondence to: R. A. Koenigsberg, Department of Radiology, Medical College of PA, 3300 Henry Avenue, Philadelphia, PA 19129, USA.
mass was firm and non-mobile and, clinically, it could not be separated from the testicles. Sonography depicted a 11.5 x 7.2 x 9.4cm mass adherent to the median raphe and completely separate from the testicles (Fig. 1). The mass had fairly homogeneous low level internal echoes suggestive of a solid tumour. Sound transmission was difficult to assess. There was no significant vascularity on colour flow Doppler scanning. A small hydrocele was incidentally identified. An MRI examination of the scrotum (Fig. 2) demonstrated a mass isointense with muscle on the 9 1995 Blackwen Science Ltd, ClinicalRadiology, 50, 576-578.
CLINICAL RADIOLOGY
Similar focal echogenic lesions were seen in the splenic substance in this patient (Fig. 1). The unusual appearance of a complex subcapsular fluid collection associated with the infarcted spleen, as seen in this patient, has not, to the best of our knowledge, been reported before. We suggest that the focal echogenic lesions seen in the spleen were old infarcts. On this admission the patient probably had atraumatic splenic rupture associated with a subcapsular haematoma, followed by infarction and necrosis of the spleen, accounting for this complex fluid collection, mimicking the appearance of a splenic abscess. We conclude that in this case the ultrasound scan showed important splenic abnormalities, which were not as clearly demonstrated on the CT scan. Furthermore, other diagnoses apart from splenic abscess should be considered if a subcapsular splenic fluid collection is seen on ultrasound examination in patients with sickle
cell disease. We therefore reiterate that an ultrasound scan of the spleen is a useful investigation in the management of sickle cell patients with abdominal pain, and may reveal important and treatable disorders. REFERENCES
1 Sarr MG, Zvidema GD. Splenic abscess, presentation, diagnosis and treatment. Surgery 1982;92/3:480-485. 2 Delaitre B, Zerbib M, Chapuis Y e t al. Splenic abscess, 3 cases. Journal of Chit (Paris) 1982;119:237-240. 3 Iko B. Splenic abscess on ultrasonography. European Journal of Radiology 1986;6:6-120. 4 Mathieson J, Cooperberg P. The spleen. Diagnostic ultrasound. Rumack CM, Wilson SR & Charboneau JW, eds. Vol. 1. St Louis, Mosby, 1991: 97-98. 5 Maresca P, Mirk A, De-Gaetano B e t al. Sonographic patterns in splenic infarct. Journal of Clinical Ultrasound 1986; 14:23-28. 6 Walker TM, Serjeant GR. Focal echogenic lesions in the spleen in sickle cell disease. Clinical Radiology 1993;47:114-116.
Clinical Radiology (1995) 50, 574-576
Case Report: The Sonographic Appearances of Neonatal Herpes Simplex Encephalitis W. H. RAMSDEN and D. A. SAPHERSON
Department of Diagnostic Imaging, BradfordRoyal Infirmary, Bradford This case report describes the sonographic appearances in a proven case of neonatal Herpes Simplex encephalitis. Both early and late phase appearances are discussed, and are compared with other reports of imaging in similar disease processes. A role for sonography in the management of neonatal Herpes Simplex encephalitis is suggested.
CASE REPORT A male infant born at 32 weeks gestation was delivered by Caesarean section and weighed 1.34kg at birth. The maternal membranes ruptured 6 d prior to delivery, resulting in amniotis. Despite initial good progress the infant's respiratory drive decreased over the first week of life, leading to intubation after 9 d, and subsequent prolonged ventilator dependence. Bullous skin lesions were noted on the eighth day of life, and swabs from these areas revealed Herpes Simplex type II. A lumbar puncture performed at 11 d of age demonstrated the same organism, as did material from a throat swab. Subsequently abnormal jittery movements were observed. At a later stage there were few spontaneous movements, and eventually the only responses were to painful stimuli. Despite three courses of intravenous Acyclovir, the infant's condition steadily deteriorated, and he died following the withdrawal of intensive therapy at 45 d of age. A postmortem was refused. There was no evidence of an acquired cause of infection and the illness was presumed to be congenital, despite the absence of maternal symptoms or signs. The patient's poor condition meant that sonography was the optimal means of examining the brain during the illness. Cranial sonography was
Correspondence to: Dr W. H. Ramsden, X-Ray Department, Clarendon Wing, The Leeds General Infirmary, Belmont Grove, Leeds LS2 9NS.
performed on six occasions, the last five being performed at weekly intervals after the diagnosis was established. An initial examination performed at 2 d of age was normal. Two weeks later, and 5 d after Herpes Simplex encephafitis had first been diagnosed, cranial sonography revealed a right-sided subependymal bleed and a normal size ventricular system. Several well-defined echogenic areas were demonstrated in the brain parenchyma, within the right frontal and both parietal lobes (Fig. la,b). The largest of these measured 1 era in diameter. Sonography at 23d of age was preceded by a 10d course of Acyclovir. The echogenic areas had become less prominent, and some had developed hypoechoic centres (Figs 2a,b). The subependymal bleed and ventricular size were unchanged. Dramatic changes were noted 1 week later, there being extensive cyst formation concentrated upon the previously echogenic areas. In addition, the third and lateral ventricles had become dilated. These appearances extended throughout the brain parenchyma over the next 2 weeks (Fig. 3a,b) despite two further courses of Acyclovir, and the infant died the day after the final examination.
DISCUSSION The sonographic appearances of Herpes encephalitis have previously been described in an infant aged 11 months [1]. Similar findings to our case were described as regions of increased echogenicity developed within the brain parenchyma, followed by cystic changes in the 9 1995 BlackwellScience Ltd, ClinicalRadiology,50, 574-576.
CASE REPORTS
575
(a)
( i~ )
Fig i i~r cchogcnic t'oci zuad right >ubcpcnd}real bleed.
16d,~l',l,_.'c.,hox~/n~
same areas. The report detailed an indistinct appe~rancc of the brain parenchyma consistent ~vitln focal cerebral oedema, a finding not seen in our case. It has previously been suggested that the echodensities which precede cystic change are haemorrhagic in nature [1]. Both computed tomography and magnetic resonance have been used to image viral encephalitis [2]. The former technique has revealed abnormal hypodense areas in the midbrain, basal ganglia and cerebral white matter. It has been postulated that these changes may be ischaemic in nature. Although unproven, we suggest that the cystic areas demonstrated sonographically may also be due to ischaemia or infarction. These findings would be consistent with the necrotizing nature of Herpes Simplex encephalitis [3]. Previously brain biopsy has been advo:~, 1995 Blackwell Science Ltd, Clinical Radiology, 50, 574 576,
it', ~)Ov]C:l,C LI:Cd- ,~, I[hlI1 I}l< CCllO$CIII~ [OCI
cared ~ t h c ' G o l d Stundard" in the diagnosis of Herpcs Simplex encephalitis [4], but this max be inappropriate in the sick neonate. Analxsis of cerebrospinal fluid for Herpes Simplex antibod\ synthesis is less invasixe and has a high degree of accuracy [5]. This may be supported b} demonstrating changes in the brain parenchyma sonographically, and allows appropriate therapy' to be commenced without moving the patient from the intensive care unit. Sonography will also allow changes within the brain to be monitored as the disease progresses. without undue disturbance of an ill neonate.
AcknoMedgements. The authors thank Dr S. L. Chatfield. Consultant Neonatologist. for permission to report this case.
576
CLINICAL RADIOLOGY
(a) Fig. 3
(b)
(a, b) Saggital and coronal views taken at 44 d of age, showing extensive cystic changes and ventricular dilatation.
REFERENCES 1 Riccabona M, Grubbauer HM. Ultrasonography findings in a case with infantile herpes encephalitis. (German) Klinische Padiatrie 1991;203(5):403 405. 2 Protheroe SM, Mellor DH. Imaging in influenza A encephalitis. Archives of Disease in Childhood 1991;66:702-705.
3 Kohl S. Herpes simplex virus encephalitis in children. Pediatric Clinics o f North America 1988;35:465-482. 4 Kohl S, James AR. Herpes simplex virus encephalitis during childhood: Importance of brain biopsy diagnosis. Journal of Pediatrics 1985;107:212-215. 5 Klapper PE, Laing I, Longson M. Rapid non-invasive diagnosis of Herpes encephalitis. Lancet 1981; (ii):607-609.
Clinical Radiology (1995) 50, 576-578
Case Report: Ultrasound and MRI Findings in a Scrotal Epidermoid Cyst R. A. KOENIGSBERG, D. KELSEY* and A. C. FRIEDMAN
Department of Radiology, Medical College of PA, Philadelphia, PA and "361 Lankenau Medical Building, E Wynnewood, PA, USA lntrascrotal masses in the adult are worrisome due to their possible malignancy. Most intratesticular masses are malignant whereas most extratesticular masses are benign. The differential diagnosis of intrascrotal cysts usually includes simple testicular cysts, intratesticular epidermoid and dermoid cysts, tunica albuginea cysts, epididymai cysts and spermatoceles [1-7]. This case report describes a large epidermoid cyst of the scrotum presenting as an enlarging scrotal turnout.
CASE REPORT A 69-year-old male presented with a tender scrotal mass. Although the mass was enlarging, it had been present for about 30 years. The Correspondence to: R. A. Koenigsberg, Department of Radiology, Medical College of PA, 3300 Henry Avenue, Philadelphia, PA 19129, USA.
mass was firm and non-mobile and, clinically, it could not be separated from the testicles. Sonography depicted a 11.5 x 7.2 x 9.4cm mass adherent to the median raphe and completely separate from the testicles (Fig. 1). The mass had fairly homogeneous low level internal echoes suggestive of a solid tumour. Sound transmission was difficult to assess. There was no significant vascularity on colour flow Doppler scanning. A small hydrocele was incidentally identified. An MRI examination of the scrotum (Fig. 2) demonstrated a mass isointense with muscle on the 9 1995 Blackwen Science Ltd, ClinicalRadiology, 50, 576-578.