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Huang E, Wolfe VG, Yaeger SK, Fugok KL. Case Presentation of a Nine-Year-Old Female With Chronic Recurrent Multifocal Osteomyelitis. Cureus 2023; 15:e38054. [PMID: 37228560 PMCID: PMC10208142 DOI: 10.7759/cureus.38054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 04/22/2023] [Indexed: 05/27/2023] Open
Abstract
Multifocal bone pain in a pediatric patient prompts a broad differential diagnosis, which should include chronic recurrent multifocal osteomyelitis (CRMO), particularly when the patient has a personal or family history of autoimmune diseases or chronic inflammatory disorders. CRMO is a difficult diagnosis, as several similar disorders must be ruled out first, and it requires extensive verification based on clinical, radiological, and pathological criteria. It often mimics other medical diagnoses, including Langerhans cell histiocytosis and infectious osteomyelitis. Maintaining a high index of suspicion for CRMO is important to minimize unnecessary medical testing, optimize pain control, and preserve physical function. We present the case of a nine-year-old female who presented with multifocal bone pain and was diagnosed with CRMO.
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Affiliation(s)
- Evanie Huang
- Department of Emergency and Hospital Medicine/University of South Florida (USF) Morsani College of Medicine, Lehigh Valley Health Network, Bethlehem, USA
| | - Viktoriya G Wolfe
- Department of Pediatrics/University of South Florida (USF) Morsani College of Medicine, Lehigh Valley Health Network, Bethlehem, USA
| | - Susan K Yaeger
- Department of Emergency and Hospital Medicine/University of South Florida (USF) Morsani College of Medicine, Lehigh Valley Health Network, Allentown, USA
| | - Kimberly L Fugok
- Department of Emergency and Hospital Medicine/University of South Florida (USF) Morsani College of Medicine, Lehigh Valley Health Network, Bethlehem, USA
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Jarvill T, Lauber P, Umaru S, Villalobos T, Yaeger SK. Challenges in Evaluating Pediatric Fever and Rash in the Era of COVID-19 and (Multisystem Inflammatory Syndrome in Children) MIS-C. Cureus 2022; 14:e21764. [PMID: 35251835 PMCID: PMC8890603 DOI: 10.7759/cureus.21764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 01/30/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has challenged the medical community to characterize and treat a new illness. Now almost two years after the initial confirmed cases of COVID-19, medical teams are faced with another unique disease process temporally related to the pandemic-multisystem inflammatory syndrome in children (MIS-C). The comparison of these patients’ presentations illustrates the new challenges of evaluating a pediatric rash and fever in the era of MIS-C. Case Reports: This report presents three cases with features of MIS-C, positivity for SARS-CoV-2, rashes, fevers, gastrointestinal involvement, and elevated inflammatory markers. The first case poses a diagnostic dilemma. While the case 1 patient has many features of MIS-C, his nasal swab was positive for Methicillin-sensitive Staphylococcus Aureus (MSSA). While the second case falls into the case definition of MIS-C, the case 2 patient also met the criteria for atypical Kawasaki disease. Although the third case was positive for SARS-CoV-2, the patient comparatively had a mild elevation of inflammatory markers and a stable clinical course led the treatment team to be more suspicious of immunoglobulin A (IgA) vasculitis versus hand, foot, and mouth disease. The variability in skin rash in patients with MIS-C contributes to the challenge of correctly diagnosing and managing pediatric patients with fever and rash in the emergency department (ED). Conclusion: Although most children infected with SARS-CoV-2 are asymptomatic or present with mild respiratory illness, it is critical to recognize children at-risk for fluid-refractory shock in MIS-C. With the continuing SARS-CoV-2 pandemic, emergency department (ED) providers will have to be alert and have high suspicion when evaluating a child with a fever and a rash to properly identify children presenting with this serious illness.
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Abstract
OBJECTIVES Serious bacterial infections (SBIs) in young infants can present with fever or hypothermia. There are substantial data on fever as a presentation for SBI that help to inform the clinical approach. In contrast, data on hypothermia are lacking, thus leaving clinicians without guidance. We aimed to describe the workup and findings, specifically the occurrence, of SBIs in infants younger than 60 days of life with hypothermia. METHODS We reviewed the medical records of infants younger than 60 days of life with rectal temperature of less than 36.5°C upon arrival to a children's hospital emergency department between January 2013 and December 2014. Comparisons were made between those who were found to have an SBI and those without. Serious bacterial infection was defined as bacteremia, bacterial meningitis, pneumonia, or urinary tract infection (UTI). RESULTS From the 414 patients identified, 104 (25%) underwent a sepsis evaluation of blood, urine, and/or cerebrospinal fluid culture. Serious bacterial infections were identified in 9 patients: 4 with UTI, 1 with pneumonia, 2 with bacteremia, 1 with pneumonia and UTI, and 1 with meningitis and bacteremia. Compared with patients with negative cultures, patients with SBI were older and had elevated absolute band counts and elevated immature-to-total neutrophil ratio. CONCLUSIONS Approximately a quarter of infants younger than 60 days with hypothermia were evaluated for SBI. Serious bacterial infection was identified in 9% of evaluated infants (2% of all hypothermic infants). Hypothermia can be a presenting sign of SBI.
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Affiliation(s)
- Michelle C Perry
- Children’s Hospital of Pittsburgh of UPMC, Department of Pediatrics
| | - Susan K Yaeger
- Lehigh Valley Health Network, Department of Emergency Medicine
| | - Katie Noorbakhsh
- Children’s Hospital of Pittsburgh of UPMC, Department of Pediatrics
| | - Andrea T Cruz
- Baylor College of Medicine, Department of Pediatrics
| | - Robert W Hickey
- Children’s Hospital of Pittsburgh of UPMC, Department of Pediatrics
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Karn MN, Johnson NP, Yaeger SK, Fugok KL. A teenager with fever, chest pain, and respiratory distress during the coronavirus disease 2019 pandemic: a lesson on anchoring bias. J Am Coll Emerg Physicians Open 2020; 1:1392-1394. [PMID: 33043318 PMCID: PMC7537251 DOI: 10.1002/emp2.12261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/25/2020] [Accepted: 08/03/2020] [Indexed: 11/21/2022] Open
Abstract
Symptoms of coronavirus disease 2019 overlap with other important illnesses affecting young adults. We report a case of a 17-year old male presenting to the emergency department in the midst of a pandemic with symptoms of coronavirus disease 2019. He had fever, dyspnea, chest pain, and myalgias, with bilateral infiltrates on chest radiograph, and developed septic shock secondary to infectious thromboembolic events. However, his blood cultures grew group G streptococcus secondary to his oropharyngeal infection, and he experienced an infectious thrombus in the internal jugular vein, consistent with the rare but well-described Lemierre's syndrome. This case report calls attention to the importance of maintaining differential diagnoses and thereby minimizing the biases and assumptions that come with clinical care during a pandemic.
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Affiliation(s)
- Michele N. Karn
- Department of Emergency and Hospital Medicine/University of South Florida, Morsani College of MedicineLehigh Valley Health NetworkAllentownPennsylvaniaUSA
| | - Nicholas P. Johnson
- Department of Emergency and Hospital Medicine/University of South Florida, Morsani College of MedicineLehigh Valley Health NetworkAllentownPennsylvaniaUSA
| | - Susan K. Yaeger
- Lehigh Valley Health Network, Department of Emergency and Hospital MedicineDivision of Pediatric Emergency Medicine/University of South Florida, Morsani College of MedicineAllentownPennsylvaniaUSA
| | - Kimberly L. Fugok
- Lehigh Valley Health Network, Department of Emergency and Hospital MedicineDivision of Pediatric Emergency Medicine/University of South Florida, Morsani College of MedicineAllentownPennsylvaniaUSA
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Alloway BC, Yaeger SK, Mazzaccaro RJ, Villalobos T, Hardy SG. Suspected case of COVID-19-associated pancreatitis in a child. Radiol Case Rep 2020; 15:1309-1312. [PMID: 32572339 PMCID: PMC7275143 DOI: 10.1016/j.radcr.2020.06.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 12/15/2022] Open
Abstract
The world has been challenged by SARS CoV-2, a new virus causing pneumonia and acute respiratory distress syndrome, with common symptoms of COVID-19 in pediatric patients including both respiratory and GI symptoms. There is a lack of literature implicating COVID-19 in pancreatitis, yet viruses are generally understood to be a cause of pancreatitis in children. We present a case of a previously well 7-year-old girl, who presented to the emergency department with a chief complaint of abdominal pain and anorexia. She was diagnosed with acute pancreatitis with an abnormal lipase, ultrasound, and computed tomography, and was found to be COVID-19 positive by polymerase chain reaction. Our case suggests that, in the current pandemic, consideration for SARS CoV-2 testing in children with gastrointestinal symptoms and pancreatitis may be considered. Additionally, this case highlights the need for appropriate personal protective equipment for providers, even when COVID is not initially on the differential.
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Affiliation(s)
- Brian C Alloway
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network, USF Morsani College of Medicine, Cedar Crest Boulevard & I-78, Allentown 18103, PA, USA
| | - Susan K Yaeger
- Division of Pediatric Emergency Medicine, Department of Emergency and Hospital Medicine, Lehigh Valley Health Network, USF Morsani College of Medicine, Allentown, PA, USA
| | - Richard J Mazzaccaro
- Department of Pediatrics, Lehigh Valley Health Network/USF Morsani College of Medicine, Allentown, PA, USA
| | - Tibisay Villalobos
- Department of Pediatrics, Section of Infectious Disease, Lehigh Valley Health Network, USF Morsani College of Medicine, Allentown, PA, USA
| | - Steven G Hardy
- Department of Emergency and Hospital Medicine, Lehigh Valley Health Network, USF Morsani College of Medicine, Cedar Crest Boulevard & I-78, Allentown 18103, PA, USA
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Esposito SB, Miller AHF, Rajan R, Villalobos T, Yaeger SK. Complication of otitis media leads to opisthotonos in a toddler. Am J Emerg Med 2020; 38:1296.e5-1296.e7. [PMID: 31987742 DOI: 10.1016/j.ajem.2020.01.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 01/14/2020] [Accepted: 01/16/2020] [Indexed: 10/25/2022] Open
Abstract
Opisthotonos, extreme involuntary neck and back extension, is rarely seen in modern emergency departments. Vaccines have prevented the most common causes of this clinical presentation. Alternatively, otitis media is one of the most common pediatric infections and is characteristically non-invasive and harmless. In exceedingly rare cases, otitis media can develop complications and progress to invasive pneumococcal diseases including mastoiditis and meningitis. Streptococcus pneumoniae accounts for the majority of otitis media infections, however, since the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7) and 13-valent pneumococcal conjugate vaccine (PCV13) otitis media and its complications have decreased significantly. The present case reports of a previously healthy and immunized child presenting to a pediatric emergency department (PED) with opisthotonos, and was found to have pneumococcal meningitis, bacteremia and mastoiditis arising from otitis media.
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Affiliation(s)
- Samantha B Esposito
- Lehigh Valley Health Network, Department of Emergency and Hospital Medicine/USF, Morsani College of Medicine, Cedar Crest Boulevard & I-78, Allentown, PA 18103, USA.
| | - Andrew H F Miller
- Lehigh Valley Health Network, Department of Emergency and Hospital Medicine/USF, Morsani College of Medicine, Cedar Crest Boulevard & I-78, Allentown, PA 18103, USA
| | - Roy Rajan
- Lehigh Valley Health Network, Department of Surgery (ENT and Otolaryngology)/USF, Morsani College of Medicine, Cedar Crest Boulevard & I-78, Allentown, PA 18103, USA
| | - Tibisay Villalobos
- Lehigh Valley Health Network, Department of Pediatrics, Section of Infectious Disease/USF, Morsani College of Medicine, Cedar Crest Boulevard & I-78, Allentown, PA 18103, USA
| | - Susan K Yaeger
- Lehigh Valley Health Network, Department of Emergency and Hospital Medicine/USF, Morsani College of Medicine, Cedar Crest Boulevard & I-78, Allentown, PA 18103, USA
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Perry MC, Yaeger SK, Toto RL, Suresh S, Hickey RW. A Modern Epidemic: Increasing Pediatric Emergency Department Visits and Admissions for Headache. Pediatr Neurol 2018; 89:19-25. [PMID: 30343832 PMCID: PMC8485652 DOI: 10.1016/j.pediatrneurol.2018.07.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/28/2018] [Accepted: 07/28/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Headaches represent 0.9% to 2.6% of visits to a pediatric emergency department (PED). We noted a trend of increasing visits for headache in our tertiary care PED and sought to further characterize this trend. METHODS We identified PED visits with International Classification of Disease, Ninth Revision, Clinical Modification diagnoses for headache at 25 hospitals in Pediatric Health Information System between 2003 and 2013. To further characterize demographics and treatment trends over time we used the electronic health record in our emergency department to identify children ages four to 18 between January 2007 and December 2014 with International Classification of Disease, Ninth Revision codes for headache: a random sample of 50 visits per year were chosen for chart review. RESULTS Pediatric Health Information System visits for headache increased by 166% (18,041 in 2003 and 48,020 in 2013); by comparison, total PED visits increased by 57.6%. The percent admission increased by 300% (2020 admissions in 2003 and 8087 admissions in 2013). At our hospital, headache visits increased 111% from 896 visits in 2007 to 1887 visits in 2014; total PED visits increased 30.2%. The admission percentage for headache increased 187% with 156 admissions in 2007 and 448 in 2014. Management over time differed in the frequency of head computed tomography which decreased 3.7% per year (r = -0.93, 95% CI -0.99, -0.64) from 34% in 2007 to 18% in 2014. CONCLUSION Pediatric emergency department visits for headache are increasing and a growing proportion of these patients are admitted. This finding identifies a potential patient population to target for interventions to improve outpatient management and reduce pediatric emergency department utilization.
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Affiliation(s)
- Michelle C Perry
- A Children's Hospital of Pittsburgh of UPMC, Department of Pediatrics, Pittsburgh, Pennsylvania.
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Yaeger SK, Perry MC, Caperell K, Coffman KA, Hickey RW. In reply:. Ann Emerg Med 2017; 70:927-928. [DOI: 10.1016/j.annemergmed.2017.07.475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Indexed: 11/29/2022]
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Yaeger SK, Perry MC, Caperell K, Coffman KA, Hickey RW. Ropivacaine Intramuscular Paracervical Injections for Pediatric Headache: A Randomized Placebo-Controlled Trial. Ann Emerg Med 2017; 70:323-330. [DOI: 10.1016/j.annemergmed.2017.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 02/24/2017] [Accepted: 03/03/2017] [Indexed: 11/28/2022]
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Yaeger SK, Bhende MS. Pediatric Hand Injuries. Clinical Pediatric Emergency Medicine 2016. [DOI: 10.1016/j.cpem.2016.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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