Ali Yikilmaz

Background: Upper gastrointestinal (GI) contrast studies are frequently requested to aid superior mesenteric artery syndrome diagnosis, a rare entity. Compression of the third duodenal part is expected to be mid-to-left of the midline where the superior mesenteric artery arises from the aorta; however, a duodenal impression to the right of the midline due to normal anatomic impression by the inferior vena cava (IVC) is often encountered and frequently misdiagnosed. Objective: The purpose of this study was to determine the frequencies of (1) normal right-of-midline duodenal impressions and (2) mid-to-left of midline compressions in upper GI studies in a tertiary pediatric referral center. Materials and methods: All upper GI studies performed at our institution over 2 years were retrospectively evaluated to determine whether the duodenum had vertical duodenal impression to the right of the vertebral midline, mid-to-left of the vertebral midline, or no identifiable duodenal impression at all. Results: In total, 538 upper GI studies were included in this analysis. A total of 275 male and 247 female patients between 0 and 17 years of age (median: 6 years, range: 1 month-17 years) were included. Of 538 total upper GI studies, there were 240 studies (44.6%) with a right-of-midline impression. There were only 10 studies (1.9%) with a mid-to-left of midline compression, and 9/10 also showed a concurrent right-sided impression sign. Conclusion: Right-of-midline duodenal impression is a normal anatomic finding caused by the IVC and should not be confused with superior mesenteric artery syndrome. In the presence of an appropriate clinical context, proximal duodenal dilation, “to-and-fro” motion of contrast, and duodenal impression at mid-to-left of midline, a diagnosis of superior mesenteric artery syndrome should be considered. Graphical

Guillain-Barré syndrome is a rapidly progressive symmetrical muscle weakness associated with acute inflammatory disease. Transverse myelitis (TM) is the inflammation of the spinal cord characterized by rapidly evolving muscle weakness in the lower extremities, defects in sensory level and sphincter dysfunction. Guillain-Barré syndrome, and TM association occurs very rarely in childhood. A 7-year-old girl presented with complaints of neck pain, spout-style vomiting, cough, shortness of breath, and acute paraparesis with sensory and sphincter disturbance. The patient was intubated because of increased respiratory distress. A positive direct fluorescein antigen test in bronchoalveolar lavage confirmed Legionella pneumophila infection. Imaging and neurophysiologic studies were diagnostic for TM with acute motor and sensory axonal neuropathy. She was treated with a combination of high-dose methylprednisolone and intravenous immunoglobulins, and we observed incomplete recovery. The presented case is the first child with concomitant TM and acute motor and sensory axonal neuropathy related to L. pneumophila infection.

Objective To describe the spinal magnetic resonance imaging (MRI) features in children with Guillain–Barre syndrome (GBS) and to investigate the correlation with the clinical/laboratory findings. Material and methods Clinical/laboratory findings of 40 children (mean age 5.7 years; range, 3 months–15 years) who had a final diagnosis of GBS were retrospectively reviewed. Clinical severity was graded according to Hughes classification. Electromyogram and cerebrospinal fluid analysis of the patients were recorded. All patients had a contrast-enhanced spinal MRI. The contrast enhancement pattern was determined, and the diameters of anterior and posterior spinal nerve roots were measured. The clinical/laboratory findings were correlated with the MRI findings. Results Twenty-eight patients had an electromyogram examination, and 25 of them revealed findings consistent with GBS. Cerebrospinal fluid analysis of 37 out of 40 patients showed albumino-cytologic dissociation. All but two patients had thickening and contrast enhancement of the nerve roots and cauda equina on spinal MRI. The most common MRI finding was enhancement of both the anterior and the posterior nerve roots of cauda equina which was prominent anteriorly. The mean anteroposterior diameter of the anterior nerve roots was 2.19 mm (range, 1.38–3.30 mm) and the posterior nerve root was 1.80 mm (range, 1.07–2.97 mm). Conclusion Spinal MRI is a reliable imaging method for the diagnosis of GBS as it was positive in 38 of 40 patients. The severity on MRI does not correlate with severity of the clinical condition. MRI can be used as a supplementary diagnostic modality to clinical and laboratory findings of GBS.