Menstrual toxic shock syndrome

Mortensen N, Dizdarevic E. A girl in her teens with recurrent fever, abdominal pain and diarrhoea. Tidsskr Nor Laegeforen. 2019 Feb 8;139(3).

“Of menstruating women, 70-80% have developed antibodies to toxic shock syndrome toxin-1 when late in their teens, and in the 40s this has risen to 90-95%. People with toxic shock syndrome more often have lower antibody levels than others and also have an impaired ability to form antibodies after an illness episode. This explains why some people are at risk of relapse [13].

Toxic shock syndrome related to tampon use is still relevant as differential diagnosis of abdominal pain, fever and diarrhea in adolescents and young adults. Early diagnosis and treatment are important for the course.”

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Local anesthetic systemic toxicity (LAST)

Gitman M, et al. Local Anesthetic Systemic Toxicity: A Narrative Literature Review and Clinical Update on Prevention, Diagnosis, and Management. Plast Reconstr Surg. 2019 Sep;144(3):783-795.

Between March of 2014 and November of 2016, there were 47 cases of systemic toxicity described. Twenty-two patients (47 percent) were treated with intravenous lipid emulsion and two patients (4.3 percent) died. Seizures were the most common presentation. The spectrum of presenting neurologic and cardiovascular symptoms and signs are broad and can be obscured by perioperative processes. Local anesthetic type, dosage, and volume; site of injection; and patient comorbidities influence the rate of absorption from the site of injection and biodegradation of local anesthetics. Consider discussing appropriate dosages as a component of the surgical “time-out.” A large-volume depot of dilute local anesthetic can take hours before reaching peak plasma levels. Oxygenation, ventilation, and advanced cardiac life support are the first priorities in treatment. Lipid emulsion therapy should be given at the first sign of serious systemic toxicity with an initial bolus dose of 100 ml for adults weighing greater than 70 kg and 1.5 ml/kg for adults weighing less than 70 kg or for children.

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Choosing Wisely

Choosing Wisely is an initiative of the ABIM Foundation that seeks to advance a national dialogue on avoiding unnecessary medical tests, treatments and procedures

Choosing Wisely: Things We Do For No Reason: “Inspired by the ABIM Foundation’s Choosing Wisely® campaign, the “Things We Do for No Reason™” (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.”

Healthcare Bluebook: “Save money and find high-quality providers with Healthcare Bluebook’s online healthcare shopping solution. Bluebook’s Fair Price™ is the reasonable amount you should pay for a medical service. It’s calculated from a nationwide database of medical payment data and customized to your geographic area.”

Erythema nodosum

Ozbagcivan O, et al. Examination of the Microbial Spectrum in the Etiology of Erythema Nodosum: A Retrospective Descriptive Study. J Immunol Res. 2017; 2017:8139591.

Even though infections are the most common cause of erythema nodosum (EN), only certain microorganisms take the great interest such as streptococci in knowledge. Our aim was to examine the frequency and type of infections in EN, to determine the characteristics of patients with an infectious etiology, and to discuss the role of these microbes in EN pathology in the context of their interactions with humans. Charts of 81 patients with EN who were seen between 2003 and 2017 were retrospectively reviewed. Identified etiological factors were classified into three groups: infectious, noninfectious, and idiopathic. While there were no significant demographic and clinical differences between the infectious and idiopathic groups, systemic symptoms (p = 0.034) and the number of EN lesions (p = 0.016) were significantly lower; the mean erythrocyte sedimentation rate was significantly higher (p = 0.049), but the mean aspartate aminotransferase value was significantly lower in the infectious group compared to the noninfectious group (p = 0.019). Besides streptococci, many other microbes, including the ones living on and inside us, were identified in the etiology of EN. There is a need for large-scale prospective studies involving control groups for a better understanding of the microbial immunopathology of EN.

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Vesicles and pustules in the newborn infant

Manice CS, et al Management of afebrile neonates with pustules and vesicles in a pediatric emergency department. Pediatr Dermatol. 2018 Sep;35(5):660-665.

“Based on our present data and the results of prior retrospective studies [4,5] it seems that afebrile neonates with pustules alone without any clinical suspicion for HSV may not require a full SBI examination as long as they can be monitored by responsible caregivers for the development of any signs of SBI. Our data suggest that surface bacterial cultures can be useful to confirm suspicion of staphylococcal pustulosis and could potentially dimish the use of more‐invasive testing. On routine surface cultures, especially in the diaper area, there is risk of contamination with nonpathogenic skin or gut flora, such as Klebsiella or Enterococcus spp., which may lead to unnecessary interventions if taken out of clinical context. Thus, bacterial surface culture should be used judiciously, bearing in mind the clinical picture. Although these retrospective data show these contaminants, our laboratory now performs specific skin cultures reporting only gram‐positive skin pathogens, to minimize possible confusion.”

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Mogre DA. Generalised staphylococcal pustulosis in a neonate: A case report. Australas Med J. 2013 Oct 31;6(10):532-5.

Pustular eruptions in a neonate are mostly benign, but several are serious and have infectious aetiology. A detailed history, complete physical examination and careful assessment of the lesions are essential for diagnosis. The need to investigate every neonate with pustules for an infectious aetiology is emphasised. This case of generalised pustulosis in a neonate is reported as it is an uncommon presentation of Staphylococcus aureus infection, diagnostic difficulty caused by atypical skin lesions and similarity of clinical features with other causes of neonatal pustular diseases.

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Genetic predisposition for recurrent rhabdomyolysis

Scalco RS, et al. Rhabdomyolysis: a genetic perspective. Orphanet J Rare Dis. 2015 May 2;10:51.

Rhabdomyolysis (RM) is a clinical emergency characterized by fulminant skeletal muscle damage and release of intracellular muscle components into the blood stream leading to myoglobinuria and, in severe cases, acute renal failure. Apart from trauma, a wide range of causes have been reported including drug abuse and infections. Underlying genetic disorders are also a cause of RM and can often pose a diagnostic challenge, considering their marked heterogeneity and comparative rarity.In this paper we review the range of rare geneticdefects known to be associated with RM. Each gene has been reviewed for the following: clinical phenotype, typical triggers for RM and recommended diagnostic approach. The purpose of this review is to highlight the most important features associated with specific genetic defects in order to aid the diagnosis of patients presenting with hereditary causes of recurrent RM.

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Practice Based Learning: Rhabdomyolysis: Complications and management in children






Presented by Collin Dubick MD (as PGY-1, 2016)


  • Muscle cell breakdown with intracellular leakage
    • Mechanical stress: viral, alcohol/drugs, overuse, crush, burn, pressure
    • Cell membrane damage
    • Intracellular leakage (Myoglobin, CK, Phosphate, K+)


  • Presenting symptoms: muscle pain/weakness, fever, viral symptoms, dark urine
  • Elevated CK
    • Peaks in 2-3 days post injury
    • Myoglobin rises/falls first
  • Urinary dipstick positive for blood/heme with scant/no RBCs, indicating myoglobinuria

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Neonatal hemophagocytic lymphohistiocytosis

McLean J, et al. Neonatal Hemophagocytic Lymphohistiocytosis. Neoreviews. 2019 Jun;20(6):e316-e325.

Hemophagocytic lymphohistiocytosis (HLH) is extremely rare in the neonatal period. The incidence of neonatal HLH is not confirmed and may range from 1 in 50,000 to 150,000. The incidence varies based on ethnicity, particularly in populations in which consanguinity is common. HLH is associated with a high fatality rate and poor prognosis, making it important to recognize and diagnose it early. This review will concentrate primarily on the diagnosis and management of neonatal HLH.

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AAP PCO Webinar: What Every Pediatrician Needs to Know About Child Passenger Safety

Wednesday, August 21, 2019
1:00 – 2:00 pm EDT

We invite you to join us tomorrow when Benjamin Hoffman, MD, FAAP, CPST-I discusses child passenger safety.

By the end of this webinar, viewers should be able to:

  1. Discuss basic principles of child passenger safety (CPS) science, including:
    • Epidemiology
    • Physics
    • Anatomy and physiology of children
    • Crash dynamics
  2. List 5 ways car safety seats help prevent injury to children.
  3. Discuss best practice recommendations for appropriate child passenger restraint.
  4. Identify and access CPS resources in your community, including for children with special health care needs.

To view the webinar on Wednesday, August 21, please click here or use the following url:

Unable to view the webinar live or have you missed past webinars?
All PCO webinars are archived at:

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Cavitary lung lesions

Gafoor K, et al. Cavitary Lung Diseases: A Clinical-Radiologic Algorithmic Approach. Chest. 2018 Jun;153(6):1443-1465.

Cavities occasionally are encountered on thoracic images. Their differential diagnosis is large and includes, among others, various infections, autoimmune conditions, and primary and metastatic malignancies. We offer an algorithmic approach to their evaluation by initially excluding mimics of cavities and then broadly classifying them according to the duration of clinical symptoms and radiographic abnormalities. An acute or subacute process (< 12 weeks) suggests common bacterial and uncommon nocardial and fungal causes of pulmonary abscesses, necrotizing pneumonias, and septic emboli. A chronic process (≥ 12 weeks) suggests mycobacterial, fungal, viral, or parasitic infections; malignancy (primary lung cancer or metastases); or autoimmune disorders (rheumatoid arthritis and granulomatosis with polyangiitis). Although a number of radiographic features can suggest a diagnosis, their lack of specificity requires that imaging findings be combined with the clinical context to make a confident diagnosis.

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