Ayelet Rimon

Late presentation of massive pleural effusion from intrathoracic migration of a ventriculoperitoneal shunt catheter: case report and review of the literature.

We report an unusual case of ventriculoperitoneal (VP) shunt intrathoracic migration, associated with massive symptomatic hydrothorax. The VP shunt was inserted 10 years before presentation, after hemorrhagic hydrocephalus caused by prenatal intraventricular hemorrhage. The pleural fluid was drained via tube thoracostomy and the shunt was externalized, with full resolution of symptoms and signs. The patient was subsequently managed with shunt revision with drainage into the abdominal cavity. We review the 10 pediatric cases of cerebrospinal fluid hydrothorax reported in the literature and discuss the mechanism of shunt tip migration. Pleural effusion secondary to VP shunt insertion is a rare and potentially life-threatening occurrence, and it should be suspected in any patient with a VP shunt and respiratory distress.

An Unusual Cause of Small Bowel Obstruction in a Child: Ingested Rhubarb

Small bowel obstruction is rarely caused by bezoars concretions formed from undigested foreign material in the gastrointestinal tract. An important cause of bezoars is phytobezoars, formed from vegetables or fruits. A four-year-old boy presented to our emergency department with symptoms of acute intestinal obstruction. Upright plain abdominal radiography revealed multiple air fluid levels. Ultrasound showed no abnormalities, and because of worsening symptoms computed tomography of abdomen was performed. It showed intraluminal obstruction of the terminal ileum. Exploratory laparotomy revealed a phytobezoar consisting of undigested rhubarb. The mass was milked through the large bowel and out the anus. Although rare in humans, bezoars are a well-documented cause of small bowel obstruction and should be considered when intraluminal bowel obstruction occurs. Bezoars causing small bowel obstruction may require surgical treatment.

Radiologic Predictors of Hyponatremia in Children Hospitalized With Community-Acquired Pneumonia

Background Hyponatremia (HNa) is the most common electrolyte imbalance seen in clinical practice and a common laboratory finding in children with community-acquired pneumonia (CAP). This study investigated whether there is a link between the radiological pattern seen in patients with CAP and the occurrence of HNa, hypothesizing that children with moderate and severe HNa would have a lobar-segmental pattern on chest radiograph. Methods The medical files and chest radiographs of 54 children with moderate to severe HNa (sodium <130 mmol/L) admitted with CAP over a 2-year period at our institution were retrospectively studied. Community-acquired pneumonia was defined as either lobar-segmental or interstitial by a radiologist blinded to laboratory results. Results Hyponatremia was seen more frequently in children with lobar-segmental pneumonia: 40 (74%) compared with 14 (26%) with interstitial pneumonia (P = 0.004). There was no relationship between the pattern of pneumonia seen on chest radiograph and severity of HNa; however, all 6 cases of severe HNa had lobar-segmental CAP, and all patients with complicated CAP were from the lobar-segmental group. Conclusions We found an association between lobar-segmental CAP and moderate or severe HNa. In addition, all cases of severe HNa occurred in patients with lobar-segmental CAP. The presence of a lobar-segmental pattern on chest radiography in CAP suggests the need for assessment of electrolyte status even in patients with adequate respiratory status.

Does extreme leukocytosis predict serious bacterial infections in infants in the post-pneumococcal vaccine era? The experience of a large, tertiary care pediatric hospital.

Background Extreme leukocytosis, defined as a peripheral white blood cell count greater than 25,000/mm3, may alarm clinicians and prompt extensive evaluation in infants with fever, especially in the pediatric emergency department. Methods We reviewed data from children aged 3 to 36 months with extreme leukocytosis, fever and the risk of serious bacterial infections (SBI) at our institution from July 2010 to December 2012, a period after the universal introduction of pneumococcal vaccine. Results Serious bacterial infection was recorded in 57 (39%) of the 147 infants. The most common SBI were segmental or lobar pneumonia, in 28 (19%) patients, and urinary tract infection in 16 (10.9%) patients. Three patients had positive blood cultures, corresponding to a bacteremia rate of 2%. C-reactive protein was significantly higher in the SBI group than in the non-SBI group. Conclusions All well-looking febrile infants with white blood cell greater than 25,000/mm3 should undergo a chest radiograph unless there are clear physical findings that indicate a different etiology. Urine culture should be considered in women. C-reactive protein can have an added value in the differential diagnosis.

Emergency use of intravenous phytonadione (vitamin K1) for treatment of severe bleeding in a child with chronic cholestasis.

We present a 5-year-old boy with multiple hematomas associated with chronic cholestasis. A week before admission he suffered minor trauma at day care. The next day he complained of trunk and limb pain and orthopedic consultation, including leg x-rays, revealed no abnormalities. Over the next 5 days multiple hematomas developed over his body and increased in size. In the Emergency Department he was in pain and looked sick but alert. He had fever and tachycardia, with normal blood pressure and respiratory status and physical examination showed several hematomas on the legs, which increased in size during observation in the Emergency Department over 2 hours. Blood work revealed multiple coagulation abnormalities, and International Normalized Ratio was 12. Intravenous phytonadione (vitamin K1) was immediately administered with normalization of coagulation abnormalities within 1 hour and the hematomas stopped growing in size. In addition to missing follow-up with the Pediatric Gastroenterology Department, social service agency inquiry found he had not taken his medications for several months. With severe abnormal bleeding and hepatic disease, intravenous vitamin K1 may be lifesaving, even before obtaining confirmatory blood work, fresh-frozen plasma, or blood transfusion.

The Effect of Antipyretic Temperature Reduction on Heart Rate in Febrile Infants: a Pilot Study.

It is generally accepted that fever is associated with tachycardia and that the relationship, of an approximate increase of 10 beats/minute per °Celsius rise in temperature, is particularly pronounced in infants. It would be useful to determine how closely pulse and fever are associated during pharmacological temperature reduction, and whether it is influenced by the infectious status of the infant. Infants with fever presenting to the pediatric emergency department were prospectively enrolled in a study to determine temperature, heart rate, and the activity at initial assessment and 1 hour after antipyretic administration. Patients were also grouped into those with and without signs of serious bacterial infection for analysis. During pharmacological antipyresis, the relationship between pulse and fever deviated from the accepted norm, established during the febrile state: there was an average pulse rate reduction of 21.1 beats/minute/°Celsius decrement in fever (P = 0.0027; 95% CI, 14.05–28.15). Pulse reduction/°Celsius may also differ in infants with suspected serious bacterial infection. Our findings suggest caution in ascribing pulse changes to fever alone, especially in sick looking infants, and that this is especially true after the administration of antipyretics, which could be related to the mechanism of action of antipyretic drugs. Further research is needed to ascertain the clinical utility and importance of our observations.

Outcome of Benign Acute Childhood Myositis: The Experience of 2 Large Tertiary Care Pediatric Hospitals

Objective The aims of the study were to determine the evolution of benign acute childhood myositis in children and to assess the relationship between creatine phosphokinase (CPK) values and myoglobinuria. Study design A retrospective study of patients with benign acute childhood myositis seen in 2 tertiary care university-affiliated pediatric hospitals during overlapping 4-year periods. Methods Demographic data, historical details, clinical, and laboratory results were extracted from the charts of children younger than 16 years with a CPK greater than 3 times normal. Complications, treatments, and outcomes were recorded. Results Fifty-four children were included, 43 (80%) were male, and mean age was 7.3 years (median [range], 6 [3–16] years), none showed abnormal neurological findings, manifested hematuria, or developed renal failure. Mean CPK level at presentation was 1872 IU/L (range, 511–8086 IU/L). None developed renal failure, and there were no adverse outcomes on follow-up. Conclusions Acute childhood myositis is a predominantly benign disease. Neurological examination is usually normal and rhabdomyolysis is rare. Although severe pathological comorbid conditions must be excluded, a complete history and examination, coupled with simple blood and urine tests, can help minimize unnecessary diagnostic investigations.

Peer-Reviewed Journal Publication of Abstracts Presented at an International Emergency Medicine Scientific Meeting: Outcomes and Comparison With the Previous Meeting.

Abstract Scientific presentations at professional organization meetings have long been recognized as a method of providing up-to-date and novel information to both the medical and scientific community. After abstract presentation at a medical conference, the subsequent publication rate of full-text articles is variable, and few studies have examined this topic with respect to international emergency medicine conferences. This studys goals were to determine the publication rate of articles resulting from abstracts presented at the 12th International Conference on Emergency Medicine 2008 in San Francisco, Calif, and to compare this with data from the previous International Conference on Emergency Medicine 2006 conference in Halifax, Nova Scotia, Canada. We found a reduction in publication rate from 33.2% in 2006 to 22.8% in 2008 and that the host country furnished a greater proportion of the abstracts. It would be interesting to examine how these potential trends played out over more extended periods.