1. Imaging in Pediatric Allergy Saem Haque, Justin Stowell, MD, Brett Donegan, MD, Erin Opfer, MD, Lisa Lowe, MD UMKC School of Medicine, Children’s Mercy Hospital INTRODUCTION Children might present with a constellation of chronic, non-specific atopic symptoms, making the clinical diagnosis of various allergic conditions uncertain. This review discusses the role of imaging in the diagnosis and management of various respiratory and non-respiratory atopic conditions and their mimics as they manifest in the pediatric patient population. Sinonasal Development Paranasal sinus development begins in utero. Development begins from the ethmoid sinus and proceeds to maxillary, sphenoid and frontal sinuses. CONCLUSION Allergic rhinitis, asthma, chronic cough and food allergies are among the most common reasons for referral of patients to the pediatric allergist, who often present in a very non- specific way. Patients with congenital variants or unexpected disease processes may present with atopic-like symptoms. These diseases may be detected through imaging. The radiologist and clinician can work together through the use of imaging to help broaden the differential diagnosis and detect various infectious, inflammatory, developmental or neoplastic conditions, which manifest with atopic symptomatology. CREDITS/DISCLOSURE/REFERENCES 1. Towbin R et al. Radiographics 1982;2:254. 2. Santiago Martinez et al. RadioGraphics 2008, 28, 1369-1382. 3. Yedururi S et al. Radiographics 2008;28:e29-e29. 4. Berrocal T et al. Radiographics 1999;19:855-872 5. All other images are property of Children’s Mercy Hospital and Clinics. Respiratory Differential Diagnosis The differential diagnosis for pediatric allergies can be classified into respiratory vs non-respiratory causes. Respiratory causes include sinonasal disease, asthma, infection, hypersensitivity pneumonitis (HP), allergic bronchopulmonary aspergillosis (ABPA), eosinophilic pneumonia and foreign body aspiration. Non-respiratory causes can include gastroesophageal reflux disease (GERD), esophageal webs, eosinophilic esophagitis and cow’s milk allergy. 1 month 3 years 15 years Acute sinusitis Chronic sinusitis In acute sinusitis, mucosal thickening often has a scalloped appearance that may vary from day to day. Multiple sinus involvement is common. In contrast, chronic sinusitis shows mucosal thickening and bony sinus wall sclerosis. Vascular anomalies such as Vascular Rings (C) and Tracheo- Esophageal Fistula (D) can often mimic respiratory conditions. Juvenile Angiofibroma (above) almost always presents in adolescent males with unilateral obstruction and epistaxis. It originates in the sphenopalatine formaen and extends into posterior wall of the nasal cavity and the nasopharynx. AB Allergic Bronchopulmonary Aspergillosis (APBA) is a hypersensitivity reaction seen in patients with longstanding asthma or cystic fibrosis. Mucoid impaction is commonly seen and “finger-in-glove” appearance (B) is characteristic for ABPA. CD Non- Respiratory Eosinophilic Esophagitis (E) can present in kids with signs of frequent vomiting, feeding intolerance, asthma and acid reflux. “Trachealization” of the esophagus is seen on esophagram. E F Esophageal webs (F) can present with progressive dysphagia and vomiting. Rarely, regurgitation and aspiration can occur in newborns. Pathologically, a thin mucosal band extends into the esophageal lumen. 1 2 3 4