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A teenager with fevers and pleuritic chest pain
A teenager with fevers and pleuritic chest pain
On 8/28, Morgan B led us in a discussion of a case of blastomycosis! Multi focal pneumonia (especitally fevers & chest pain) that doesn't respond to antibiotics? Think about everyone's favorite broad based budding yeast. Urine antigen testing better than serum antigen testing. Treat with itraconazole (amphotericin if they are very sick or have disseminated disease).
Source: Red Book 2018-2021
^ the go to source for all things pediatric infection!
Below, see a map from wikipedia of the distribution of blasto! We are right in the strike zone!
Pancreatitis - review of the literature
Pancreatitis - review of the literature
On 8/17, Brittany K and Curtis B presented a case of a teenager with a second episode of pancreatitis. Although the diagnosis was fairly straightforward, there is a large differential for what causes pancreatitis.
Differential:
Differential:
Obstructive: Biliary disease (10-30%), pancreas divisum, annular pancreas
Toxic/Metabolic: Hypercalcemia, hypertriglyceridemia, alcohol, scorpions!
Meds: L-asparaginase, valproic acid, azathioprine, mercaptopurine, mesalamine, steroids
Autoimmune: Autoimmune types 1 (elevated IgG4) and 2
Genetic: PRSS1 (trypsinogen), SPINK-1, CTRC (block trypsinogen activation), CFTR
Infectious: Mumps, coxsackie, VZV, EBV, HBV, flu
Abdominal Trauma
Idiopathic
Consider bold options with recurrent pancreatitis
Review of the Literature (above)
Review of the Literature (above)
Early re-feeding shortens duration of hospitalization.
There is data in pediatric patients!!! And it's a RCT!
Serial lipase is not helpful for understanding if your patient is improving based on the adult literature. You are better off looking at how the patient feels, their interest in eating, and their acute inflammatory markers.
LR is better than NS with pancreatitis. Shorted length of stay!! Remember to give 1.5X maintenance.
There is data in pediatric patients again! This time it is a retrospective study.
Fever and Lymphadenopathy in a 1 Year Old
Fever and Lymphadenopathy in a 1 Year Old
On 8/14 PGY3 Kimberly H presented a case of a 1 year old with an axillary lymph node and a fever. Differential is huge!
In this case, the kiddo had a large axillary lymph node and a small supraclavicular lymph node on the other side. We have always been taught that supraclavicular lymph nodes spell trouble (more likely to be malignant than other locations). Is that true? We went to the literature and found this paper. A hospital in Turkey looked at all the kids referred to their heme/onc clinic in a 8 year span for lymphadenopathy. Of 457 patients, 26 had supraclavicular lymphadenopathy. All of those 26 had malignant (as opposed to benign) etiologies.
Certainly makes us worried about any supraclavicular nodes we may find in the future!
Fever in a Newborn
Fever in a Newborn
Robert M and Loretta A presented a case of an infant with a fever. We focused on having a broad differential for similar cases. Presented 7/20.
Children's Protocols -
Children's Protocols -
Children's has many "clinical guidelines" that are very helpful. You can access them by going to their intranet > Clinical Guidelines.
Good review articles:
The Highlights:
The Highlights:
Fever = any temp >100.4F/38.0C
HPI: ask about how the baby has been acting, how alert they are, feeding, peeing, and pooping. Mom's pregnancy history is important - prenatal testing, GBS status, fevers at time of delivery, etc.
Most fevers are due to viruses, but 10.5% are due to serious bacterial infections (table above, from Peds in Review), such a meningitis/ bacteremia, UTI, soft tissue infection.
Work up in an infant <28 days with a fever always includes an LP
You should always think about HSV, even if there are no active lesions, as approximately 2% of women acquire genital herpes during pregnancy and may not have active lesions at the time of delivery
Altered Mental Status in a Teenager with IBD
Altered Mental Status in a Teenager with IBD
Erin M and Jack K presented a case of a teenager with new IBD dx presenting with 3 days of new confusion.
We talked about ways to organize your differential for AMS: MIST (From the Clinical Problem Solvers) versus AEIOUTIPS versus MOVE STUPID (sources too numerous to name).
In this case, we discussed two salient things
Any teenager with AMS has a broad ddx that necessitates a good confidential interview
In this person in particular, the recent Dx of IBD must be considered
new med exposure - not common for any IBD meds per our GI specialist
stress reaction
wrong dx - do we actually have another autoimmune condition with colitis and encephalitis? Lupus can do both.
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