0:01

So this is a, uh, newborn infant with concern for,

0:06

um, imperforate anus and so on this, uh, chest radiograph.

0:10

The important finding is

0:12

that this enteric tube is not extending into the stomach

0:15

where we think it should belong.

0:17

Um, so, uh, we have concern

0:20

for esophageal atresia in this infant.

0:22

Another important finding once,

0:24

once you're considering esophageal atresia, is,

0:27

is there a trache, esophageal fistula versus not?

0:30

And we can say there is concern for fistula

0:32

because we have distal bowel gas in this stomach

0:36

and in this bowel.

0:38

Now, this, this patient, I would also say there's concern

0:42

for hetero ataxia or, um, aus abnormality

0:46

because the stomach looks like it's right sided to me

0:49

as opposed to left sided.

0:51

Um, last but not least, we have a right sided cardiac, um,

0:55

apex as opposed to a left-sided cardiac apex.

0:58

So first we're gonna call our text

0:59

and make sure that this is not mislabeled right to left,

1:02

but, um, if, assuming that it is labeled correctly, this is

1:06

concerning for hetero ataxia.

1:08

There's one important other finding to look

1:11

for when you have a patient with esophageal atresia, um,

1:14

with or without a trache esophageal fistula.

1:17

And that is vertebral body anomalies.

1:20

So when we look super carefully at these

1:23

superior vertebral bodies,

1:25

we definitely have a vertebral anomaly.

1:27

There is a funny kind of partial fusion of, of these, um,

1:32

upper lower cervical

1:34

and upper thoracic vertebral bodies here at

1:36

the C seven T one level.

1:38

And then we have a hemi vertebra at the leftward aspect of,

1:41

uh, probably T two in this infant.

1:44

So now we're dealing with the ral, uh, spectrum.

1:47

So we found the vertebral body anomalies.

1:49

This patient on physical exam has anorectal malformation

1:52

with concern for imperfect anus.

1:55

We have a right-sided cardiac apex, so this patient needs

1:57

to undergo, uh, car echocardio echocardiography.

2:02

Um, so that's the c the renal anomalies.

2:05

This we will recommend a renal ultrasound.

2:07

And then with the vertebral anomalies,

2:09

we'll also recommend a spine ultrasound

2:11

and this patient, um, we don't see all

2:14

of the upper extremity limbs,

2:15

but hopefully on exam they would be able

2:17

to see if there's a limb abnormality, um, associated

2:19

with this patient with vl.

2:21

Um, on exam. So the first uh, uh,

2:25

screening ultrasound that, uh, was presented to us

2:28

with this patient for follow-up was the spine ultrasound.

2:31

So we are starting in the, uh,

2:32

the prone position in the transverse plane.

2:35

Um, and, uh, we know that we should be able

2:38

to see central spinal cord with central penal canal,

2:41

but instead we see this funky looking cystic structure in

2:45

the middle of this, uh, uh, spinal canal.

2:49

Um, as we are going more superiorly,

2:51

the cord does look more normal.

2:53

Um, this patient is prone in position,

2:57

but this cord is not located

2:58

In the, the anterior aspect,

3:00

anterior one third of the spinal canal.

3:02

It looks like it's more located posteriorly.

3:05

Um, hopefully we will see some, um,

3:07

some additional sagittal images later.

3:09

These lungs look okay, what I see

3:12

of adrenal glands looks okay here is probably left adrenal

3:15

gland and right adrenal gland over here.

3:18

Hopefully next we'll have some sagittal images to look at.

3:21

Yeah, so, um, this, this, uh, uh, sacrum looks like it kind

3:26

of abruptly ends here.

3:28

Um, we do see something in the rectum.

3:31

So, um, uh, this patient has in peripheral anus,

3:35

but we see rectum anterior to the sacrum here.

3:38

And then we have some definite abnormalities

3:40

of the lower aspect of the conus meis.

3:43

So a filer cyst should be, um, at the tip

3:46

of the conus meis really not involving the

3:49

conus meis itself.

3:51

So that's, um, the first thing that catches my eye.

3:53

The second abnormality is no matter

3:55

how you're gonna label this vertebral bodies,

3:58

this is too low.

3:59

So if we call this the S two sacral vertebral body

4:03

where the thecal sac ends, this would be S one,

4:06

L five, L four.

4:07

So this, uh, this spinal cord

4:10

and conus MedU go at least

4:11

to the L four vertebral body at a minimum the inferior

4:15

aspect of the L three vertebral body.

4:17

It does not have a normal, uh, triangular shaped,

4:20

uh, conus metis.

4:21

So this is gonna be concerning for tethered cord.

4:24

We'll recommend an MRI of the spine when this patient is,

4:27

uh, well enough to undergo that examination.

4:30

The last, um, ultrasound we have for screening

4:33

for additional anomalies,

4:35

and this patient is a renal ultrasound,

4:37

and so here we're in the sagittal plane, um,

4:40

and we can see part of right kidney

4:42

and it looks like it's sitting right on top

4:44

of a vertebral body.

4:45

That's what this genic sort of rounded structure is here.

4:48

The tech has labeled the, the rightward aspect

4:51

of this right-sided kidney.

4:53

It looks pretty normal.

4:54

We don't see any hydro necrosis or, um, anything.

4:57

We have good profusion with power doppler imaging.

5:00

Um, we'll keep looking at this kidney

5:02

to see if we see anything abnormal Besides,

5:04

it looks like it's a little bit too low in the location, um,

5:08

it looks like as we're going.

5:11

Um, yeah, so here's here we're seeing that the,

5:14

the renal FoST is empty where it's supposed to be.

5:17

We do have a normal abdominal aorta, um, up top

5:21

and we, um, see some part of IBC,

5:25

but this looks more like Aus continuation to me.

5:28

So typically our int hepatic IVC will be int hepatic,

5:32

it'll go into the liver over here.

5:34

So this is probably an interrupted IVC

5:36

with ASUS continuation.

5:38

So this was the patient we were concerned about hetero

5:41

ataxia and this is supporting that,

5:42

that concern that we had earlier.

5:45

Unfortunately, our urinary bladder is completely collapsed.

5:49

Um, so we can't see too much about the urinary

5:51

bladder on this examination.

5:53

Here is our left kidney, which looks, um,

5:55

a little bit more normal in

5:56

Morphology compared to that right kidney,

5:58

although it looks, looks pretty,

6:00

pretty globular in configuration.

6:02

Let's go to Aase to see if we can figure out, um,

6:05

what else is going on with this infant.

6:07

Why do these kidneys kind

6:08

of look like they're abnormal in morphology?

6:10

So that's the urinary bladder.

6:13

I think that this, this might be a horseshoe kidney.

6:16

So, um, if you look at this, uh, right kidney,

6:19

we don't really see the, uh, like the end of it very well.

6:24

Let's see if we can find,

6:26

and here's the, here's the left side, left side kidney.

6:28

So I think we have a low lying.

6:30

Yeah, look at where the sonographer has placed the marker

6:32

of where she's imaging.

6:34

So this is, this is gonna be a horseshoe kidney where both

6:37

of the, um, renal motis are located in the pelvis.

6:41

And, um, there's gonna be a, a tissue connecting,

6:44

connecting the two of them at midline.

6:49

Um, we don't have that nice, um, image showing that, uh, uh,

6:53

isus of tissue between the two renal moty.

6:57

Um, but this is, this is the renal anomaly that goes

6:59

with the ral syndrome in this infant, um, with

7:04

esophageal atresia, tracheal esophageal

7:06

fistula, vertebral anomalies.

7:07

And then we also have the spine abnormalities of the infant.

7:11

Um, here we go. So here's the trans,

7:13

this is the image I was looking for y'all.

7:15

So the, here we're in the transverse plane

7:17

of the right kidney and check out this, um, isus

7:19

of renal tissue extending across the midline.

7:22

So this is the inferior aspect of the left kidney

7:25

as we come superiorly, we have this isus

7:27

of tissue connecting the left kidney and right kidney.

7:31

Um, and then here is the right kidney.

7:32

So this is a, uh, uh,

7:34

a horseshoe pelvic kidney in this infant with bacterial.