Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine June 10-12, 2011

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1 The 48 th Annual Pediatrics for the Practitioner Symposium June 11, 2011 James H. Brien, DO James H. Brien, DO has no relevant financial relationships with commercial interests to disclose. Case #1 4½-month-old Male Presents for evaluation of pimples below his lower lip. Onset 2 days ago. Mom squeezed a small amount of pus from the larger one. Soon the baby became irritable with fever and erythema and swelling.

2 4½-month-old Male PMHx + only for being 35 weeks gestation with an otherwise normal pregnancy, labor and delivery. Was in the NICU for 5 days. Mother has no Hx of Herpes. No other HSV or sick contacts. Immunizations are up to date. 4½-month-old Male Examination revealed a healthy baby who was alert and interactive. Vital signs included a fever of 101 F with a cap. refill < 2 seconds. The pulse and respirations are normal. The only positive findings were the lesions mentioned above, erythema and swelling and the hemangioma as shown Lab tests: 4½-month-old Male CBC = 27,000 WBC s w/ 60% Gran, 19% Lymphs, 490,000 Plts. Drainage was sent for Gram stain and culture and PCR for Herpes. Results pending.

3 A. Erythema toxicum B. Cutaneous Herpes Simplex C. Staphylococcus aureus infection D. Propionibacterium acnes infection C. Staphylococcus aureus infection Gram stain and culture positive for MSSA. Treated initially with IV Clindamycin, then Nafcillin followed by Cephalexin PO. Good outcome. A. Erythema toxicum Common neonatal rash. Small papules / pustules on erythematous base: 4 14 days. Common on trunk; but anywhere. Typically contain eosinophils.

4 A. Erythema toxicum No treatment required. Just reassurance. B. Cutaneous Herpes Simplex May look just like the lesions shown in the patient presented. Only Without The Cellulitis. B. Cutaneous Herpes Simplex Not unsual to have spreading erythema and a little swelling. Significant swelling and erythema may be co-infected.

5 D. Propionibacterium acnes infection The major bacterial cause of acne. Lesions can become secondarily infected when picked. Case #2 8-Month-Old Male 3-days fever to 102 F. Had erythema of his throat. Tx for viral pharyngitis. That PM he began C/O right leg swelling and pain below the knee. ER Dx cellulitis IM Ceftriaxone & Rx for PO Amoxicillin. 8-Month-Old Male Over 3 more days, Sx worsened. Back to 1º & referred for admission. PMHx healthy / No trauma. Immunizations are up to date. Examination + for 101 F, P = 180, R = 32, Cap Refill = 2 seconds and painful swelling with erythema from knee to ankle.

6 8-Month-Old Male Lab tests: CRP = 104 WBC = 30,000 IVF & Antibiotics: Clindamycin & Ceftriaxone O.R. the next day: Pus from tissue but not bone. 8-Month-Old Male Gram stain of pus + for Gram-pos. cocci in clusters but no growth. Routine admission nasal screen + for MSSA, not MRSA. PICC line placed and went home on IV Clindamycin & followed weekly. C-RP & exam normal at 4 week check. 8-Month-Old Male At 5 weeks, the PICC came out. Antibiotics DC d. This radiograph was taken on his way home. Failed to follow up until 6 weeks later. Close F/Up again established.

7 Exam still normal. CRP briefly up (21) with URI and later with a minor Staph skin abscess. No further Tx. This radiograph is at 3 months after admission. C-RP remained NL. 8-Month-Old Male A. Gorham disease B. Chronic osteomyelitis C. Osteosarcoma D. Bone loss due to acute osteomyelitis D. Bone loss due to acute osteomyelitis Inhibition of osteoblasts and increased activity of osteoclasts. Mediators stimulated by infection, possibly by some bacteria inducing expression of mrna encoding for RANKL (receptor activator of nuclear factor-kappab ligand) a mediator of this process.

8 D. Bone loss due to acute osteomyelitis RANKL also known as osteoclast differentiation factor. D. Bone loss due to acute osteomyelitis Inflammatory mediators also inhibit production of osteoprotegerin, which helps regulate RANKL. Found mostly in orthopedic literature. A. Gorham disease (disappearing bone): Rare, congenital loss of bone. Non-malignant proliferation of vascular channels causing bone destruction. Usually Dx after pathologic Fx. Treated surgically.

9 B. Chronic osteomyelitis: Can result in similar loss of bone. Often associated with: Hardware. Inadequate debridement. Inadequate medical therapy. Often walled off (Brodie abscess) B. Chronic osteomyelitis: Usual treatment is good debridement and long-term antibiotics up to a year in some mostly oral. C. Osteosarcoma: Pain and / or fracture. Radiograph with a mass

10 Back To Our 8-Month-Old Male 8 months after initial hospitalization the child had external fixators placed to try to promote distraction osteogenesis. 3-Month-Old Male Diagnosed with pulmonary TB after persistent cough, + PPD and abnormal chest radiograph:

11 3-Month-Old Male Source was grandmother, but her sensitivities were not yet known. Treatment was started with: 1. Pyrazinamide 2. Rifampin 3. Isoniazid 4. Ethambutol (discontinued when isolate was found to be pan-sen.) 3-Month-Old Male Good initial clinical response. Chest radiograph somewhat improved after 1 month, but still abnormal: 3-Month-Old Male Two months into treatment, he still had a persistent cough with wheezes and course rhonchi. With a persistent RUL infiltrate on chest radiograph, a chest CT scan was done.

12 Repeat Bronchoscopy Showing Mass 3-Month-Old Male All BAL stains for bacteria, AFB and fungi were negative. Cultures are pending. A. Bronchial abscess B. Fungus ball C. Foreign body D. Endobronchial TB

13 D. Endobronchial TB: Known to have pulmonary TB. Treat the same as pulmonary TB. Add steroids (1 2 mg/kg/day) to decrease swelling & stenosis. Completed 6 months of antituberculous treatment & 6 weeks of steroids w/ 3 week taper. D. Endobronchial TB: Five mechanisms: 1. Direct extension from adjacent parenchymal disease. 2. Implantation from sputum. 3. Hematogenous spread. 4. Lymphatic drainage from parenchymal disease. 5. Compression & erosion of lymph node into bronchus (most likely). Case #4 4-year-old Male Painful lesion on left knee X 3 days. Started as a pustule on a red base. Grew in size along with fever starting the day prior to admission. No known injury or medical / surg. problems in past medical history. Immunizations are up to date.

14 4-year-old Male No insect bites noted. Exam reveals a healthy male with a fever of 102 F and a normal exam, except for a blister-like lesion over the lower part of the left knee with some mild swelling of the joint and pain on ROM testing. 4-year-old Male Lab tests: ESR = 21 C-RP = 18 CBC = normal Orthopedic consult requested MRI.

15 T1 T2 4-year-old Male Further Lab tests: Synovial fluid Normal appearance. Gram stain negative. Lesion fluid cloudy Gram stain = Gram-pos cocci. Cultures Pending A. Superficial Staph abscess B. Prepatellar bursitis C. Erysipelas D. Osteomyelitis of the tibia

16 A. Superficial Staph abscess Culture grew MSSA Not sure of mechanism;? Injury. Why unusual appearance? Epidermolytic toxin? A. Superficial Staph abscess MRI: Normal bones and joint. Treated with Nafcillin Keflex. No complications on follow up. Previous questions not answered D. Osteomyelitis of the tibia: Ruled out clinically and by MRI. Would not expect to present as this patient. Expect overlying soft tissue to be more erythematous - -

17 B. Prepatellar bursitis Occurs over top of patella. Usually associated with injury. Responds well to drainage and antibiotics. Typical pattern of swelling. C. Erysipelas: Usually due to group A strep. Superficial cellulitis involving the lymphatic vessels; producing a diffuse erythema with a sharp line of demarcation. Occasionally with some pustules and vesicle formation. Erysipelas Treat with a penicillin or ceph. May be due to GBS in newborns: Treat BGS with Amp + Gent pending sen. Full sepsis W/U.

18 Case #5 9-year-old Male Seen for a mildly swollen pre-auric. node and pimple-like lesion lateral to his right eye.? Insect bite & Tx with Cephalexin. Not better & Tx with Clindamycin & topical mupirocin (Bactroban ). Still not better getting bigger and became ulcerated with satellites. 9-year-old Male PMHx healthy; only mild asthma & mild MRSA cellulitis of left arm 3 months ago & a fever blister on his lower lip 4 months ago. Immunizations are UTD. No travel or unusual insect or animal exposure. No trauma. 9-year-old Male Examination was + only for the preauricular adenopathy and the following lesion:

19 Lab tests: 9-year-old Male Gram & Fungal stains negative Cultures pending. HSV and Varicella zoster PCR s are pending. Empirically treated with Acyclovir and Clindamycin pending testing. A. Cutaneous Herpes simplex B. MRSA Impetigo C. Mycobacterium marinum D. Lymphocutaneous Sporotrichosis

20 D. Lymphocutaneous Sporotrichosis Empiric Tx above had no effect. All initial tests were negative, including PCR for atypical mycobacteria. As the lesion persisted, repeated fungal cultures were done. D. Lymphocutaneous Sporotrichosis 1+ Sporothrix schenckii grew from culture obtained about 1 month after initial evaluation. Must have had a break in the skin. Itraconazole PO for 6 months. Responded well as shown: A. Cutaneous Herpes simplex: May be indistinguishable. Similar enough to empirically treat with acyclovir, as this patient did.

21 B. MRSA Impetigo: Should have been recovered on culture. Would not produce a chronic ulcer. Should have produced cellulitis but may look similar. C. Mycobacterium marinum Occurs after skin injury in contaminated water. May look very similar with chronic ulcer. Usually on extremity. C. Mycobacterium marinum Diagnosed with good H & P, supported by positive culture and / or PCR. PPD may be positive. Treatment with Clarithromycin or Doxy. or TMP/SMX or Ethambutol plus Rifampin for 4 6 weeks.

22 Case #6 20-Month-Old Male Admitted to PICU for acute onset of vomiting, AMS, and fever. Soon he had a seizure and became obtunded. PMHx prev. healthy except: Sz 5 mo earlier w/ neg work up. Hospitalized 2 weeks ago with pneumonia. 20-Month-Old Male Immunizations are up to date. No travel, pets or day care. No Hx of past ear, sinus or other pulmonary disease. Examination - 99 F, 137/100, P=150, Resp = 70. Pale, obtunded, L-sided weakness and facial droop. 20-Month-Old Male The rest of his exam = normal. Lab tests: CBC with increased WBC s CMP and UA = normal CXR and brain MRI are shown - -

23 A. Taenia solium B. Staphylococcus aureus C. Streptococcus milleri D. Pseudomonas aeruginosa C. Streptococcus milleri Grew from one of the abscesses. Likely the cause of the previous pneumonia and may have been the time of seeding of the brain. Most common cause in children and adults.

24 20-Month-Old Male Had extensive work up for heart, sinus, pulmonary or immune defects none found. Treated 130 days - IV Ceftriaxone. Clinical improvement to normal. Serial MRI s documented resolution. Remains well over a year later. B. Staphylococcus aureus Less common, but may look the same. Only a culture will tell.

25 D. Pseudomonas aeruginosa Usually associated with complicated ear / mastoid infections with temporal lobe involvement - - A. Taenia solium pork tapeworm Cause of Neurocysticercosis. Not as large as many abscesses. Not associated with fever. May see the scolex on MRI. Lesions can look very similar.

26 NEUROCYSTICERCOSIS Presenting signs and symptoms Seizures 60% Headaches 15% Altered mental status 15% Asymptomatic 15% NEUROCYSTICERCOSIS Treat with Albendazole or Praziquantel; recommend consulting ID, neurology and ophthalmology before beginning therapy. Pre-treat with steroids.