Necrotizing pneumonia

Masters IB, et al. Necrotizing pneumonia: an emerging problem in children? Pneumonia (Nathan). 2017 Jul 25;9:11.

“NP is an uncommon but increasingly recognized severe complication of pneumonia in previously healthy young children. The major pathogens are S. pneumoniae and S. aureus and the diagnosis should be considered when, despite appropriate antibiotics, the child remains febrile and unwell with persistent signs of respiratory distress and pneumonia. Most will have a PPE, empyema and/or BPF that has not improved despite chest drainage or surgical intervention. The diagnosis is confirmed by chest imaging, usually by a CT scan or sonography, while treatment requires prolonged IV antibiotics, which can be changed to oral medication for an additional 10–14 days, once the child is afebrile and clinically stable. Ideally, surgical intervention is kept to a minimum, but this is not always possible if there are mass effects from gas and fluid in the pleural cavity or pulmonary gangrene leading to massive hemoptysis, uncontrolled sepsis, or difficulties with assisted ventilation. Nevertheless, despite its severity, mortality in children is uncommon; the children improve clinically within a couple of months, radiographic changes are largely resolved after 5–6 months, and only a minority are left with mildly impaired lung function. Important targets for future research include identifying host–pathogen interactions leading to disease, improving the microbiologic diagnostic gap, optimizing medical and surgical management, and ultimately preventing this severe complication of pediatric pneumonia.”

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Adverse effects of synthetic cannabinoids

Baum RA, et al. Suspected synthetic cannabinomimetic intoxication. J Pharm Pract. 2017 Jan 1:897190017699761.

Recent legislation has failed to curb the public health concerns emanating from SC misuse. Education about the risks of SC use along with additional regulation may be required to remove the false sense of safety that some individuals, especially adolescents and young adults, may associate with these compounds, which are often misconstrued as “herbal marijuana.” Clinicians need to be prepared to identify and treat symptoms of SC intoxication as incidents of toxicity continue to rise.

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Castellanos D, Gralnik LM. Synthetic cannabinoids 2015: An update for pediatricians in clinical practice. World J Clin Pediatr. 2016 Feb 8;5(1):16-24.

Synthetic cannabinoids are a group of substances that are typically much more potent than natural cannabis. These substances have been increasingly abused by youth over the past few years. A number of published reports have emerged documenting the serious health consequences associated with use of these products. Seizures, myocardial infarction and renal damage are some of the significant physical consequences associated with their use. With current limitations of toxicological analyses pediatricians are urged to familiarize themselves with these drugs and the typical presentations of patients who use them.

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Spasmus nutans

Delorme C, Gras D, Roze E. Spasmus nutans: more than meets the eye. Pediatr
Neurol. 2015 Oct;53(4):367-8.

“Spasmus nutans is a rare transient movement disorder of early childhood, defined by the clinical triad (1) nystagmus, (2) head nodding, and (3) torticollis, in the absence of any associated ophthalmological or neurological condition. [1] This condition might be difficult to recognize and is rarely reported in the literature.”

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Staphylococcal scalded skin syndrome

Mishra AK, et al. A Systemic Review on Staphylococcal Scalded Skin Syndrome (SSSS): A Rare and Critical Disease of Neonates. Open Microbiol J. 2016 Aug 31;10:150-9.

The symptoms of Staphylococcal scalded skin syndrome (SSSS) include blistering of skin on superficial layers due to the exfoliative toxins released from Staphylococcus aureus. After the acute exfoliation of skin surface, erythematous cellulitis occurs. The SSSS may be confined to few blisters localized to the infection site and spread to severe exfoliation affecting complete body. The specific antibodies to exotoxins and increased clearance of exotoxins decrease the frequency of SSSS in adults. Immediate medication with parenteral anti-staphylococcal antibiotics is mandatory. Mostly, SSSS are resistant to penicillin. Penicillinase resistant synthetic penicillins such as Nafcillin or Oxacillin are prescribed as emergency treatment medicine. If Methicillin-resistant Staphylococcus aureus (MRSA) is suspected), antibiotics with MRSA coverage (e.g., Vancomycin or Linezolid) are indicated. Clindamycin is considered as drug of choice to stop the production of exotoxin from bacteria ribosome. The use of Ringer solution to to balance the fluid loss, followed by maintenance therapy with an objective to maintain the fluid loss from exfoliation of skin, application of Cotrimoxazole on topical surface are greatly considered to treat the SSSS. The drugs that reduce renal function are avoided. Through this article, an attempt has been made to focus the source, etiology, mechanism, outbreaks, mechanism, clinical manifestation, treatment and other detail of SSSS.

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Braunstein I, et  al. Antibiotic sensitivity and resistance patterns in pediatric staphylococcal scalded skin syndrome. Pediatr Dermatol. 2014 May-Jun;31(3):305-8.

Historical resistance patterns often guide empiric antibiotic choices in staphylococcal scalded skin syndrome (SSSS), but little is known about the difference in susceptibility between SSSS and other childhood staphylococcal infections. A retrospective chart review of culture-confirmed cases of SSSS seen in the inpatient dermatology consultation service at the Children’s Hospital of Philadelphia between 2005 and 2011 was performed. Most cases of SSSS at our institution are due to oxacillin-susceptible Staphylococcus aureus, and approximately half of the cases are due to clindamycin-resistant strains. Clindamycin and a penicillinase-resistant penicillin are suggested as empiric treatment for SSSS until culture susceptibility data are available to guide therapy.

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The utility of blood cultures in pyelonephritis

Kim Y, et al. Usefulness of Blood Cultures and Radiologic Imaging Studies in the Management of Patients with Community-Acquired Acute Pyelonephritis. Infect Chemother. 2017 Mar;49(1):22-30.

APN is diagnosed by clinical signs and symptoms of upper urinary tract infection, and isolation of the pathogen from urine [4]. In clinical practice, blood cultures and radiologic imaging studies such as CT are commonly used [5,6,13]. Although these tests have been performed on a substantial number of patients, there has been controversy as to their accuracy and usefulness. The purpose of this study was to evaluate the impact of blood cultures and radiologic tests on the management of CA-APN patients.

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Polymicrogyria

Shain C, et al. Polymicrogyria-associated epilepsy: a multicenter phenotypic study from the Epilepsy Phenome/Genome Project. Epilepsia. 2013 Aug;54(8):1368-75.

Polymicrogyria (PMG) is an epileptogenic malformation of cortical development. We describe the clinical epilepsy and imaging features of a large cohort with PMG-related epilepsy.

Participants with PMG had both focal and generalized onset of seizures. Our data confirm the involvement of known topographic patterns of PMG and suggest that more extensive distributions of PMG present with an earlier age of seizure onset and increased prevalence of developmental delay prior to seizure onset.

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Barkovich AJ. Current concepts of polymicrogyria. Neuroradiology. 2010 Jun;52(6):479-87.

Polymicrogyria is one of the most common malformations of cortical development. It has been known for many years and its clinical and MRI manifestations are well described. Recent advances in imaging, however, have revealed that polymicrogyria has many different appearances on MR imaging, suggesting that is may be a more heterogeneous malformation than previously suspected. The clinical and imaging heterogeneity of polymicrogyria is explored in this review.

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Neonatal hyperbilirubinemia

Itoh S, et al. Phototherapy for neonatal hyperbilirubinemia. Pediatr Int. 2017 May 31.

About 60 years ago in England, phototherapy for neonatal hyperbilirubinemia was actually used in clinical practice. It was introduced in Japan about 50 years ago. However, the mechanism of how the serum bilirubin concentration was decreased by the phototherapy was still unknown. The mechanism was identified by chemists, biochemists, and pediatricians. Clarification started with the report that unconjugated bilirubin was excreted into bile after the photoirradiation of Gunn rats. After the molecular conformation of bilirubin by X-ray analysis, the mechanism for bile excretion of unconjugated bilirubin was verified based on geometric configurational photoisomers in the Gunn rat. Finally, the reaction and excretion of structural bilirubin photoisomers was proved to be the main mechanism for the decrease in serum bilirubin during phototherapy for neonatal hyperbilirubinemina, which differs from the mechanism in the Gunn rat. However, the most effective and safest light source and the optimal method to evaluate phototherapy remain unknown. Moreover, as for bronze baby syndrome which is a well-known adverse reaction to phototherapy, the substances as the etiological origin are unclear. Hence, we review phototherapy for hyperbilirubinemia including a fundamental understanding of the bilirubin photochemical reactions, and discuss the subclinical carcinogenic risk of phototherapy and the increased mortality rate of extremely very low birth weight infants due to aggressive phototherapy, which is becoming a problem an increasing.

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Maisels MJ. Managing the jaundiced newborn: a persistent challenge. CMAJ. 2015
Mar 17;187(5):335-43.

“In this review, I present an approach to managing the jaundiced newborn that is based on published guidelines. [2-5] The aim is to help clinicians identify and manage jaundice in the newborn, intervene when appropriate and, when possible, prevent bilirubin-induced brain damage. It would be ideal if the published guidelines for the management of hyperbilirubinemia, including treatment with phototherapy and exchange transfusion, were based on estimates of when the benefit of these interventions exceeded their risks and costs. These estimates should come from randomized trials or high-quality, systematic observational studies, but such studies are rare. Guidelines must therefore rely on relatively uncertain estimates of risk and benefits, often from conflicting results.”

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Concurrent viral infections and Kawasaki disease

Song E, et al. Clinical and virologic characteristics may aid distinction of acute adenovirus disease from Kawasaki disease with incidental adenovirus detection. J Pediatr. 2016 Mar;170:325-30.

Incidental adenovirus detection in Kawasaki disease (KD) is important to differentiate from acute adenovirus disease. Twenty-four of 25 children with adenovirus disease and mimicking features of KD had <4 KD-like features, predominance of species B or E, and higher viral burden compared with those with KD and incidental adenovirus detection.

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Turnier JL, et al. Concurrent respiratory viruses and Kawasaki disease. Pediatrics. 2015 Sep;136(3):e609-14.

“Overall, our study supports earlier evidence that a large number of patients with KD have respiratory symptoms and evidence of viral nucleic acid in the nasopharynx. This study showed that a large percentage of patients with KD have a concurrent or recent history of respiratory viral infections and suggests that clinicians should not dismiss the diagnosis of KD based on the presence of respiratory or gastrointestinal symptoms or solely on the results of a positive respiratory viral PCR test. Furthermore, our data support the recommendation that a positive respiratory virus test result, regardless of the virus detected, should not be used to exclude the diagnosis of KD.4,16 Continued research is needed to elucidate the etiology and/or discover a more sensitive and specific diagnostic test for this important pediatric disease.”

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Pericarditis

Bergmann KR, et al. Myocarditis and pericarditis in the pediatric patient: validated management strategies. Pediatr Emerg Med Pract. 2015 Jul;12(7):1-22; quiz 23.

Myocarditis and pericarditis are inflammatory conditions of the heart commonly caused by viral and autoimmune etiologies, although many cases are idiopathic. Emergency clinicians must maintain a high index of suspicion for these conditions, given the rarity and often nonspecific presentation in the pediatric population. Children with myocarditis may present with a variety of symptoms, ranging from mild flu-like symptoms to overt heart failure and shock, whereas children with pericarditis typically present with chest pain and fever. The cornerstone of therapy for myocarditis includes aggressive supportive management of heart failure, as well as administration of inotropes and antidysrhythmic medications, as indicated. Children often require admission to an intensive care setting. The acute management of pericarditis includes recognition of tamponade and, if identified, the performance of pericardiocentesis. Medical therapies may include nonsteroidal anti-inflammatory drugs and colchicine, with steroids reserved for specific populations. This review focuses on the evaluation and treatment of children with myocarditis and/or pericarditis, with an emphasis on currently available medical evidence.

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Lead poisoning

Dapul H, Laraque D. Lead poisoning in children. Adv Pediatr. 2014 Aug;61(1):313-33.

“The management of patients with lead exposure involves not only the pharmacologic management of toxicity, but also strategies for intervention and prevention of further exposure. Once an elevated lead level is found, the local health department should be notified and a home risk assessment should be performed to determine the need for abatement strategies. With the gradual lowering of the “BLL of concern” by the CDC, the threshold for action has decreased as well. The Pediatric Environmental Health Specialty Unit Network has made recommendations on further evaluation and/or intervention based on the BLL, as outlined in Table 6 [46] .”

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