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University of Alabama at Birmingham Birmingham, AL 35233
I read with interest the review by Czermak et al. [1]. The authors are to be commended for a nice review of a disease uncommonly seen in most areas. I would like clarification of one comment, however.
The authors state, "On sonography, these lesions usually show a `hailstorm pattern."' When I lectured on the radiologic patterns of hydatid disease, I used the term "snowstorm sign" to indicate the swirling of hydatid sand within hydatid cysts at real time sonography. After one of my lectures, a young radiologist from Argentina came up to meet me, because he was the son of one of the authors of the original article describing this finding [2].
In that article [2], the authors indicate that findings of small bits of echogenic material within a cyst can help distinguish an incidental simple cyst of the liver or kidney from an uncomplicated hydatid cyst. At rest, the hydatid sand layers on the dependent surface of the cyst but can be seen after rapid change in position or shaking of the patient. The authors specifically state, "In sedimentation rate...the echoes were similar to snowflakes falling on a quiet night...."
Now, we have more hail falling in Alabama than snow, but I am familiar with both. In my experience, hail falls at a considerably higher final velocity than snowflakes on a quiet night. Unless there is another reference of which I am unaware, I am concerned that the authors have misquoted the original term for this sign.
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University Hospital of Innsbruck Innsbruck, Tyrol, Austria
We appreciate Dr. Kenney's interest in our pictorial essay, "Echinococcus multilocularis Revisited" [1], but we do not agree with his criticism.
The "falling snowflakes" sign was described by Saint Martin and Chiesa [2] as a typical sonographic pattern produced by the cystic lesions caused by Echinococcus granulosus. Our article [1], however, does not deal with the more common E. granulosus infection but with the rare multilocular alveolar type, caused by E. multilocularis. The two forms of Echinococcosis show different clinical behavior and different radiologic patterns.
As stated in our article, diagnosis of E. multilocularis is more difficult to establish than diagnosis of E. granulosus [1]. However, some radiologic features, such as the "hailstorm pattern," help the radiologist to differentiate E. multilocularis from other lesions. The hailstorm pattern was described by Didier et al. [3] as a "solid, heterogeneous echotexture...with multiple echogenic nodules of varying size." An example of this pattern is given in figure 2A in our article [1].
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  M. Macari, E. J. Bini, S. L. Jacobs, N. Lange, and Y. W. Lui Filling Defects at CT Colonography: Pseudo- and Diminutive Lesions (The Good), Polyps (The Bad), Flat Lesions, Masses, and Carcinomas (The Ugly) RadioGraphics, September 1, 2003; 23(5): 1073 - 1091. [Abstract] [Full Text] [PDF]
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