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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