Pediatrics

Pediatrics: Refusal to use arm

Clinical Scenario:
A 5 week old infant presented to the Emergency Department (ED) with refusal to move right arm for the past 3 days. No significant past medical history; the pregnancy was uncomplicated, and born via Cesarian-section due to failure to descend at full term at 40 weeks.  The patient has otherwise been feeding well and moving all of his other extremities. No history of trauma or fever. The arm and shoulder have no erythema, no swelling, however the patient screams in pain whenever you move the arm. 

X-rays of the right shoulder and entire right arm were unremarkable. Laboratory tests demonstrated a slightly elevated white blood cell count (WBC), however the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were both elevated.  You admit the patient for further work up.  The following day (actually a few hours later since was a late admission) the patient underwent a sedated MRI, which revealed humeral osteomyelitis with associated septic arthritis.

Clinical Question:
What are common causes of osteomyelitis/septic arthritis in a newborn?  What is the best tests/imaging to diagnose it?

Literature review:
Osteomyelitis can cause significant morbidity and mortality in a neonate/infant and can be difficult to diagnose.  In one small study, Wong and colleagues found that only 10 of the 30 babies studied demonstrated any systemic signs of infection, such as fever.  This study also found that more than half of the infants affected were born pre-term, and 70% of the patients with osteomyelitis had extended contact with the healthcare system (eg prolonged stay in the hospital).

A review by Montgomery and colleagues found that Staphylococcus aureus (S. aureus), to be the most common cause of osteomyelitis, with cases of Methicillin resistant S. aureus rising nationally.  In infants and children specifically, other common bacteria causing osteomyelitis are Group B Streptococcus, Ecsherichia coli, Kingella kingae usually spread hematogenously.

In a review of septic arthritis with concomitant adjacent osteomyelitis, such as this particular case, it was found that the shoulder was the most likely of all the joints (elbows, hips, knees, ankle) to be infected, as it was in this patient.  S. aureus again was the most common organism to cause a simultaneous osteomyelitis with associated septic arthritis.

In osteomyelitis, the WBC is often not a sensitive marker. One study in the journal of Pediatrics found that only 35% of children with osteomyelitis had an elevated WBC.  In contrast, ESR and CRP elevations were more sensitive, at 92% and 98% respectively.  Combined together, ESR and CRP offered the greatest sensitivity in detecting osteomyelitis.  After initiation of treatment, the ESR usually normalized within 24 days and the CRP in 10 days.

The recommended imaging modality for acute osteoarticular infections is magnetic resonance imaging (MRI) with contrast given the superior imaging it provides of bone as well as the soft tissues when compared to other imaging modalities.  In follow up after treatment, positron emission tomography (PET) or commuted tomography appears to be better imaging modalities. 

Take home points:
-Osteomyelitis/septic arthritis needs a high degree of suspicion for diagnosis given paucity of other symptoms such as fever.
-WBC can be normal, ESR and CRP together are more sensitive.
-Patients can have no other symptoms besides from joint pain.
-Preferred imaging is MRI with contrast.

References: 
1. Montgomery NI, Rosenfeld S. Pediatric Osteoarticular Infection Update. J. Pediatr Orthop. 2014.
2. Unkila-Kallio L, Kallio MJ, Eskola J, Peltola H. Serum C-reactive protein, erythrocyte sedimentation rate, and white blood cell count in acute hematogenous osteomyelitis of children. Pediatrics. 1994;93(1):59
3. Wong M, Isaacs D, Howman-Giles R, Uren R. Clinical and diagnostic features of osteomyelitis occurring in the first three months of life. Pediatr Infect Dis J. 1995;14(12):1047-53

Submitted by Steven Hung (@DocHungER), PGY-2
Faculty reviewed by Joan Noelker

Pediatrics: There's blood in the stool!

Clinical Scenario:
A 2 week old child presented to the emergency department with blood in the stool.  The child was otherwise well, tolerating feeds, no apparent abdominal pain, no abdominal distension, no fever.  Other than the dark red blood, the stool appeared about the same.  Child was born via vaginal delivery following an uncomplicated 40 week pregnancy.  Had stool within minutes of birth and has had normal stooling since.

Clinical Question:
What should be considered in a neonate/infant presenting with bloody stool?

Differential Diagnosis (DDx) of bloody stool in neonate:
-Swallowed maternal blood
-Anorectal fissure
-Necrotizing enterocolitis (NEC)
-Malrotation with midgut volvulus
-Hirschsprung disease
-Food protein-induced proctitis/colitis (not to be confused with similar food protein-induced enterocolitis syndrome [FPIES] where child is usually sicker and involves vomiting)

Other Differentials in later infancy:
-Intussusception (more common between 6-36 months of age, 60% before 1 year, 80% before 2 years)
-Infectious colitis – rare during neonate period given reduced exposure
-Meckels direrticulum – rare cause of bleeding in neonatal period

Several of the DDxs listed above could be excluded after review of the history and physical exam. Physical exam in this patient excluded anorectal fissure.  The child was 2 weeks old, making persistent swallowed maternal blood highly improbable.  As the patient was a well appearing neonate NEC and malrotation were also unlikely.  Normal stooling made Hirschsprung less likely.  Her age made intussusception, infectious colitis, and Meckels less likely.  This left food protein allergy, most commonly due to cows milk.  But there was a problem: I remembered asking the mother about the child’s diet, and she had reported that the infant was exclusively breastfed.  How could cows milk be a causal factor in a breast fed infant?

Literature review: 
As it turns out, many of the proteins consumed by mothers are passed onto their infants and can cause food protein-induced proctitis/colitis in which the only symptom in infants under 2 months of age is blood in the stool.  A small study of 95 breastfed infants presenting with only bloody stool found that elimination of specific proteins in the maternal diet or through use of extensively hydrolyzed casein-based formula resolved the bleeding within 72 to 96 hours.  65% of the infants were found to be sensitive to cows milk, 19% to egg, 6% to corn, and 3% to soy.  This proctitis/colitis, as the name implies, only induces an inflammatory response in the rectum and distal sigmoid colon.  At least half of the infants manifesting this condition are breast fed.  The symptoms will usually resolve by one year of age with the elimination of the offending protein, and most of these children can go on an unrestricted diet with no further problems.  Interestingly, this reaction does not appear to be IgE-mediated, so routine food allergy testing is not recommended.

Take home points:
-With blood in stool, must have wide differential
-If child otherwise well, with other dangerous conditions ruled out, can send stool culture and discharge home with trial of elimination of most common offending agents
-Most common agent is cow's milk, even if the only source is through the mother's breast milk

References:
1. Lake AM. Food-induced eosinophilic proctocolitis. J Pediatr Gastroenterol Nutr 2000;30 Suppl:S58
2. Odze RD, Wershil BR, Leichtner AM, Antonioli DA. Allergic colitis in infants. Journal of Pediatrics 1995;126(2):163-170.

Submitted by Steven Hung (@DocHungER), PGY-2
Faculty reviewed by Joan Noelker

A Happy Ending?

Your patient is a young adult male with no significant past medical history presenting with a chief complaint of testicular pain and heaviness. He reports that the pain occurred 2 hours prior to presentation. It was gradual in onset, progressively worsened, and is now plateaued. The pain is constant, dull, and achy. It is not localized to a single side. The patient feels like his scrotum is heavy, like someone is weighing it down. It is worse with movement, better when still. The patient could not recall any inciting trauma. 

Prior to onset of symptoms, the patient reports “getting my swerve on” with a new female partner, which he insisted did not consist of penetrating vaginal or anal intercourse would not further elaborate. He denies ejaculation prior to pain onset. He denies a history of penetrating intercourse altogether, but does endorses receptive oral sex activity. He denies a history of STI. Further ROS is negative. 

The physical exam is notable for bilaterally descended testes, and normal-appearing Tanner stage 4 genitalia. There is generalized bilateral testicle tenderness to palpation, without scrotal discoloration, testicular deformation, or penile discharge. There is no transverse lie, nor change in symptoms with elevation. The cremasteric reflex is intact.

You’re pretty sure you are least colloquially familiar with this patient’s current affliction, but have no idea if there’s any evidence-based interventions to lessen his discomfort.

Clinical Question:

What are suggested treatments for male pelvic congestion?

The Literature:

There is a paucity of academic information regarding this phenomenon:  scrotal pain following sustained sexual arousal unrelieved due to lack of orgasm and ejaculation. In the limited literature available, it is known as male pelvic congestion or epididymal hypertension. In lay terms, it has been referred to as “blue balls,” “lover’s nuts,” or “deadly sperm build-up” (DSB). Most of the available information is from anecdotal reports – “common knowledge and experience,” as one (unreferenced) article from a human sexuality journal described in 1989. Prior to the publication of a case report, with responding letters to the editor/author, published in Pediatrics in 2000, there was no information on the subject to be found in textbooks or online searchable databases (as concluded by medical librarians in three different institutions queried by the authors of this case report).

The included signs and symptoms are similar to the patient’s presentation above. In most cases the tenderness appears to be localized to the epididymis. The remainder of the GU exam and urinalysis should be normal. The pain usually resolves spontaneously within three hours of onset.

Proposed pathophysiology involves sexual arousal that produces increased blood flow to the penis and testes leading to pelvic venous dilatation. If this persists over time, testicular venous drainage slows, pressure builds, and this causes pain. 

Anecdotal treatments include sexual release via ejaculation, Valsalva maneuver, or lifting a heavy object. The case report included an anecdote about a physician in Los Angeles in the 1940s who, while teaching a course on human sexuality, gave a lecture on “lover’s nuts” in which he advised that masturbation was an appropriate medical treatment. This view is shared by most sexual health "experts" in the lay press.

Take home:

Male pelvic congestion is a real phenomenon, but is rarely discussed in medical literature.

It is a self-limiting and non-morbid process, but anecdotal evidence suggests that Valsalva, weight-lifting, or ejaculation via masturbation may expedite relief of discomfort.  

References:
1) Pediatrics. 2000;106;843-843.
2) Pediatrics 2001;108;1233

Contributed by Daniel Kolinsky, PGY-2.

A suspected case of Eczema Herpeticum


Your patient is a 2 y/o with a history of eczema who was brought in by his mother for a new rash x 1 day, associated with fever. The rash is pustular-appearing and in other places vesicular. It covers the arms, legs (including palms and soles), and trunk with relative sparing of the face. There are no oral lesions were noted. In the emergency department, the patient is febrile and tachycardic, but otherwise non-toxic appearing.

You are worried that he might have eczema herpeticum or a staph superinfection. You collect viral and bacterial swabs, and admit him to the pediatrics service. 


Question:


Should you start acyclovir right away, or is it okay to wait until the swab results come back?


Literature: 


Fortunately, an article in Pediatrics aimed at answering this very question. The study was a large, retrospective cohort study conducted between 2001-2010. This study included 1331 children age 2 mo to 17 yrs treated at 42 different centers for eczema herpeticum (identified by their primary discharge diagnosis). The primary objective of the study was to determine whether delayed acyclovir therapy was associated with increased LOS. Secondarily, the study examined the mortality rate (0%), the rate of ICU admission (3.8% ), co-existing bacterial infection (30.3%) and Staph bacteremia (~3.9%). Using multivariable linear regression models, the authors found that a delay in initiation of acyclovir was associated with an increased length of stay. Adjusted increase in LOS was 11% (95 % CI 3-20), 41% (95 % CI 19 - 67), and 98% (95% CI 60-145) for a delay in initiation by 1, 2, and 3-6 days respectively. These results were statistically significant (p <.001). The authors found no significant difference between the administration of acyclovir in IV vs. oral form. Given the above results, the authors concluded that “Patients clinically suspected of having eczema herpeticum should receive empiric therapy with acyclovir because there is a statistically significant time-dependent increase in LOS with every day of delaying in initiating acyclovir therapy". Adverse events from acyclovir therapy were not addressed.


Take Home:


1) If you are admitting a child because you are worried about eczema herpeticum, start acyclovir. Oral form is fine if kid can take it.


2) Send blood cultures and start antibiotics for co-existing Staph infection, especially if the kid is febrile because ~ 30% have co-existing Staph infection and ~4% are bacteremic.


Reference:


Aronson et. al. “Delayed Acyclovir and Outcomes of Children Hospitalized with Eczema Herpeticum.” Pediatrics 2011; 128; 1161.