C. Maréchal

Serotonin Syndrome Induced by Tramadol Intoxication in an 8-Month-Old Infant

Severe cases of pediatric tramadol intoxication are rarely reported. We report on serotonin syndrome after tramadol intoxication. An 8-month-old girl developed extreme agitation after accidentally ingesting a tablet of her fathers medication (Monocrixo LP (Thérabel Lucien Pharma, Levallois Perret, France), 200 mg tramadol). Unable to sleep, she was admitted the next morning to our Pediatric Emergency Department after an episode of epistaxis. Vital signs were significant for sinus tachycardia and a neurologic examination revealed intermediately reactive pupils, agitation alternating with drowsiness with a Glasgow Coma Scale of 10, and increased lower-limb reflexes. Within 24 hours, she developed hyperthermia and high blood pressure. She did not experience seizures. Neurologic and cardiovascular effects resolved on day 2. Tramadol serum plasma levels confirmed the intoxication (680 μg/L). She was discharged on day 5 with no sequelae. Serotonin syndrome was described in adults when tramadol was associated with selective serotonin-reuptake inhibitors in contexts of therapy or intoxication. Our patient developed moderate serotonin syndrome. The clinical presentation was unusual compared with previous pediatric cases of tramadol intoxication, in which opioid effects and seizures were usually predominant. This case illustrates that serotonin syndrome can occur in children intoxicated with tramadol.

Corps étranger nasal chez l’enfant

AIMSnProvide a descriptive analysis of children admitted to a tertiary care pediatric emergency department (PED) for a nasal foreign body (NFB) and describe the current knowledge and management of such accidents.nnnMATERIAL AND METHODSnA retrospective study was conducted from January 2003 to May 2008, including all patients aged less than 15 years admitted for a NFB. The data collected were age, sex, geographic origin, time and day of admission, duration in PED, duration of NFB insertion, nostril location, symptoms and clinical signs, prehospital extraction attempts, facial x-ray, extraction mode, referral to an ENT specialist, progression, and complications. For statistical analysis, the data were entered in Microsoft Excel spreadsheets. The data were analyzed with StatView 5.1 (SAS Institute) and EpiInfo 6.04fr (VF, ENSP Epiconcept). In the descriptive analysis, the data are presented as mean values with standard deviation, median with extreme values or with 95% confidence intervals where appropriate, unless otherwise indicated. To compare qualitative variables, a chi(2) test (Mantel-Haenszel) was used and the two-tailed Fisher exact test if the expected value was 5 or less. Statistical significance was set at p<0.05.nnnRESULTSnA total of 388 patients were included (393 NFB). The annual mean number of cases was 68. The annual distribution showed a higher number in January, March, April, and October following Christmas, Easter and Halloween celebrations, totaling 40% of all NFB admissions. The sex-ratio was 0.95. Children aged less than 4 years accounted for 71% of the studied population. The mean age was 3.5+/-1.6 years (range, 1.4-13 years). The majority of accidents occurred at home (95%). The length of time spent in the PED was 78+/-57 min. The NFB duration of insertion was unknown in one-quarter of cases, present for less than 4 h in 65% of cases. No symptoms were described in most cases (88%). When symptoms were described, bleeding, pain or nasal discomfort, and foul nasal odor were the principal symptoms. The right nostril was the predominant location (60%). This difference tended to disappear in the group of children aged less than 4 years. Five children had bilateral NFB. Nonorganic compounds accounted for 80% of the NFB: plastic beads or balls (39%), plastic or toy parts (20%), stones or pebbles (11%), and paper (6%). The extraction was instrumental in 82% of cases, and 26% of patients were referred to an ENT specialist when PED attempts were unsuccessful. One child needed hospitalization for extraction under general anesthesia of two beads located deep in the same nostril. No complication occurred. Five children had repeated accidents within an average delay of 6 months.nnnCONCLUSIONnOften benign, this frequent accident can be serious in case of batteries or neodymium magnet insertion: the extraction becomes an emergency because of risks of nasal mucosa necrosis and/or nasal septum perforation. In other cases, positive pressure techniques (the parents kiss or its variants) could be tried first in the emergency department or at home at the time of a call to emergency services before a medical visit.

Risque de trouble du rythme et électrisation par courant domestique

AIMnAnalysis of domestic low-voltage (220-240 V) electrical injury in children admitted to a pediatric emergency department to illustrate the low risk of initial or delayed risk of arrhythmia.nnnMATERIAL AND METHODSnRetrospective study between 2001 and 2008 analyzing all children aged less than 15 years admitted for a low-voltage electrical injury. The data collected were age, sex, time and circumstances of the accident, time and day of admission, transport modalities, presence of risk factors for arrhythmia (transthoracic current, wet skin, tetany, loss of consciousness or neurological symptoms, and initial EKG abnormalities), injuries, EKG, muscular and/or cardiac enzyme values, progression and complications. For statistical analysis, data were entered in Microsoft Excel tables. Analysis was done with StatView5.1 (SAS Institute) and Epi Info 6.04fr (VF, ENSP epiconcept). In the descriptive analysis, the data are presented as mean values with SD, median and range.nnnRESULTSnForty-eight children were included. The mean annual number of admissions was equal to 6 (range, 3-12). The mean age was 6.2 + or - 4.3 years (median, 4.6 years). There was a male predominance: the overall sex ratio was 1.5, i.e., 3 before the age of 2 and 2.6 before the age of 10. The electrical injury occurred after contact with a wire or a connected cord or after the introduction of a metallic object in a wall socket. Ten children had risk factors of arrhythmia (mainly wet skin or thoracic pain). Twenty-nine children suffered from burns to the extremities (digits and hands, 70 %). At admission, 45 children had an EKG performed. The initial EKG was considered abnormal in 8 cases showing: sinusal tachycardia (n=4), incomplete right bundle branch block (n=4), and V(1) negative T waves (n=1). The EKG normalized within the first 12h. Hospitalization for cardiac monitoring was required for 18 children. No delayed arrhythmia occurred. In a mean time of 3.5h after the accident, a troponin dosage was given to 15 children and was normal in all cases. One child developed rhabdomyolysis and evolved without needing dialysis.nnnCONCLUSIONnAfter a low-voltage electrical injury, initial arrhythmia is not frequent, with often a nonspecific and transitory EKG expression; delayed arrhythmia is very rare. Children presenting to the emergency department after such an electrical accident, who are asymptomatic, without any risk factors for arrhythmia (wet skin, tetany, vertical pathway of the current, preexistent cardiological conditions, loss of consciousness) and with a normal initial EKG do not require cardiac monitoring.

Pediatric adder bites

UNLABELLEDnAdder bites and their progression to severe envenomations are more frequent in children than in adults.nnnAIMnTo describe the clinical, biological, and therapeutic characteristics of children bitten by adders and to identify risk factors associated with severe envenomations corresponding to grades II and III of the Audebert et al. classification (Toxicon 1992).nnnMATERIAL AND METHODSnA retrospective study was conducted between 2001 and 2009 in the pediatric emergency department of a tertiary childrens hospital. The data collected were: age and sex of children; day and time of admission; day, time, and circumstances of the accident; snake identification; bite location; envenomation severity based on the Audebert et al. classification; presence of fang marks; prehospital care; use of specific immunotherapy (Viperfav(®)), associated treatments; length of stay; orientation, progression, and any complications.nnnRESULTSnFifty-eight children were included (43 boys, 15 girls). The mean age was 7.8 ± 4.1 years (range, 1.8-15 years). Bites occurred more often between 12:00 pm and 6:00 pm (62%), and were most often located in the lower extremities (77%). The classification of envenomation was: 83% low grade (grade 0, absence of envenomation, fang marks present; grade I, minor envenomation) and 17% high grade (grades II and III, moderate and severe envenomations). All high-grade envenomations received specific immunotherapy (Viperfav(®) F(ab)(2) fragments against Vipera aspis, Vipera berus, and Vipera ammodytes). The mean time from bite to Viperfav(®) injection was 23 ± 11 h (range, 8-36 h). Being bitten on the upper extremities (p < 0.001), during the afternoon (p = 0.025), feeling an immediate violent pain (p = 0.037), and high initial glycemia (p = 0.016) were associated with a significant risk of progressing to high-grade envenomation. There was no significant correlation between age, gender, and upper extremity bite. In the final model of the multivariate statistical analysis, three factors remained associated with this risk: bite location in the upper extremities (relative risk [RR] = 60.5 [3.5-1040[; p = 0.005), immediate violent pain (RR = 21.5 [1.3-364.5[; p = 0.03), and female gender (RR = 17.5 [0.9-320.3[; p = 0.053).nnnCONCLUSIONnA certain number of criteria seem related with a more significant risk of progression to high-grade envenomation following an adder bite. These results need to be studied on a larger cohort of patients. Bites to the upper extremities should be handled with caution because of the association with more severe envenomation.

Oligo-arthrite tuberculeuse : un diagnostic différentiel de l’arthrite juvénile idiopathique

UNLABELLEDnWe report a case of extrapulmonary tuberculosis with oligoarthritis and synovitis in a 6-year-old girl with undiagnosed disseminated tuberculosis.nnnCLINICAL CASEnThe child, adopted from Ethiopia, was admitted to the pediatric rheumatology unit for suspected idiopathic juvenile arthritis. She presented with clinical signs of subacute arthritis of the right knee. Joint symptoms began insidiously and followed a short period of fever and pain in the right hip. Clinical examination showed voluminous cervical lymphadenitis, night sweats, and a moderate alteration of the childs general condition. The medical history revealed that since her arrival in France, 2 years before, she had had febrile subacute pneumonia. A review of the chest x-ray diagnosed primary pulmonary tuberculosis. An intradermal tuberculin test confirmed the diagnosis with a phlyctenular response and a diameter exceeding 20mm. Additional evaluation showed cervical lymphadenitis and intense synovitis of the right hip and knee joints. With an appropriate antitubercular regimen, her condition improved within a few months. After 1 year of treatment, magnetic resonance imaging (MRI) showed normalization of the impaired joints with no functional sequelae.nnnDISCUSSIONnAlthough the spine is a common target for osteoarticular tuberculosis (OAT), peripheral involvement in this case underlines the polymorphism of OAT in children. It illustrates a case of OAT strictly located to the synovial membranes, which usually occurs in one-third of OAT cases. In addition, MRI showed tenosynovitis of the quadriceps. The child presented with unilateral oligoarthritis instead of chronic insidious monoarthritis or symmetrical oligoarthritis as usually described in pediatric OAT. When available, MRI is the best way to evaluate OAT lesions. Mycobacterium tuberculosis can be isolated from sputum, gastric aspiration, and joint fluid or synovial biopsy. Histological lesions can reveal advanced tuberculosis with the presence of caseous follicular lesions. Rapid bacterial detection using polymerase chain reaction remains insufficiently useful in those situations. The recommended therapeutic regimen consists of 3 months with four antitubercular agents (rifampicin, isoniazid, pyrazinamide, and ethambutol) followed by 9 months of a dual therapy (isoniazid, rifampicin).

Status Epilepticus in a Pediatric Patient With Amantadine Overdose

A 2-year-old boy who ingested 0.8-1.5 g of amantadine developed status epilepticus. One hour later, the child presented with agitation, diaphoresis, and vomiting. He was admitted to the pediatric emergency department 2 hours later. Generalized seizures evolved to status epilepticus, with alternating generalized tonic-clonic and partial seizures, over a period of 7 hours. Other initial clinical signs were sinusal tachycardia and reactive bilateral mydriasis. All symptoms resolved within 20 hours, with a good recovery; the child was released from the hospital on day 3.

Risk factors for high-grade envenomations after French viper bites in children.

Background Viper bites and subsequent evolution to severe envenomations are more frequent in children. Aim The aims of this study were to describe the clinical, biological, and therapeutic characteristics of children bitten by vipers in France and to identify risk factors associated with severe envenomations. Methods A retrospective study was conducted between 2001 and 2009 in the pediatric emergency department of a tertiary-level children hospital. Collected data were age and sex of children; day and time of admission; day, time, and circumstances of the accident; snake identification; bite location; envenomation severity; presence of fang marks; prehospital care; use of specific immunotherapy and associated treatments; length of stay; and hospital course. Results Fifty-eight children were included (43 boys, 15 girls). The mean age was 7.8 ± 4.1 years. Bites were most often located on the lower extremities (77%). The classification of envenomation was: 83% low grade (absence or minor envenomation) and 17% high-grade (moderate to severe envenomations). All high-grade envenomations received specific immunotherapy (Viperfav). Being bitten on an upper extremity (P < 0.001), during the afternoon (P = 0.025), feeling violent pain (P = 0.037), and high initial glucose level (P = 0.016) were associated with a significant risk of high-grade envenomation. In the multivariate analysis, 3 factors remained significant: upper-extremity location (relative risk [RR], 60.5 [3.5–1040]; P = 0.005), immediate violent pain (RR, 21.5 [1.3–364.5]; P = 0.03), and female sex (RR, 17.5 [0.9–320.3]; P = 0.053). Conclusions A certain number of criteria seem related to more significant risk of progression to high-grade envenomation. Bites to the upper extremities should be carefully observed because of the risk of evolution to a high-grade envenomation.

Nasal foreign body in infants

AIMSnProvide a descriptive analysis of children admitted to a tertiary care pediatric emergency department (PED) for a nasal foreign body (NFB) and describe the current knowledge and management of such accidents.nnnMATERIAL AND METHODSnA retrospective study was conducted from January 2003 to May 2008, including all patients aged less than 15 years admitted for a NFB. The data collected were age, sex, geographic origin, time and day of admission, duration in PED, duration of NFB insertion, nostril location, symptoms and clinical signs, prehospital extraction attempts, facial x-ray, extraction mode, referral to an ENT specialist, progression, and complications. For statistical analysis, the data were entered in Microsoft Excel spreadsheets. The data were analyzed with StatView 5.1 (SAS Institute) and EpiInfo 6.04fr (VF, ENSP Epiconcept). In the descriptive analysis, the data are presented as mean values with standard deviation, median with extreme values or with 95% confidence intervals where appropriate, unless otherwise indicated. To compare qualitative variables, a chi(2) test (Mantel-Haenszel) was used and the two-tailed Fisher exact test if the expected value was 5 or less. Statistical significance was set at p<0.05.nnnRESULTSnA total of 388 patients were included (393 NFB). The annual mean number of cases was 68. The annual distribution showed a higher number in January, March, April, and October following Christmas, Easter and Halloween celebrations, totaling 40% of all NFB admissions. The sex-ratio was 0.95. Children aged less than 4 years accounted for 71% of the studied population. The mean age was 3.5+/-1.6 years (range, 1.4-13 years). The majority of accidents occurred at home (95%). The length of time spent in the PED was 78+/-57 min. The NFB duration of insertion was unknown in one-quarter of cases, present for less than 4 h in 65% of cases. No symptoms were described in most cases (88%). When symptoms were described, bleeding, pain or nasal discomfort, and foul nasal odor were the principal symptoms. The right nostril was the predominant location (60%). This difference tended to disappear in the group of children aged less than 4 years. Five children had bilateral NFB. Nonorganic compounds accounted for 80% of the NFB: plastic beads or balls (39%), plastic or toy parts (20%), stones or pebbles (11%), and paper (6%). The extraction was instrumental in 82% of cases, and 26% of patients were referred to an ENT specialist when PED attempts were unsuccessful. One child needed hospitalization for extraction under general anesthesia of two beads located deep in the same nostril. No complication occurred. Five children had repeated accidents within an average delay of 6 months.nnnCONCLUSIONnOften benign, this frequent accident can be serious in case of batteries or neodymium magnet insertion: the extraction becomes an emergency because of risks of nasal mucosa necrosis and/or nasal septum perforation. In other cases, positive pressure techniques (the parents kiss or its variants) could be tried first in the emergency department or at home at the time of a call to emergency services before a medical visit.

A Transatlantic Caterpillar

Background: Saddleback caterpillar sting has been very rarely reported in European countries. We report a French case of a stung toddler. Case: A 2-year-old girl was brought to the pediatric emergency department after being stung by a caterpillar in a furniture store. The emergency department physical examination revealed an inflammatory edema of the stung finger, normal vital signs, and no fever. Three hours after presentation, she was discharged with local ointment prescription. The caterpillar brought in by the parents was unusual compared to common French caterpillar species. The regional poison center was unable to identify it. With the help of the Internet, we succeeded in its identification as a saddleback caterpillar. Tracing its transatlantic importation was the most difficult. Conclusions: Saddleback caterpillars can be imported to France and carried across the Atlantic Ocean on house or garden plants especially Areca trees. French garden store owners should be informed about this risk and should check and treat host plants (especially Areca trees) at the arrival time.

Pediatric nasal foreign body.

AIMSnProvide a descriptive analysis of children admitted to a tertiary care pediatric emergency department (PED) for a nasal foreign body (NFB) and describe the current knowledge and management of such accidents.nnnMATERIAL AND METHODSnA retrospective study was conducted from January 2003 to May 2008, including all patients aged less than 15 years admitted for a NFB. The data collected were age, sex, geographic origin, time and day of admission, duration in PED, duration of NFB insertion, nostril location, symptoms and clinical signs, prehospital extraction attempts, facial x-ray, extraction mode, referral to an ENT specialist, progression, and complications. For statistical analysis, the data were entered in Microsoft Excel spreadsheets. The data were analyzed with StatView 5.1 (SAS Institute) and EpiInfo 6.04fr (VF, ENSP Epiconcept). In the descriptive analysis, the data are presented as mean values with standard deviation, median with extreme values or with 95% confidence intervals where appropriate, unless otherwise indicated. To compare qualitative variables, a chi(2) test (Mantel-Haenszel) was used and the two-tailed Fisher exact test if the expected value was 5 or less. Statistical significance was set at p<0.05.nnnRESULTSnA total of 388 patients were included (393 NFB). The annual mean number of cases was 68. The annual distribution showed a higher number in January, March, April, and October following Christmas, Easter and Halloween celebrations, totaling 40% of all NFB admissions. The sex-ratio was 0.95. Children aged less than 4 years accounted for 71% of the studied population. The mean age was 3.5+/-1.6 years (range, 1.4-13 years). The majority of accidents occurred at home (95%). The length of time spent in the PED was 78+/-57 min. The NFB duration of insertion was unknown in one-quarter of cases, present for less than 4 h in 65% of cases. No symptoms were described in most cases (88%). When symptoms were described, bleeding, pain or nasal discomfort, and foul nasal odor were the principal symptoms. The right nostril was the predominant location (60%). This difference tended to disappear in the group of children aged less than 4 years. Five children had bilateral NFB. Nonorganic compounds accounted for 80% of the NFB: plastic beads or balls (39%), plastic or toy parts (20%), stones or pebbles (11%), and paper (6%). The extraction was instrumental in 82% of cases, and 26% of patients were referred to an ENT specialist when PED attempts were unsuccessful. One child needed hospitalization for extraction under general anesthesia of two beads located deep in the same nostril. No complication occurred. Five children had repeated accidents within an average delay of 6 months.nnnCONCLUSIONnOften benign, this frequent accident can be serious in case of batteries or neodymium magnet insertion: the extraction becomes an emergency because of risks of nasal mucosa necrosis and/or nasal septum perforation. In other cases, positive pressure techniques (the parents kiss or its variants) could be tried first in the emergency department or at home at the time of a call to emergency services before a medical visit.