Valentina Moressa

An adolescent with an altered state of mind

A 17 year old previously healthy adolescent presented to the emergency department with severe headache, vomiting, and an altered state of mind. His mother reported that he had returned home one hour before, looking confused and agitated; afterwards he mentioned a worsening headache and had vomited twice. On arrival at the emergency department he was conscious but drowsy and slow in answering simple questions. He reported frontal headache (8/10 on a visual analogue scale) and photophobia, and he was unable to stand unassisted. He was afebrile, his heart rate was 170 beats/min, and his blood pressure was 132/80 mm Hg. His pupils were mydriatic and poorly reactive to light. The remainder of the physical examination was unremarkable. He denied taking any drugs or medication, and a urine screen test was negative for cannabinoids, opioids, amphetamines, benzodiazepines, ethanol, and cocaine. Computed tomography of the brain and a basic set of blood tests were performed, and all results were normal. On further questioning by his parents he admitted having smoked “herbal incense” with friends in the afternoon, after which he reported having experienced visual and auditory hallucinations. ### 1. Which diagnosis does this story suggest? #### Short answer Acute intoxication by an emerging drug of misuse, probably a synthetic cannabinoid. Clues to the diagnosis include acute onset, otherwise unexplained, central nervous system and autonomic disturbances in a healthy young person with negative drug screening tests and a history of smoking herbal incense. #### Long answer The evaluation of an adolescent or young adult presenting to the emergency department with a change of mental status can be challenging. The differential diagnosis is extensive, comprising psychiatric conditions and medical conditions, including cerebrovascular events, unreported trauma, intoxication, carbon monoxide poisoning, …

PReS-FINAL-2088: Risk of severe adverse events in juvenile idiopathic arthritis and pediatric-onset inflammatory bowel disease, treated with anti-tnf drugs

Severe adverse events have been described in children affected by Juvenile Idiopathic Arthritis (JIA) and Inflammatory Bowel Disease (IBD) treated with anti-tnf drugs.

PReS-FINAL-2255: Primary pyomiositis in children: a challenging diagnosis

Primary Pyomiositis (PM) is an uncommon and potentially serious bacterial infection of striated muscle. It is typically a tropical disease but its frequency has been increasing in the Western Countries. Staphylococcus Aureus is the most frequently isolated organism from blood samples of patients affected by this condition. The rarity in temperate climates of this potentially fatal disease and its non-specific signs can represent a diagnostic challenge, leading to a dangerous diagnostic delay.

PReS-FINAL-2165: Pharmacogenetic determinants of response to methotrexate in juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) is the most common arthritis disease of childhood and is an important cause of disability. Methotrexate (MTX) is the mainstay treatment in JIA. Unfortunately, 30-35% of patients fail to respond MTX, and the delay in identifying the optimal treatment at an early stage of disease can lead to long-term joint damage. Recent studies have evaluated comprehensively the effect of genetic variants in candidate genes involved in MTX pharmacokinetics and pharmacodynamics on the response to the medication in children with JIA. These studies seem to indicate that the most relevant variants to predict MTX response in JIA are those in ATIC, ITPA and SLC19A1 genes.

Normal voiding does not exclude posterior urethral valves

A 6-week-old male infant with a prenatal diagnosis of bilateral hydronephrosis from the 20th week of gestation was seen for diagnostic workup. At 38 weeks of gestation, right and left renal pelvis anterior–posterior diameters measured 11 and 7 mm, respectively, with dilated calyces. Renal cortex thickness, amniotic fluid volume and bladder volume were within normal limits. He was born at 39 weeks via an uncomplicated vaginal delivery, and …