Henoch–Schonlein purpura

Reid-Adam J. Henoch-Schonlein purpura. Pediatr Rev. 2014 Oct; 35(10) :447-9; discussion 449.

“The hallmark of HSP is cutaneous palpable purpura, often involving the lower extremities and buttocks. The appearance of the rash in this pattern reflects its tendency to distribute in pressure-dependent areas, so that in infants the rash may actually appear in upper body areas, such as the upper extremities or face. Lesions, which arise in crops and last 3 to 10 days, vary in size from petechiae to large, confluent, palpable ecchymoses. Although HSP is largely a clinical diagnosis, a skin biopsy specimen would reveal leukocytoclastic vasculitis or granulocytic infiltration of the small vessels, along with IgA deposition in the vessel walls. A nonpitting edema that involves the scalp, face, trunk, and/or extremities is also common, especially in infants and young children. This swelling does not correlate with the degree of proteinuria or level of serum albumin, although patients with HSP may also have pitting edema as a consequence of protein loss in the urine.”

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Diagnostic value of imaging for Guillain-Barre syndrome

Zuccoli G, et al. Redefining the Guillain-Barré spectrum in children: neuroimaging findings of cranial nerve involvement. AJNR Am J Neuroradiol. 2011 Apr;32(4):639-42.

“GBS and its MFS variant are acute polyneuropathies that are considered to represent a continuum rather than distinct entities, due to the overlap in their clinical features. Enhancement of the CE roots represents the neuroradiologic hallmark of GBS, while findings of neuroimaging studies in MFS are usually unremarkable. Our purpose was to evaluate the MR imaging findings of polyneuropathy in 17 children affected by GBS and its MFS variant. Fourteen of our 17 patients demonstrated CE  enhancement, with predominant involvement of the anterior roots. Of 6 patients who underwent MR imaging of the brain, 5 had cranial nerve involvement. In children affected by GBS-MFS, involvement of the CE roots may be considered part of a more extensive autoimmune neuropathy, as demonstrated by enhancement of cranial nerves. Brain MR imaging should be considered in the routine evaluation in pediatric patients with GBS-MFS for the evaluation of the cranial nerves.”

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Hematuria

Davis TK, Hmiel P. Pediatric Hematuria Remains a Clinical Dilemma. Clin Pediatr (Phila). 2015 Aug;54(9):817-30.

“Hematuria in the pediatric population is a common clinical dilemma for the clinician. The clinician should attempt to categorize it further into gross versus microscopic, symptomatic versus asymptomatic, and transient versus persistent. Gross hematuria if confirmed to be persistent, regardless of symptoms, almost always warrants further diagnostic testing. A standardized approach toward microscopic hematuria cannot be recommended. The differential diagnosis is too broad. Recommendations toward screening for asymptomatic hematuria have been dynamic, but currently, the AAP recommends against screening.4 Although it is never normal to have blood in the urine, isolated microscopic hematuria is rarely an indicator of significant kidney disease. Admittedly, this can be difficult to convey to skeptical patients and families, but invasive diagnostic procedures are unlikely to yield a treatable diagnosis or guide management. Reassurance is warranted. However, reassurance without periodic follow-up is no longer acceptable because long-term data have now identified an overall small but statistically significant risk of chronic kidney disease progression during long-term follow-up.”

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Staphylococcal coinfection in influenza

Morris DE, et al. Secondary bacterial infections associated with influenza pandemics. Front Microbiol. 2017 Jun 23;8:1041.

Lower and upper respiratory infections are the fourth highest cause of global mortality (Lozano et al., 2012). Epidemic and pandemic outbreaks of respiratory infection are a major medical concern, often causing considerable disease and a high death toll, typically over a relatively short period of time. Influenza is a major cause of epidemic and pandemic infection. Bacterial co/secondary infection further increases morbidity and mortality of influenza infection, with Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus reported as the most common causes. With increased antibiotic resistance and vaccine evasion it is important to monitor the epidemiology of pathogens in circulation to inform clinical treatment and development, particularly in the setting of an influenza epidemic/pandemic.

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Klein EY, et al. The frequency of influenza and bacterial coinfection: a systematic review and meta-analysis. Influenza Other Respir Viruses. 2016 Sep;10(5):394-403.

We found that bacterial coinfection of hospitalized patients with influenza is often common, although results were highly heterogeneous. The predominant coinfecting organism in the studies was S. pneumoniae followed by S. aureus, but many other organisms were also found to cause infections. Providers should consider possible bacterial coinfection in patients hospitalized with influenza, and bacterial cultures should be taken to avoid patient exposure to the risks of prolonged unnecessary antibiotic use. If antibiotic treatment is started, possible coinfection with MRSA should be considered, particularly for community‐acquired pneumonia infections, when selecting appropriate antibiotics, and therapy should be discontinued or de‐escalated as indicated by microbiological results. Finally, the frequency of coinfection should be better characterized in the entire influenza patient population, including outpatients, in future analyses.

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Incarcerated umbilical hernias

Abdulhai SA, et al. Incarcerated pediatric hernias. Surg Clin North Am. 2017 Feb;97(1) :129-145.

Presenting symptoms of umbilical hernia incarceration are those seen commonly with bowel obstruction, namely abdominal pain, nausea, and vomiting. Physical examination shows umbilical hernia, abdominal distention, and abdominal tenderness to palpation. There may be skin changes, such as erythema, associated with the umbilicus. [94,101,102,103,104] Although the traditional presentation is that of acute umbilical hernia incarceration, some patients have been observed to experience symptomatic, recurrent incarceration of umbilical hernia followed by spontaneous reduction. [100]

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Diagnostic utility of serum lipase for pancreatitis

Ismail OZ, Bhayana V. Lipase or amylase for the diagnosis of acute pancreatitis? Clin Biochem. 2017 Dec;50(18):1275-1280.

Acute pancreatitis is a rapid onset of inflammation of the pancreas causing mild to severe life threatening conditions [1, 2]. In Canada, acute pancreatitis is the 5th most expensive digestive disease in Canada with a considerable economic burden on the health care system [3]. The diagnosis of acute pancreatitis is usually based on the presence of abdominal pain and elevated levels of serum amylase and/or lipase. Many health care centers use either serum amylase, lipase or both to diagnose acute pancreatitis without considering which one could provide a better diagnostic accuracy. The aim of this review is to investigate whether serum lipase alone is a sufficient biomarker for the diagnosis of acute pancreatitis. We have examined various studies looking at the utilization, sensitivity, specificity and cost associated savings of lipase and amylase in the diagnosis of acute pancreatitis. When comparing different studies, serum lipase offers a higher sensitivity than serum amylase in diagnosing acute pancreatitis. Lipase also offers a larger diagnostic window than amylase since it is elevated for a longer time, thus allowing it to be a useful diagnostic biomarker in early and late stages of acute pancreatitis. Several recent evidence-based guidelines recommend the use of lipase over amylase. Nevertheless, both lipase and amylase alone lack the ability to determine the severity and etiology of acute pancreatitis. The co-ordering of both tests has shown little to no increase in the diagnostic sensitivity and specificity. Thus, unnecessary testing and laboratory expenditures can be reduced by testing lipase alone.

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Myocarditis

Di Filippo S. Improving outcomes of acute myocarditis in children. Expert Rev  Cardiovasc Ther. 2016;14(1):117-25.

Acute viral myocarditis may impair prognosis in children of all ages. Its true incidence is underestimated because of heterogeneity of presentation and outcome. Patients may either recover or progress to chronic cardiomyopathy or death. Improving short-term and long-term prognosis is challenging but can probably be achieved by new diagnostic techniques and novel targeted therapies. The objectives of this review are: (1) to detail the current state of knowledge of the pathophysiological mechanisms of acute myocarditis; (2) to provide an update on diagnostic tools such as magnetic resonance imaging and endomyocardial biopsy; and (3) to present new insights in therapeutic strategies, targeted therapies and management of fulminant cases. Options for improving outcomes in acute myocarditis in the pediatric population are discussed.

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Sialadenitis

Carlson ER, Ord RA. Benign Pediatric Salivary Gland Lesions. Oral Maxillofac Surg Clin North Am. 2016 Feb;28(1):67-81.

Salivary gland lesions are rare in pediatric patients. In addition, the types of salivary gland tumors are different in their distribution in specific sites in the major and minor salivary glands in children compared with adults. This article reviews benign neoplastic and nonneoplastic salivary gland disorders in pediatric patients to help clinicians to develop an orderly differential diagnosis that will lead to expedient treatment of pediatric patients with salivary gland lesions.

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Francis CL, Larsen CG. Pediatric sialadenitis. Otolaryngol Clin North Am. 2014 Oct; 47(5):763-78.

Sialadenitis in the pediatric population accounts for up to 10% of all salivary gland disease. Viral parotitis and juvenile recurrent parotitis are the two most common causes. Multiple factors, independently or in combination, can result in acute, chronic, or recurrent acute salivary gland inflammation. Sialendoscopy has emerged as the leading diagnostic technique and intervention for pediatric sialadenitis. Sialendoscopy is a safe and effective gland-preserving treatment of pediatric sialadenitis. Investigational studies are needed to address the impact of steroid instillation, postoperative stenting, and long-term outcomes of pediatric sialendoscopy. This article presents a comprehensive review of pathophysiology, clinical presentation, diagnosis, and treatment of pediatric sialadenitis.

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