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419

Letters . 1

4,

Pulmonary Lymphangioleiomyomatosis: Fruste” of Tuberous Sclerosis?

of our eight

A “Forme

AJR. The relation of pulmonary Iymphangioleiomyomatosis to pulmonary tuberous sclerosis is not clear [2, 3]. Lymphangioleiomyomatosis develops in approximately 1% of persons who have tuberous sclerosis [4]. Pulmonary tuberous sclerosis and lymphangiobeiomyoccur

pathologic ered

by many

intellectual

mostly

similarities,

in women.

Because

of radiologic

lymphangioleiomyomatosis

to be a “forrne

impairment

fruste”

patients

of tuberous

sclerosis

and

seizures are less common than in patients who do not,

Child’s

04-736

[2-4].

in patients

The remaining of tuberous

Health

Centre

Warsaw, Poland

of the lungs:

pulmonary

tuberous

sclerosis? Chest 1989:95:234-237 3. Sobonya RE, Quan SF, Fleishman JS. Pulmonary lymphangioleiomyomatosis: quantitative analysis of lesions producing airflow limitation. Hum Pathol 1985;16:1122-1128

4. Slingerland JM, Grossman AF, Chamberlain D, Tremblay CE. Pulmonary manifestations of tuberous sclerosis in first-degree relatives. Thorax

In our experience,

the greater

to

Caroline

Chiles

Robert H. Shemer Duke

University

Medical

Durham,

CT Demonstration

of Ingested

The plain film evaluation of cocaine

has become

tract

difficult

of them. The results

markable.

The

upright

patient

abdominal

geneously

radiographs

showed

cylindrical

approximately at either

Recently, drug packets of drugs liquids

because

quently,

all have

packets

of smuggling

a rectal

multiple,

densities

drugs

by ingesting

examination

were unre-

examination.

Flat

well-defined,

throughout

the

and

homecolon

(Fig.

history of ingestion of packets. CT multiple, high-density (200 H), well-

1 .5 x 4.0 cm with triangular

areas of

end (Fig. 1 B).

smugglers have attempted by concomitantly ingesting

it is difficult

of ingesting

of smuggling

to have

1A), compatible with the clinical examination of the pelvis showed

defined cylinders

Packets

as methods

of physical

refused

radiopaque,

27710

become

man was suspected

packages

Center NC

more refined. We compare of ingested cocaine packets.

have

the plain film and CT appearance A 37-year-old

Cocaine

of patients suspected

increasingly

via the gastrointestinal

equivalent

to delineate

densities

the margins

to disguise ingested water, oils, or other on plain films.

of the packets

Conse-

and to

distinguish the packets from residual bowel contents, particularly after administration of cleansing enemas and multiple bowel movements [1 1. Earlier attempts to use contrast enhancement were cum-

bersome

and unrewarding [2]. the capability of CT for differentiating densities is so good, we think that this technique is useful in detecting packets, Because

when

The packets

the results

of other

imaging

studies

are equivocal.

easily on the basis of their distinctive density and shape. The high density of the packet may be related to the intrinsic amine structure of the drug or perhaps to metallic

Reply

Dr. Jozwiak correctly points out that lymphangioleiomyomatosis considered by many to be a “forme fruste” of tuberous sclerosis.

challenge

radiologists is to suggest a diagnosis of Iymphangioleiomyomatosis in patients who do not have evidence of tuberous sclerosis.

especially

1989;44:212-214

at

seven patients had no clinical or radiobogic features

sclerosis.

As

1 . Sherrier, RH, Chiles C, Roggli V. Pulmonary lymphangioleiomyomatosis: CT findings. AJR 1989;153:937-940 2. Wagoner OE, Roncoroni AJ, Barcat JA. Severe pulmonary hypertension proliferation

and mental

who

REFERENCES

muscle

sclerosis

of seizures

retardation. Abdominal CT in this patient showed an angiomyolipoma. Chest CT helped to establish a diagnosis of Iymphangioleiomyomatosis.

low attenuation

smooth

of tuberous

and histo-

woman with renal angiomyolipoma, the diagnosis of tuberous sclerosis seems quite probable. In my opinion, it is important to exclude or confirm tuberous sclerosis in every case of pulmonary lymphangioleiomyomatosis. The hypothesis that the pulmonary lymphangioleiomyomatosis might be a forme fruste of tuberous sclerosis remains an open question, which the cases presented [1 ) do not help to solve. Sergiusz J#{244}wiak

diffuse

diagnosis

has been consid-

have pulmonary lesions the diagnosis of tuberous sclerosis is even more difticult. The findings of Sherrier et al. are interesting and may be of great significance. Unfortunately, the authors did not mention seizures, mental status, or other clinical signs of tuberous sclerosis. Abdominal CT was performed in only three patients, and, especially in one

with

had a known

the time of her CT scan. She had a history

I read with interest the article by Sherrier et al. [1], Pulmonary Lymphangiobeiomyomatosis: CT Findings,” in the November 1989

omatosis

““

is One

impurities, attenuation

are recognized

such as talc, with which the drugs are mixed. The lowregions undoubtedly represent gas trapped in the ends

LETTERS

420

AJA:155,

August 1990

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REFERENCES 1 . Cordone RP, Brandeis SZ, Aichman H. Rectal perforation during barium enema: report of a case. Ois Colon Rectum 1988:31 :563-569 2. Rimarenko S. Finkel L, Taft ML, et al. Fatal complications related to diagnostic barium enema. Am J Forensic Med Pathol 1988:9:78-84 3. Johnson JO, Amberg JR. Air-contrast colon examination and sigmoid hemia: avoiding perforation (letter). AJR 1988;1 50:948

Percutaneous Neoplasms:

Fig. 1.-A,

Abdominal radiograph shows multiple packets of cocaine throughout colon. B, CT scan at level of transverse colon clearly shows individual packets.

of the packets. We conclude that the ability of CT to distinguish density characteristics of tissues and foreign substances makes it an ideal technique for providing definitive proof of cocaine ingestion, despite attempts to mask the packets by ingesting water, oils, or other liquids. William

J. Vanarthos

Richard Jackson

Henry

N. Aizpuru H. Lerner

Memorial Miami,

Hospital FL 33136

1 . Pinsky

MF. Ducas

J. Auggene

MD.

Narcotic

smuggling:

the double

condom

sign. J Can Assoc Radio! 1978:29:78-81 2. McCarron MM, Wood JD. The cocaine body packer” syndrome: diagnosis and treatment. JAMA 1983:205:1417-1420 3. Sinner W. The gastrointestinal tract as a vehicle for drug smuggling. Gastrointest

Epigastric Contrast

Percutaneous injection of ethanol has been attracting attention in the treatment of liver neoplasms [1 -3]. One shortcoming of this method is that several sessions are required. Injected ethanol is distributed in a limited area, and the distribution may not be homegeneous even within this area because of the capsule and septa of the lesion. It is therefore essential to inject ethanol into various sites in the lesion. Once ethanol is injected, however, the lesion becomes

masked by hyperechoic

Radio!

1981 :6 :319-323

Hernia and Perforation Barium Examinations

University

near the left edge of the lesion and the second needle

near the right edge. Initially, these needles were inserted nearly through the lesion. After ethanol was injected into a deep portion of the lesion, the needle was withdrawn a certain distance, and then ethanol was injected into a shallower portion. The same process was repeated then with the other needle. Thus ethanol could be injected into several parts of the lesion in a single session.

By using the multiple-needle

During

Air-

Colonic perforation due to air-contrast barium enemas occurs with a frequency of one to two in 5000 examinations and is an important hazard of a relatively benign procedure [1 J. Perforations occur because of underlying colonic disease, instrumentation, or local catheter-related trauma and only rarely are due to overinsufflation of air [2]. That this distressing event may occur was demonstrated in a recent patient of ours, an 89-year-old woman who underwent an aircontrast barium examination because of heme-positive stools. She had a large epigastric hernia containing multiple loops of bowel and most of the transverse colon. Unfortunately, this was not recognized immediately. During the examination, obstruction to the flow of barium occurred at the transverse colon. When the colon was insufflated with air, the patient complained of severe abdominal discomfort. A radiograph showed free air in the abdomen. At surgery, a 5-cm tear was found in the transverse colon. In patients with inguinal hernias, barium enemas are performed with the hernia reduced by a lead-gloved hand [3]. Although the importance of doing this is widely appreciated for inguinal hernias, it is not as generally understood for epigastnic hernias. Anirudh Masand Rai Sabrina Johnson State

changes, and the needle cannot be reinserted

in the same session. Livraghi et al. [1] injected ethanol an average of 3.9 separate times for lesions

Pulmonary lymphangioleiomyomatosis: a "forme fruste" of tuberous sclerosis?

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