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978-3-319-68195-5 106

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Infrared Thermography Versus Conventional
Image Techniques in Pediatrics: Cases Study
Olga Benavent Casanova1(&), Francisco Núñez Gómez1,
Jose Ignacio Priego Quesada2, Rosa Mª Cibrián Ortiz de Anda2,
Rolando González-Peña2, Teresa Cuenca Bandín2,
and Rosario Salvador Palmer2
1
2
Pediatrics Department, Hospital Clínico Universitario de Valencia,
Avda. Blasco Ibáñez, 17, 46010 Valencia, Spain
olguius_bc@hotmail.com, olbeca@alumni.uv.es
Biophysics and Medical Physics Group, Department of Physiology,
Faculty of Medicine, University of Valencia, Valencia, Spain
Abstract. The use of infrared thermography has been shown to be useful in
several areas. Its applicability in medicine is based on the fact that the skin emits
spontaneously and continuously infrared radiation, whose body distribution is
symmetrical in a healthy individual. Infrared thermography can offer an alternative to X-rays for a large number of diseases related to peripheral vascularization. In these cases, infrared thermography can avoid the use of biologically
ionizing radiation. This is of special interest in pediatric patients who, because of
their age, are more radiosensitive.
We present a prospective descriptive study of 3 cases study of children with
inflammatory/infectious cutaneous, osteoarticular and vascular (hemangioma)
pathology. The objective of this study is double, on the one hand to evaluate the
use of infrared thermography for the diagnosis and follow-up of these patients,
through quantitative and qualitative analysis of the temperature differences
between symmetric zones and, on the other hand, to evaluate the correlation
with other imaging techniques (Ultrasonography, Computerized Tomography,
Magnetic Resonance).
Keywords: Thermal image
Orbital cellulitis
Children Hemangioma Foot osteomyelitis 1 Introduction
The use of infrared thermography has proved useful in various areas, such as industry,
astronomy and for military purposes, but it has only been in recent years that its
importance has increased in the medical field. Its successful application has been
reported in diagnosing breast cancer, diabetic neuropathy, peripheral vascular diseases,
musculoskeletal lesions, sport, screening for fever and, in short, in all those pathologies
that affect, in one or another, peripheral circulation [1–3]. Several recent cases in
pediatric populations report successful usage in inflammatory/infectious cutaneous and
osteoarticular pathologies, and in external uses such as burns, vascular alterations
© Springer International Publishing AG 2018
J.M.R.S. Tavares and R.M. Natal Jorge (eds.), VipIMAGE 2017,
Lecture Notes in Computational Vision and Biomechanics 27,
DOI 10.1007/978-3-319-68195-5_106
Infrared Thermography Versus Conventional Image Techniques
971
(hemangiomas, amputations…), cutaneous reactions/allergies [4–7]. However, there
have been few studies carried out on children and, moreover, there is a lack of references and clear protocols for using these techniques on that said population. Nevertheless, thermography may provide an alternative to X-rays for a large number of
diseases, so avoiding the use of biologically ionizing radiation in those pediatric
patients, who, because of their age, are more radiosensitive.
The applicability of thermography in medicine is based on the fact that the skin
spontaneously and continuously emits infrared radiation, whose corporal distribution is
symmetrical in a healthy individual [8]. That symmetry is altered in a wide spectrum of
pathologies in which the processes of inflammation, infection, vascular alterations, etc.
intervene, so altering the homeostasis and, therefore, causing changes in the thermal
energy map emitted by each individual [8, 9]. The recording by thermographic camera
of such distribution of the thermal energy emitted by the surface of the body is
completely harmless, fast and allows an immediate qualitative analysis that can show
the importance of the clinical finding [5, 10]. Later these images can be analyzed
quantitatively, regions of interest (ROIs) being selected to obtain variables and indices
of clinical use for diagnosis and follow-up.
2 Objectives
To assess the use of infrared thermography for the diagnosis and follow-up of pediatric
patients with inflammatory/infectious cutaneous, osteoarticular pathology and vascular
problems (hemangioma) through the quantitative and qualitative analysis of the differences in temperature between symmetrical zones or with respect to reference zones
and to evaluate the correlation with other imaging techniques (Ultrasonography,
Computerized Tomography, Magnetic Resonance).
3 Material and Methods
A prospective, descriptive study was undertaken on 3 children affected by hemangioma,
osteomyelitis and abscess on the left foot, and orbital cellulitis, respectively. A protocol
was drawn up for taking the thermographic images adapted to the using an IRT camera
with infrared resolution standards and protocols referring to adults [11]. The protocol
was approved by the Hospital’s Scientific Committee. The parents or legal representatives of the patients gave their consent for publication of these case studies and human
images. Skin temperature was measured of 320 240 pixels and thermal sensitivity < 0.05 °C (FLIR E-60, Flir Systems Inc., Wilsonville, Oregon, USA). The mean
temperature of each region of interest (ROI) was obtained using a thermography software (Thermacam Researcher Pro 2.10 software, FLIR, Wilsonville, Oregon, USA).
Moreover, a Thermal Index was determined at the time of diagnosis and subsequent
evolution. Thermal Index was obtained as a difference in mean temperatures between
pathological and contralateral areas divided by the average temperature of the reference
zone, and it was useful for assessing the evolution of the pathology.
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O. Benavent Casanova et al.
The thermographic images obtained for each type of lesion were analyzed by
comparing a photograph of the lesion, a thermal image and another image from a
conventional radiological study in accordance with the pathology. They correspond to
clearly different pathologies but relatively frequent ones in the paediatric population. In
all cases, images taken at diagnosis and follow-up were also compared.
4 Results and Discussion
4.1
Case 1
A six-month old breast-fed girl diagnosed with hemangioma on the upper left part of
her back, of 4 3.5 cm, of smooth consistency, and profound component (Fig. 1A).
She did not present any family or personal background of interest and the cardiological
study was normal. A thermographic image (Fig. 1B), an ultrasonograph and another
Doppler ultrasonograph (Fig. 1C and D, respectively) of the lesion were taken.
Treatment began with oral Propranolol, with a good clinical evolution, aiming at a
significant reduction of the hemangioma at 6 months of treatment (Fig. 2A and B).
Fig. 1. Images taken at diagnosis. A: Photograph: hemangioma in left scapular region. B:
Thermographic image: raised temperature in the hemangioma area. Thermal Index = 5.8%. C:
Ultrasound image: lesion occupying space of skin and subcutaneous cellular tissue of the back,
homogeneous and hyperechoic of 3.6 1.5 cm. D: Image of Doppler Sonography: great density
of vessels in interior of lesion with arterial flows of low resistance and venous indices.
Infrared Thermography Versus Conventional Image Techniques
973
Fig. 2. Images taken at 6 month of starting the treatment with propranolol. A: Photograph:
hemangioma in left scapular region. B: Thermographic image: raised temperature in the
hemangioma area, but reduction the temperature in comparison with the diagnosis. Thermal
Index = 3.2%.
An area of high temperature can be seen in the thermograph in the hemangioma
region compared with the contralateral area corresponding to: the visual image of
photograph (Fig. 1A); the space occupied by the injury in the skin and subcutaneous
cellular tissue of the back, homogeneous and hyperechoic of 3.6 1.5 cm in the
ultrasound image (Fig. 1C) and the increase of vessel density in the interior of the
lesion, with arterial flows of low resistance and venous indices of the Doppler sonograph image (Fig. 1D). The Thermal Index was 5.8% at diagnosis and 3.2% six months
after beginning the treatment, decreasing in correlation with clinical improvement.
4.2
Case 2
A 13-year-old adolescent girl diagnosed with osteomyelitis and abscess in left foot
(Fig. 3A). She presented fever and increase of acute phase reactants (PCR 50.6 mg/L)
on admission. Traumatic background 8 days before in that area, but no other history of
interest. A thermographic image was taken (Fig. 3B) and sonograph (Fig. 3C) that
shows an abscess in the subcutaneous cellular tissue of the outer part on the forefoot
and adjacent collection to the fifth metatarsal that could correspond to a subperiosteal
abscess. Surgical debridement was undertaken in surgery, Staphylococcus aureus being
isolated in the bacteriological culture of the material drained and intravenous antibiotic
therapy administered. The clinical evolution was favorable, so, after 10 days of
intravenous antibiotic therapy, oral antibiotic therapy was administered and continued
for the next 4 weeks of treatment.
The images taken at the moment of diagnosis show, in the case of the thermographic image, a correlation between the area affected in the photograph and the
increase in temperature of the corresponding zone in contrast to the healthy foot. The
Thermal Index in this case was 12.4%. Moreover, this rise in temperature observed in
the thermograph corresponds with the hyperechoic zone of the sonograph corresponding to an increase in vascularization. Specifically, in the sonograph, the subcutaneous cellular tissue of the external part of the left forefoot can be seen corresponding
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O. Benavent Casanova et al.
Fig. 3. Images taken at diagnosis. A: Photograph: Purple erythema and edema on left forefoot
mainly affecting the external face with fluctuating blood pressure collection on the 5th toe base. It
is associated with a local increase in temperature and painful palpation. B: Thermographic image:
a rise in temperature of affected foot compared to right foot. Thermal Index = 12.4%. C:
Ultrasound images: Identified in the subcutaneous cellular tissue of the external part of the left
forefoot is a badly demarcated heterogeneous collection of 3.4 9 cm, without vascularization
in the interior, compatible with abscess, accompanied by important inflammatory changes in the
subcutaneous cellular tissue with an increase in echogenicity and vascularization of the same.
Joined to that abscess can be observed another parallel collection adjacent to the fifth metatarsal,
limited by the hyperechoic line that could correspond to a subperiosteal abscess.
with the badly demarcated heterogeneous collection of 3.4 9 cm, with no internal
vascularization, compatible with abscess accompanied by important inflammatory
changes in the subcutaneous cellular tissue, with an increase of echogenicity and
vascularization of the same. Joined to that abscess can be seen another parallel collection adjacent to the fifth metatarsal, limited by a hyperechoic line and which could
correspond to a subperiosteal abscess.
The images taken 4 weeks after diagnosis (Fig. 4), at the end of the antibiotic
therapy treatment, show resolution of the erythema and edema in the left foot (Fig. 3A)
and that no differences of temperature exist between the two feet, the thermal map
being symmetrical (Fig. 4B), as shown by the value of the Thermal Index which is
reduced to 1.1%.
Fig. 4. Images taken during follow-up, 4 weeks after diagnosis. A: Photograph: resolution of the
erythema and edema on left forefoot. B: Thermographic image: symmetry of temperatures in
both feet. Thermal Index = 1.1%.
Infrared Thermography Versus Conventional Image Techniques
4.3
975
Case 3
A 7-year-old child diagnosed with left orbitary cellulitis with subperiosteal paraseptal
abscess in left orbit and sinusitis. He presented fever and local inflammatory signs on
the left eyelid, with the impossibility of eye opening and pain in eye movement
(Fig. 5A). A thermographic image was taken (Fig. 5B), Thermal Index = 3.50%, and
an orbitary Computerized Tomography (CT) undertaken (Fig. 5C) that confirmed that
diagnosis. In the thermograph an increase in Temperature is noted that corresponds
with the orbitary subperiosteal paraseptal associated with the palpebral edema detected
in the CT. Treatment was administered with intravenous antibiotic therapy and corticosteroid therapy. In the 5-day CT control, a worsenning of the subperiosteal abscess
was observed, so surgical drainage was undertaken via endoscopy. After 12 days of
admission, a new CT control was undertaken, aimed at determining the persistence of
the abscess, after which there was further surgery. Following the second surgery, a
good evolution began. 15 days after diagnosis, the edema and palpebral erythema
diminished and there was an improvement in the opening of the eye (Fig. 6A); in the
thermal image, greater symmetry is observed in the distribution of the temperature
between the two eye regions (Fig. 6B), Thermal Index = 1.10%, also indicates good
evolution of the patohology; and in the control Magnetic Resonance (MR), swelling
persisted and discrete build-up of the left orbitary fat which provoked a slight proptosis
corresponding to the already known cellulitis, but without dispalying abscesses or other
complications (Fig. 6C). After two more admissions due to torpid evolution, he finally
needs a third surgical intervention, and completes a total of 2 months with antibiotic
and corticosteroid therapy.
Fig. 5. Images taken at diagnosis. A: Photograph: Edema and erythema on upper left eyelid,
impeding the opening of the eye. B: Thermographic image: rise of temperature in the affected eye
region in comparison to the other eye. Thermal Index = 3.50%. C: CT eye image: orbital
subperiosteal paraseptal abscess of 40 7 mm, associated with eyelid edema. Almost complete
occupation of maxillary sinuses and bilateral ethmoidal cells. Mucosal thickening of frontal and
sphenoidal sinuses, with hydroaerial level in front left sinus.
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O. Benavent Casanova et al.
Fig. 6. Images taken in follow-up, 15 days after diagnosis. A: Photograph: Minimal edema on
upper left eyelid, without erythema, and with good eye opening. B: Thermographic image:
symmetry in temperature distribution in both eye regions. Thermal Index = 1.10%. C: MR eye
image: thickening with stringiness and discrete orbital fat uptake causing a slight proptosis,
corresponding to his already known cellulitis, without abscesses.
5 Conclusions
Infrared thermography showed a great potential in the assessment of pediatric patients
and it may be a tool to be used in daily clinical practice, given that it is harmless,
accessible and quick in the determination of the grade and development of lesions.
Thermal Index can be a valuable data to assess the degree of improvement after a
treatment. This index has decreased in all cases, approaching 0 when remission of the
pathology has been complete (equal temperature between contralateral zones). Values
of the Thermal Index around 1% imply temperature differences between contralateral
zones of the order of 0.5°, which are considered normal.
Currently and until other studies are undertaken with an extensive pediatric population, infrared thermography would be interesting to use as a complementary technique. However, depending on the pathology its utility could be different and, in this
way, future studies should determine the correlation between the different techniques. If
a good correlation is found between the infrared thermography and the protocolized
imaging technique for determining a certain pathology, it would be beneficial to
undertake a close follow-up of the patient by means of thermography and due to its
non-invasive nature. If there is not a good correlation, it would be advisable to
undertake the standardized technique for each pathology.
Acknowledgments. The authors are grateful to the patients and their families for their valuable
contributions, and to all people of the Pediatrics Department of Hospital Clínico Universitario of
Valencia for the facilities and help offered for the realization of the study.
Infrared Thermography Versus Conventional Image Techniques
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