Acute rheumatic fever and post-streptococcal reactive arthritis

Barash J. Rheumatic Fever and post-group a streptococcal arthritis in children. Curr Infect Dis Rep. 2013 Jun;15(3):263-8.

There are several diseases associated with group A beta hemolytic streptococcal infection; the two most common are acute rheumatic fever (ARF) and poststreptococcal reactive arthritis (PsRA). Epidemiological and clinical data for both diseases are described, as well as current recommendations for treatment and prevention. There is an ongoing debate as to whether these two are different diseases or are parts of the spectrum of the same disease. There are some reports of carditis developing after PsRA, suggesting that PsRA may be part of the spectrum of ARF. However, since there are substantial clinical, immunological, and genetic differences between PsRA and ARF, we believe PsRA to be a distinct entity.

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Uziel Y, et al. Post-streptococcal reactive arthritis in children: a distinct entity from acute rheumatic fever. Pediatr Rheumatol Online J. 2011 Oct 20;9(1):32.

There is a debate whether post-streptococcal reactive arthritis (PSRA) is a separate entity or a condition on the spectrum of acute rheumatic fever (ARF). We believe that PSRA is a distinct entity and in this paper we review the substantial differences between PSRA and ARF. We show how the demographic, clinical, genetic and treatment characteristics of PSRA differ from ARF. We review diagnostic criteria and regression formulas that attempt to classify patients with PSRA as opposed to ARF. The important implication of these findings may relate to the issue of prophylactic antibiotics after PSRA. However, future trials will be necessary to conclusively answer that question.

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Indeterminate pulmonary nodules

Assefa D, Atlas AB. Natural history of incidental pulmonary nodules in children. Pediatr Pulmonol. 2015 May;50(5):456-9.

As there are no evidence based guidelines for the diagnosis and/or management of pulmonary nodules in children, there is an over reliance on the adult based algorithms when dealing with pulmonary nodules in children. We present our experience of pediatric patients evaluated for incidentally found pulmonary nodules.

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Spontaneous pneumomediastinum

Gasser CR, et al. Pediatric Spontaneous Pneumomediastinum: Narrative Literature Review. Pediatr Emerg Care. 2016 Feb 6. [Epub ahead of print]

Spontaneous pneumomediastinum is uncommon in children but must be considered in pediatric patients with acute chest and/or neck pain. History taking, physical examination, and standard chest x-ray are most often diagnostic, and there is rarely a need for other investigation.Hospitalization is not always indispensable; ambulatory management can be considered. Outcome is good, and follow-up can be clinical, therefore avoiding further x-rays.

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Abbas PI, et al. Spontaneous pneumomediastinum in the pediatric patient. Am J Surg. 2015 Dec;210(6):1031-5; discussion 1035-6.

“This is the largest series of pediatric SPM patients to date. Our study reveals potentially no added benefit from obtaining additional imaging with chest CT or esophagographies. This suggests that patients with SPM may be managed primarily with CXRs with additional imaging obtained only when clinically indicated. In addition, we noted that patients with secondary SPM were frequently admitted to treat their underlying disease, whereas those with primary SPM were often observed and discharged home without any interventions or adverse outcomes. Because of this, we suggest that patients with primary SPM may be managed conservatively in the ED and discharged with appropriate follow-up, if they do not have respiratory concerns. These management strategies for pediatric SPM may help to decrease unnecessary hospital admissions and eliminate additional costly imaging.”

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Practice Based Learning: Refeeding Syndrome – what is it, who’s at risk, and how do we manage it?

Taylor Maturo

 

 

 

 

Presented by Taylor Maturo, MD (PGY1)

Clinical questions:

  • Is there a biochemical marker that can predict which at-risk patients will develop refeeding syndrome, specifically hypophosphatemia?
  • Among the pediatric population, does calorie restriction during electrolyte replacement result in more positive outcomes versus standard nutrition?

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Antibiotics for appendicitis (focus on perforated appendicitis)

Kronman MP, et al. Extended- Versus Narrower-Spectrum Antibiotics for Appendicitis. Pediatrics. 2016 Jul;138(1). pii: e20154547.

“This large, multicenter study found no advantage of empiric extended-spectrum antibiotic therapy for children with uncomplicated or complicated appendicitis. Given these findings and the frequency of extended-spectrum antibiotic use for this condition, pediatric appendicitis represents an important target for antimicrobial stewardship efforts. A prospective study could determine the optimal antibiotic selection for those with complicated appendicitis.”

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Lee JY, et al. Once Daily Dosing of Ceftriaxone and Metronidazole in Children With Perforated Appendicitis. J Pediatr Pharmacol Ther. 2016 Mar-Apr;21(2):140-5.

While there was no statistically significant difference in the outcomes evaluated, the rate of infectious complications was twofold higher in those given ceftriaxone and metronidazole than in others. A larger prospective randomized controlled trial is warranted to better understand the risks of using these agents.

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Oculomotor nerve palsies

Lyons CJ, et al. Cranial nerve palsies in childhood. Eye (Lond). 2015 Feb;29(2):246-51.

We review ocular motor cranial nerve palsies in childhood and highlight many of the features that differentiate these from their occurrence in adulthood. The clinical characteristics of cranial nerve palsies in childhood are affected by the child’s impressive ability to repair and regenerate after injury. Thus, aberrant regeneration is very common after congenital III palsy; Duane syndrome, the result of early repair after congenital VI palsy, is invariably associated with retraction of the globe in adduction related to the innervation of the lateral rectus by the III nerve causing co-contraction in adduction. Clinical features that may be of concern in adulthood may not be relevant in childhood; whereas the presence of mydriasis in III palsy suggests a compressive aetiology in adults, this is not the case in children. However, the frequency of associated CNS abnormalities in III palsy and the risk of tumour in VI palsy can be indications for early neuroimaging depending on presenting features elicited through a careful history and clinical examination. The latter should include the neighbouring cranial nerves. We discuss the impact of our evolving knowledge of congenital cranial dysinnervation syndromes on this field.

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Sadagopan KA, Wasserman BN. Managing the patient with oculomotor nerve palsy.
Curr Opin Ophthalmol. 2013 Sep;24(5):438-47.

Recent case reports highlight emerging new causes of oculomotor cranial nerve palsies, including sellar chordoma, odontogenic abscess, nonaneurysmal subarachnoid hemorrhage, polycythemia, sphenoiditis, neurobrucellosis, interpeduncular fossa lipoma, metastatic pancreatic cancer, leukemia, and lymphoma. Surgical studies have focused on modifications and innovations regarding strabismus surgery for this condition. New globe fixation procedures may include fixation to the medial orbital wall by precaruncular and retrocaruncular approaches, apically based orbital bone periosteal flap fixation and the suture/T-plate anchoring platform system.

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Lightning injuries

See alsoElectrical injuries and burns


Sanford A, Gamelli RL. Lightning and thermal injuries. Handb Clin Neurol. 2014;120: 981-6.

Electrical burns are classified as either high voltage (1000 volts and higher) or low voltage (<1000 volts). The typical injury with a high-voltage electrical contact is one where subcutaneous fat, muscles, and even bones are injured. Lower voltages may have lesser injuries. The electrical current has the potential to injure via three mechanisms: injury caused by current flow, an arc injury as the current passes from source to an object, and a flame injury caused by ignition of material in the local environment. Different tissues also have different resistance to the conduction of electricity. Voltage, current (amperage), type of current (alternating or direct), path of current flow across the body, duration of contact, and individual susceptibility all determine what final injury will occur. Devitalized tissue must be evaluated and debrided. Ocular cataracts may develop over time following electrical injury. Lightning strikes may conduct millions of volts of electricity, yet the effects can range from minimal cutaneous injuries to significant injury comparable to a high-voltage industrial accident. Lightning strikes commonly result in cardiorespiratory arrest, for which CPR is effective when begun promptly. Neurologic complications from electrical and lightning injuries are highly variable and may present early or late (up to 2 years) after the injury. The prognosis for electricity-related neurologic injuries is generally better than for other types of traumatic causes, suggesting a conservative approach with serial neurologic examinations after an initial CT scan to rule out correctable causes. One of the most common complications of electrical injury is a cardiac dysrhythmia. Because of the potential for large volumes of muscle loss and the release of myoglobin, the presence of heme pigments in the urine must be evaluated promptly. Presence of these products of breakdown of myoglobin and hemoglobin puts the injured at risk for acute renal failure and must be treated. The exact mechanism of nerve injury has not been explained, but both direct injury by electrical current overload or a vascular cause receive the most attention. Because electrical injuries carry both externally visible cutaneous injuries and possible hidden musculoskeletal damage, conventional burn resuscitation formulas based on body surface area injured may not provide enough fluid to maintain urine output.

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Lupus nephritis

Thakur N, et al. Pediatric lupus nephritis: review of literature. Curr Rheumatol Rev. 2016 Apr 4. [Epub ahead of print]

Systemic lupus erythematous (SLE) is a multisystem autoimmune disorder characterized by immune dysregulation and formation of autoantibodies. A high index of suspicion is necessary to diagnose SLE. Children have more systemic involvement than adults. Kidney involvement is seen in a significant proportion of children. With advancement of therapy the survival rate of patients with SLE has significantly improved. Even then lupus nephritis is still the most important predictor of morbidity and mortality. Treatment of lupus nephritis is mostly derived from studies in adults as data on children is still lacking. Prednisolone and cyclophosphamide was the mainstay of treatment till now. Recently drugs like mycophenolate mofetil, azathioprine, rituximab are also being used in treatment of lupus nephritis with promising results and without significant adverse effects. In this review we will be discussing lupus nephritis, its diagnosis, pathogenesis, clinical picture and treatment advancements.

Children’s and Emory users, request article from Emily Lawson.


Sinha R, Raut S. Pediatric lupus nephritis: Management update. World J Nephrol. 2014 May 6;3(2):16-23.

Childhood-onset systemic lupus erythematosus (cSLE) is a severe multisystem autoimmune disease. Renal involvement occurs in the majority of cSLE patients and is often fatal. Renal biopsy is an important investigation in the management of lupus nephritis. Treatment of renal lupus consists of an induction phase and maintenance phase. Treatment of childhood lupus nephritis using steroids is associated with poor outcome and excess side-effects. The addition of cyclophosphamide to the treatment schedule has improved disease control. In view of treatment failure using these drugs and a tendency for non-adherence, many newer agents such as immune-modulators and monoclonal antibodies are being tried in patients with cSLE. Trials of these novel agents in the pediatric population are still lacking making a consensus in the management protocol of pediatric lupus nephritis difficult.

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Antibiotic prophylaxis for urinary tract infections

Brandström P, Hansson S. Long-term, low-dose prophylaxis against urinary tract infections in young children. Pediatr Nephrol. 2015 Mar;30(3):425-32.

Urinary tract infection (UTI) affects about 2 % of boys and 8 % of girls during the first 6 years of life with Escherichia coli as the predominant pathogen. Symptomatic UTI causes discomfort and distress, and carries a risk of inducing renal damage. The strong correlation between febrile UTI, dilating vesicoureteral reflux (VUR), and renal scarring led to the introduction of antibiotic prophylaxis for children with VUR to reduce the rate of UTI recurrence. It became common practice to use prophylaxis for children with VUR and other urinary tract abnormalities. This policy has been challenged because of a lack of scientific support. Now, randomized controlled studies are available that compare prophylaxis to no treatment or placebo. They show that children with normal urinary tracts or non-dilating VUR do not benefit from prophylaxis. Dilating VUR may still be an indication for prophylaxis in young children. After the first year of life, boys have very few recurrences and do not benefit from prophylaxis. Girls with dilating VUR, on the other hand, are more prone to recurrences and benefit from prophylaxis. There has been a decline in the use of prophylaxis due to questioning of its efficacy, increasing bacterial resistance, and a propensity to low adherence to medication. Alternative measures to reduce UTI recurrences should be emphasized. However, in selected patients carefully followed, prophylaxis can protect from recurrent UTI and long-term sequelae. 1. There is a strong correlation between UTI, VUR, and renal scarring. 2. Children with normal urinary tracts or non-dilating VUR do not benefit from prophylaxis. 3. Young children, mainly girls, with dilating VUR are at risk of recurrent UTI and acquired renal scarring and seem to gain from antibiotic prophylaxis. 4. Increasing bacterial resistance and low adherence with prescribed medication is a major obstacle to successful antibiotic prophylaxis.

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Summer injuries and accidents

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Krau SD. Summer activities: incidents and accidents. Crit Care Nurs Clin North Am. 2013 Jun;25(2):287-95.

  • Summer is a season of unique activities and unique injuries.
  • Pathophysiologic features and treatments are different for victims of freshwater and saltwater drowning.
  • Treatment of drowning victims involves a comprehensive set of interventions and monitoring protocols.
  • Males are more prone to water-related injuries and accidents than females.
  • Drowning is a leading cause of death for children 0 to 4 years of age.
  • Most burns in adults are the result of accelerant use, and usually involve alcohol.
  • Children can experience severe campfire burns hours after the fire is believed to be extinguished.

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Previous related PBLs and posts:

Practice Based Learning: Pediatric drowning.

Article of Interest: Drowning.

Practice Based Learning: Indications for use of antivenom and antibiotics in snake bites.

Soft tissue infections caused by waterborne bacterial pathogens.

Management of bite wounds.

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