Diagnosing meningitis: biomarkers and clinical prediction rules

Sanaei Dashti A, et al. Diagnostic value of lactate, procalcitonin, ferritin, serum-C-reactive protein, and other biomarkers in bacterial and viral meningitis: A cross-sectional study. Medicine (Baltimore). 2017 Sep;96(35):e7637.

There are many difficulties distinguishing bacterial from viral meningitis that could be reasonably solved using biomarkers. The aim of this study was to evaluate lactate, procalcitonin (PCT), ferritin, serum-CRP (C-reactive protein), and other known biomarkers in differentiating bacterial meningitis from viral meningitis in children.All children aged 28 days to 14 years with suspected meningitis who were admitted to Mofid Children’s Hospital, Tehran, between October 2012 and November 2013, were enrolled in this prospective cross-sectional study. Children were divided into 2 groups of bacterial and viral meningitis, based on the results of cerebrospinal fluid (CSF) culture, polymerase chain reaction, and cytochemical profile. Diagnostic values of CSF parameters (ferritin, PCT, absolute neutrophil count [ANC], white blood cell count, and lactate) and serum parameters (PCT, ferritin, CRP, and erythrocyte sedimentation rate [ESR]) were evaluated.Among 50 patients with meningitis, 12 were diagnosed with bacterial meningitis. Concentrations of all markers were significantly different between bacterial and viral meningitis, except for serum (P = .389) and CSF (P = .136) PCT. The best rates of area under the receiver operating characteristic (ROC) curve (AUC) were achieved by lactate (AUC = 0.923) and serum-CRP (AUC = 0.889). The best negative predictive values (NPV) for bacterial meningitis were attained by ANC (100%) and lactate (97.1%).The results of our study suggest that ferritin and PCT are not strong predictive biomarkers. A combination of low CSF lactate, ANC, ESR, and serum-CRP could reasonably rule out the bacterial meningitis.

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Sigmoid volvulus

Gunasekaran SS, et al. Common Presentation of a Common Disease in an Unusual Age. J Pediatr. 2017 Jun;185:247-247.e1.

“Although sigmoid volvulus is well reported among adults, it is uncommon among children and occurs when the sigmoid colon wraps around the mesentery, leading to an obstruction. 12 The main risk factor for sigmoid volvulus among children is colonic dysmotility, as seen with chronic constipation. Imaging findings on both AXR and CT are similar and specific for sigmoid volvulus, although a diagnosis can be made with AXR alone, with CT reserved for cases of equivocal findings. On both modalities, a distended and displaced sigmoid colon with transition to a decompressed rectum is diagnostic for sigmoid volvulus. 3 These findings must be differentiated from cecal volvulus, where the transition point is noted within a displaced cecum. Unlike cecal volvulus, which requires surgical intervention, most cases of sigmoid volvulus can be treated with endoscopic decompression and the placement of a rectal tube. Early diagnosis of the sigmoid volvulus is critical because delay can lead to ischemia, perforation, peritonitis, and death.”

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Colinet S, et al. Presentation and endoscopic management of sigmoid volvulus in children. Eur J Pediatr. 2015 Jul;174(7):965-9.

Although rare in children, sigmoid volvulus should be advocated when abdominal pain is associated with dilated sigmoid loops. Sigmoidoscopic exsufflation can be considered as the first-line management in the absence of perforation. However, sigmoidectomy is often required for prevention of recurrence.

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Parolini F, Alberti D. Sigmoid volvulus in children. Surgery. 2017 Feb;161(2):562-563.

Sigmoid volvulus is extremely rare in children and is usually associated with a long-standing history of constipation or pseudo-obstruction. 12 In these patients, redundant sigmoid colon could have a narrow mesenteric attachment to the posterior abdominal wall; this configuration allows close approximation of 2 limbs of sigmoid colon, making it prone to torsion around the mesenteric axis. Less frequently, other predisposing factors are Hirschsprungh’s disease and roundworm infestation, especially in smaller children. Presentations can range from acute to recurrent abdominal pain, often relieved by passage of stool or flatus. 23 Early diagnosis and management are crucial to preventing the appearance of hemorrhagic infarction of the twisted loop and avoiding further complications such as necrosis, perforation, and sepsis.

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Somatic symptom disorders

Malas N, et al. Pediatric Somatic Symptom Disorders. Curr Psychiatry Rep. 2017 Feb;19(2):11.

Somatic symptom disorder (SSD) is a common disorder encountered in pediatric medicine. It involves the presentation of physical symptoms that are either disproportionate or inconsistent with history, physical examination, laboratory, and other investigative findings. SSDs result in significant impairment with considerable increase in healthcare utilization, school absenteeism, and the potential for unnecessary diagnostic evaluation and treatment intervention. Patients and families often feel dismissed and may worry that a serious condition has been missed. Primary care providers are frequently frustrated due to a lack of a successful approach to patients and families impacted by SSD. The result is often a cycle of disability, frustration and missed opportunities for collaboration towards enhanced patient functionality. This review summarizes the current evidence-based understanding, as well as insights from clinician experience, on the evaluation and management of pediatric SSD.

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Serum sickness-like reaction

Yorulmaz A, et al. Demographic and clinical characteristics of patients with serum sickness-like reaction. Clin Rheumatol. 2017 Aug 9.

In this study, we aimed to review the demographic, clinical, and laboratory characteristics of patients who were followed up and treated with the diagnosis of serum sickness-like reactions (SSLR) in our pediatric rheumatology clinic retrospectively and emphasize the importance of early diagnosis and treatment. The files of 29 patients who were hospitalized in the pediatric rheumatology clinic between September 2016 and March 2017 with the diagnosis of type 3 hypersensitivity reaction were reviewed retrospectively. Patient records including C-reactive protein, erythrocyte sedimentation rate, serum electrolytes, blood glucose, urea, and liver function were recorded by using the computerized patient database. The gender, age, length of hospital stay, accompanying clinical findings, family history of atopy, preceding infection, and drug usage data were obtained from the files of the patients. Twenty-nine patients with the diagnosis of type 3 hypersensitivity reaction were evaluated. Fifteen (51.7%) of the patients were male and 14 (48.3%) were female. The male to female ratio was 1.07. The age distribution of patients ranged from 18 to 192 months (mean ± SD 100.66 ± 53.75 months). The hospitalization duration was 3-16 days (mean ± SD 5.14 ± 3.20 days). The use of many drugs, especially antibiotics, has increased even in the treatment of viral upper air way infections. As a result, side effects have also increased. The most important of these is SSLR. However, this disease is not well recognized by clinicians.

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Shiari R, et al. Clinical and laboratory profile of serum sickness-like reaction in children. Ind J Rheumatol. 2011 Dec; 6(4): 173-177.

“This study aims to determine the aetiological factors of serum sickness-like reaction, influence of age and sex, clinical manifestation, and lab findings of this disease during the time period between April 2009 and September 2010 in a university-affiliated children’s hospital.”

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Abusive head trauma

Shaahinfar A, et al. Update on abusive head trauma. Curr Opin Pediatr. 2015 Jun;27(3) :308-14.

This article provides an update on abusive head trauma (AHT), focusing on new developments most salient to the emergency medicine clinician, including epidemiology, clinical recognition, diagnostic work-up, management of neurologic injury, and public health implications.

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Greeley CS. Abusive head trauma: a review of the evidence base. AJR Am J
Roentgenol. 2015 May;204(5):967-73.

The purpose of this article is to review the constellation of findings of abusive head trauma, which may be accompanied by injuries to the appendicular and axial skeleton, brain and spinal cord, and retina. Additional common features include skin and soft-tissue injury, visceral findings, and evidence of oral trauma.

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Evaluation of abnormal liver function tests

Lamireau T, et al. A practical approach to the child with abnormal liver tests. Clin Res Hepatol Gastroenterol. 2014 Jun;38(3):259-62.

The presence of elevated aminotransferases on routine blood tests can reveal liver diseases of various severities. In children, etiologies are more numerous and complex than those usually considered in adults. Information derived from family and personal history, physical examination and basic laboratory data are necessary to reach a timely and correct diagnosis. A stepwise approach is proposed to guide the timing of more specific investigations that are often required.

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Autoimmune hemolytic anemia

Liebman HA, Weitz IC. Autoimmune Hemolytic Anemia. Med Clin North Am. 2017 Mar;101(2):351-359.

Autoimmune hemolytic anemia is an acquired autoimmune disorder resulting in the production of antibodies directed against red blood cell antigens causing shortened erythrocyte survival. The disorders can present as a primary disorder (idiopathic) or secondary to other autoimmune disorders, malignancies, or infections. Treatment involves immune modulation with corticosteroids and other agents.

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Sankaran J, et al. Autoimmune Hemolytic Anemia in Children: Mayo Clinic Experience. J Pediatr Hematol Oncol. 2016 Apr;38(3):e120-4.

We studied 35 pediatric patients with autoimmune hemolytic anemia seen at Mayo Clinic from 1994 to 2014. The median age was 10.0 years and 65.7% were males. Most had warm antibodies (80.0%) and some secondary to viral (14.3%) or autoimmune disorders (31.4%). Seven (20.0%) patients presented with Evans syndrome, 3 of whom also had common variable immunodeficiency. The median hemoglobin at diagnosis was 6.1 g/dL and 62.8% patients required red cell transfusions. The severity of anemia was worse among children below 10 years (median 5.5 vs. 7.0 g/dL, P=0.01). Steroid was the initial treatment for 88.5% patients, with overall response rate of 82.7% (68.5% complete, 14.2% partial) and median response duration of 10.7 months (range, 0.2 to 129.7+ mo). After median follow-up of 26.6 months, 8 (22.8%) patients relapsed. Salvage treatments included splenectomy, intravenous immunoglobulin, rituximab, and mycophenolate mofetil. Infectious complications occurred in 9 (25.7%) patients and 1 patient died of cytomegalovirus infection. Four patients had cold agglutinin disease and 3 (75.0%) responded to steroids. Autoimmune hemolytic anemia is a rare disorder in pediatric population and most respond well to steroids regardless of the type of antibody. Infectious complications are common and screening for immunodeficiency is recommended among those with Evans syndrome.

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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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