Preseptal cellulitis

Santos JC, et al. Pediatric preseptal and orbital cellulitis: A 10-year experience. Int J Pediatr Otorhinolaryngol. 2019 May;120:82-88.

“Preseptal and orbital infections are distinct diseases, in which orbital septum is the dividing reference point [ 8 ]. Although preseptal cellulitis is generally a mild condition that rarely leads to serious complications, orbital cellulitis represents a serious infection with potential catastrophic complications such as visual loss, intracranial infection and death [ [ 2 , 9 ]]. The differential diagnosis between these two conditions can be challenging, since the clinical manifestations with periorbital erythema and edema are similar. However, some clinical signs can help to differentiate both conditions: ocular pain and fever can be present in both, but are more frequent in orbital cellulitis; proptosis, diplopia, diminished visual acuity, abnormal pupillary reflex, ophthalmoplegia, chemosis and pain with eye movements are signs suggesting orbital involvement and predict postseptal involvement/orbital cellulitis [ 7 ]. These signs should be evaluated in every patients presenting with periorbital erythema and edema. In our study we confirmed that the exclusion of those signs of orbital involvement in the initial evaluation of the patient was strongly associated with the diagnosis of preseptal cellulitis (p = 0.001). An accurate ophthalmologic examination is therefore crucial.”

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Catatonia

Sorg EM, et al. Pediatric Catatonia: A Case Series-Based Review of Presentation, Evaluation, and Management. Psychosomatics. 2018 Nov;59(6):531-538.

Untreated catatonia can be a lethal childhood psychiatric illness and there is a small, but increasing, amount of literature related to its clinical manifestations and treatment. Given its prevalence and treatability, pediatric catatonia ought to be regularly considered by all clinicians whose clinical duties include the care of children and adolescents. Psychiatrists working in a C-L setting may also be asked by their colleagues to guide the diagnosis and treatment of pediatric catatonia, and should thus be comfortable with the unique considerations of this disease as well as its overlap with catatonia in adults.

We present 6 cases from our pediatric C-L psychiatry service at a general hospital to illustrate the presentation, evaluation, and management of catatonia in this population.

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MMWRs of Interest: Congenital Syphilis

Slutsker JS, et al. Factors Contributing to Congenital Syphilis Cases – New York City, 2010-2016. MMWR Morb Mortal Wkly Rep. 2018 Oct 5;67(39):1088-1093.

Congenital syphilis occurs when syphilis is transmitted from a pregnant woman to her fetus; congenital syphilis can be prevented through screening and treatment during pregnancy. Transmission to the fetus can occur at any stage of maternal infection, but is more likely during primary and secondary syphilis, with rates of transmission up to 100% at these stages (1). Untreated syphilis during pregnancy can cause spontaneous abortion, stillbirth, and early infant death. During 2013-2017, national rates of congenital syphilis increased from 9.2 to 23.3 cases per 100,000 live births (2), coinciding with increasing rates of primary and secondary syphilis among women of reproductive age (3). In New York City (NYC), cases of primary and secondary syphilis among women aged 15-44 years increased 147% during 2015-2016. To evaluate measures to prevent congenital syphilis, the NYC Department of Health and Mental Hygiene (DOHMH) reviewed data for congenital syphilis cases reported during 2010-2016 and identified patient-, provider-, and systems-level factors that contributed to these cases. During this period, 578 syphilis cases among pregnant women aged 15-44 years were reported to DOHMH; a congenital syphilis case was averted or otherwise failed to occur in 510 (88.2%) of these pregnancies, and in 68, a case of congenital syphilis occurred (eight cases per 100,000 live births).* Among the 68 pregnant women associated with these congenital syphilis cases, 21 (30.9%) did not receive timely (≥45 days before delivery) prenatal care. Among the 47 pregnant women who did access timely prenatal care, four (8.5%) did not receive an initial syphilis test until <45 days before delivery, and 22 (46.8%) acquired syphilis after an initial nonreactive syphilis test. These findings support recommendations that health care providers screen all pregnant women for syphilis at the first prenatal care visit and then rescreen women at risk in the early third trimester.

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Bowen V, Su J, et al. Increase in incidence of congenital syphilis – United States, 2012-2014. MMWR Morb Mortal Wkly Rep. 2015 Nov 13; 64(44) :1241-5.

Congenital syphilis (CS) occurs when a mother infected with syphilis transmits the infection to her child during pregnancy. CS can cause severe illness, miscarriage, stillbirth, and early infant death. However, among pregnant women with syphilis who deliver after 20 weeks gestation, maternal treatment with penicillin is 98% effective at preventing CS (1). In the United States, the rate of CS decreased during 1991–2005 but increased slightly during 2005–2008 (2). To assess recent trends in CS, CDC analyzed national surveillance data reported during 2008–2014, calculated rates, and described selected characteristics of infants with CS and their mothers. The overall rate of reported CS decreased from 10.5 to 8.4 cases per 100,000 live births during 2008–2012, and then increased to 11.6 cases per 100,000 live births in 2014, the highest CS rate reported since 2001. From 2012 to 2014, reported cases and rates of CS increased across all regions of the United States. To reduce CS, the timely identification of and response to increases in syphilis among women of reproductive age and men who have sex with women are essential. All women should have access to quality prenatal care, including syphilis screening and adequate treatment, during pregnancy (3).

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Impact of physician communication with vaccine-hesitant parents

de St Maurice A, et al. Addressing Vaccine Hesitancy in Clinical Practice. Pediatr Ann. 2018 Sep 1;47(9):e366-e370.

Vaccines have had a profound impact on public health; however, parents are increasingly refusing or delaying vaccines for their children. Population-based studies have demonstrated the safety and efficacy of vaccines. Pediatricians should be well informed about vaccine development, safety, and efficacy to inspire parental confidence in vaccines. Systemic challenges in discussing and providing immunizations exist. Discussions about immunizations may be lengthy and time spent discussing immunizations is not routinely reimbursed. Adolescents may be inadequately immunized because they do not routinely present for preventive health visits. Routine immunizations should be offered and discussed at sick visits, particularly for adolescents. Improving immunization rates requires a multifaceted approach.

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McClure CC, Cataldi JR, O’Leary ST. Vaccine Hesitancy: Where We Are and Where We Are Going. Clin Ther. 2017 Aug;39(8):1550-1562.

FINDINGS: Few evidence-based strategies exist to guide providers in their discussions with vaccines-hesitant parents. Recent research has shown a presumptive approach (ie, the provider uses language that presumes the caregiver will vaccinate his or her child) is associated with higher vaccination uptake. Motivational interviewing is a promising technique for more hesitant parents.

IMPLICATIONS: At the community level, evidence-based communication strategies to address vaccine hesitancy are needed. The practice of dismissing families from pediatric practices who refuse to vaccinate is common, although widely criticized. Other controversial and rapidly evolving topics include statewide vaccination mandates and school exemption policies. Electronic interventions, such as text-messaging services and social media, have recently emerged as effective methods of communication and may become more important in coming years.

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Article of interest: Measles, Mumps, Rubella Vaccination and Autism: A Nationwide Cohort Study.

Hviid A, Hansen JV, Frisch M, Melbye M. Measles, Mumps, Rubella Vaccination and Autism: A Nationwide Cohort Study. Ann Intern Med. 2019 Mar 5. [Epub ahead of print]

CONCLUSION: The study strongly supports that MMR vaccination does not increase the risk for autism, does not trigger autism in susceptible children, and is not associated with clustering of autism cases after vaccination. It adds to previous studies through significant additional statistical power and by addressing hypotheses of susceptible subgroups and clustering of cases.

PRIMARY FUNDING SOURCE: Novo Nordisk Foundation and Danish Ministry of Health.

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Article of interest: Neurodiagnostic evaluation of the child with a simple febrile seizure.

Subcommittee on Febrile Seizures; AAP. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011 Feb;127(2):389-94.

Clinicians evaluating infants or young children after a simple febrile seizure should direct their attention toward identifying the cause of the child’s fever. Meningitis should be considered in the differential diagnosis for any febrile child, and lumbar puncture should be performed if there are clinical signs or symptoms of concern. For any infant between 6 and 12 months of age who presents with a seizure and fever, a lumbar puncture is an option when the child is considered deficient in Haemophilus influenzae type b (Hib) or Streptococcus pneumoniae immunizations (ie, has not received scheduled immunizations as recommended), or when immunization status cannot be determined, because of an increased risk of bacterial meningitis. A lumbar puncture is an option for children who are pretreated with antibiotics. In general, a simple febrile seizure does not usually require further evaluation, specifically electroencephalography, blood studies, or neuroimaging.

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More PubMed results on Dx of febrile seizures.

Nontuberculous mycobacterial head and neck infections

Willemse SH, et al. Diagnosing nontuberculous mycobacterial cervicofacial lymphadenitis in children: A systematic review. Int J Pediatr Otorhinolaryngol. 2018 Sep;112:48-54.

In patients with a high clinical suspicion for NTM cervicofacial lymphadenitis, a positive PPD-S skin is indicative for the diagnosis of NTM cervicofacial lymphadenitis. Either PCR or culture is necessary to confirm the diagnosis. Interferon-γ release assays with purified protein derivative stimulation appear to provide good sensitivity and specificity as a non-invasive pre-operative test, but the evidence is weak. More studies of high methodological quality are needed to validate the results of this systematic review.

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Ludwig angina

An J, Singhal M. Ludwig Angina. 2018 Dec 6. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2018 Jan-.

Ludwig’s angina is a life-threatening cellulitis of the soft tissue involving the floor of the mouth and neck. It was named after a German physician, Wilhelm Friedrich von Ludwig who first described the condition in 1836.  It involves two compartments on the floor of the mouth namely sublingual and submaxillary space. It usually does not involve lymphatic system nor it forms abscess. Infection of the lower molars is the most common cause of Ludwig’s angina. The infection is rapidly progressive leading to aspiration pneumonia and airway obstruction.

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