Orbital Osteomyelitis and Periorbital Abscess Due to Coccidioidomycosis Following Trauma.

Ocular involvement due to Coccidioides sp.is extremely rare, and most patients with disseminated coccidioidomycosis present as extrapulmonary or disseminated disease that involves the skin, bone joints, and central nervous system. Here, we describe a 13-year-old previously healthy Black male residing in an area endemic for coccidioidomycosis. The child presented to our hospital with left eye pain, diplopia, and proptosis two weeks after being struck on the left side of the face with a basketball. He was initially presumed to have bacterial orbital cellulitis and was started on empiric antibiotics. Due to severe disease, he underwent surgical drainage and debridement. Fungal stain from the intraoperative specimen showed spherules with endosporulation, and fungal culture revealed Coccidioides immitis. Based on this, the child was diagnosed with orbital osteomyelitis and periorbital abscess due to coccidioidomycosis. He was started on intravenous liposomal amphotericin B and fluconazole. Antibiotics were discontinued. He underwent additional investigations to assess for sites of dissemination. His nuclear medicine bone scintigraphy and cerebrospinal fluid studies were negative. A computed tomography (CT) scan of the chest demonstrated multiple small pulmonary nodules. His Coccidioides complement fixation(CF) titer was 1:32. The patient completed one month of treatment with liposomal amphotericin B and fluconazole. Our case highlights the need for healthcare professionals to consider coccidioidomycosis when evaluating patients with orbital disease as delays in the diagnosis may result in visual loss and central nervous system involvement. Prompt diagnosis, evaluation, and treatment are crucial to reduce long-term morbidity and mortality.

Pediatric Laryngeal Coccidioidomycosis: A Case Series in an Endemic Region.

BACKGROUND: Laryngeal coccidioidomycosis is a rare but life-threatening manifestation of coccidioidomycosis. Data in children are sparse and limited to case reports. We conducted this study to review the characteristics of laryngeal coccidioidomycosis in children. METHODS: We performed a retrospective review of patients ≤21 years of age with laryngeal coccidioidomycosis who were treated from January 2010 to December 2017. We collected demographic data, clinical and laboratory studies and patient outcomes. RESULTS: Five cases of pediatric laryngeal coccidioidomycosis were reviewed. All children were Hispanic and 3 were female. The median age was 1.8 years and the median duration of symptoms before diagnosis was 24 days. The most common symptoms included fever (100%), stridor (60%), cough (100%) and vocal changes (40%). Airway obstruction requiring tracheostomy and/or intubation for airway management was present in 80%. The most frequent location of lesions was the subglottic area. Coccidioidomycosis complement fixation titers were frequently low and culture/histopathology of laryngeal tissue was necessary to make a definitive diagnosis. All patients required surgical debridement and were treated with antifungal agents. None of the patients had recurrence during the follow-up period. CONCLUSIONS: This study suggests that laryngeal coccidioidomycosis in children presents with refractory stridor or dysphonia and severe airway obstruction. Favorable outcomes can be achieved with a comprehensive diagnostic work-up and aggressive surgical and medical management. With the rise in cases of coccidioidomycosis, physicians should have a heightened awareness regarding the possibility of laryngeal coccidioidomycosis when encountering children who have visited or reside in endemic areas with stridor or dysphonia.

Systemic Lupus Erythematosus Lymphadenopathy Presenting as Kikuchi-Fujimoto Disease in an Adolescent.

Systemic lupus erythematosus is a multisystem autoimmune disorder with a highly heterogeneous clinical presentation. The clinical phenotype varies from mild cutaneous and musculoskeletal manifestations to neurological involvement. Lymphadenopathy is a frequent manifestation of SLE, but the association is often not recognized, as lymphadenopathy is not a criterion for diagnosis. An unusual and seldom reported mimicker of lupus lymphadenitis is Kikuchi-Fujimoto Disease. This is a rare self-limiting disease of young adult females that presents with lymphadenopathy, fever, and systemic symptoms. Lupus lymphadenitis and KFD share some common clinical and pathologic features; but distinguishing between those two diseases can be challenging. We describe a 16-year-old Hispanic female who presented with axillary lymphadenopathy and was initially diagnosed with KFD based on an excisional lymph node biopsy; but later met the criteria for the 2019 European League Against Rheumatism/American College of Rheumatology classification criteria SLE. This case highlights the need for clinicians to be aware that patients with SLE may present with lymphadenopathy and to consider the association between Kikuchi disease and SLE to prevent misdiagnosis and allow for timely treatment to avoid complications.

Increasing Patient Safety Event Reporting Among Pediatric Residents.

Background and objective Despite their role as frontline providers, resident physicians often underreport adverse patient events or safety issues they encounter. The objective of this study was to increase the number of patient safety events (PSE) reported at our institution through the implementation of a longitudinal, multi-pronged approach. Methods We designed and implemented a series of interventions focused on increasing patient safety events reported by resident physicians from October 2018 to April 2021. Interventions consisted of formal didactic sessions, increasing awareness among organizational leaders about the integral role of residents, implementing a direct feedback process to residents regarding the events, and encouraging them to develop solutions to their PSE that were associated with a financial incentive. We collected the rates of reports every month to assess the impact of our interventions. Results The mean number of PSEs submitted monthly increased from zero to two reports at baseline to 10.4 during the study period. The mean number of PSE increased to 5.8 (range: 2-11) at the end of the first intervention. Following the third intervention, the average number of reported PSE was 12.3 (range: 5-18). There was a continued increase in the number of events reported across the study period, which was sustained. The outcome of interest was not achieved after intervention 1 but was achieved in 27% and 62% of months following interventions two and three. By theend of the study period, our goal of >13 PSEs per month was consistently met. The most significant increase in reporting occurred when residents received positive timely feedback regarding their reports. Conclusions The number of patient safety events reported by pediatric residents increased at our institution following the implementation of a multi-pronged approach including enhanced education, recognition of the residents as frontline reporters among institutional stakeholders, and direct feedback regarding submissions. Our strategies may be replicated at other residency programs seeking to establish resident involvement in safety initiatives. Further work is necessary to ensure residents gain an understanding of how patient safety events are addressed and prevented at an organizational level.

Vaccines for International Pediatric Travelers.

The pretravel management of the international pediatric traveler is based on provision of preventive education, chemoprophylaxis against malaria and traveler's diarrhea, as well as travel vaccinations. Immunization requirements are determined based on the traveler's pretravel immunization status, age, medical history, and destination. Immunization needs also vary depending on the exposures during the trip. Potential exposure to water, insects, or animals as well as duration of travel will help tailor risk avoidance education and travel immunizations. This review provides clinicians an overview of vaccines recommended for children traveling internationally.

Review of Wearable Devices and Data Collection Considerations for Connected Health.

Wearable sensor technology has gradually extended its usability into a wide range of well-known applications. Wearable sensors can typically assess and quantify the wearer's physiology and are commonly employed for human activity detection and quantified self-assessment. Wearable sensors are increasingly utilised to monitor patient health, rapidly assist with disease diagnosis, and help predict and often improve patient outcomes. Clinicians use various self-report questionnaires and well-known tests to report patient symptoms and assess their functional ability. These assessments are time consuming and costly and depend on subjective patient recall. Moreover, measurements may not accurately demonstrate the patient's functional ability whilst at home. Wearable sensors can be used to detect and quantify specific movements in different applications. The volume of data collected by wearable sensors during long-term assessment of ambulatory movement can become immense in tuple size. This paper discusses current techniques used to track and record various human body movements, as well as techniques used to measure activity and sleep from long-term data collected by wearable technology devices.

Management of Infants Born to Mothers with HIV Infection.

In the United States, approximately 5,000 women living with HIV infection give birth each year. HIV can be transmitted from a mother to her child at any time during pregnancy, labor and delivery, and breastfeeding. Because of effective preventive measures, the transmission rate from pregnant women to their children has declined significantly. Strategies to prevent mother-to-child transmission include maternal and infant antiretroviral therapy and formula-feeding instead of breastfeeding. All infants born to mothers with HIV infection should receive antiretroviral postexposure prophylaxis as soon as possible, ideally within six hours after delivery. The type of prophylaxis depends on whether the mother has achieved virologic suppression, defined by an HIV RNA load of less than 50 copies per mL, and if the infant is at high risk of vertical transmission of HIV. Risk factors for vertical transmission include maternal seroconversion during pregnancy or breastfeeding, high maternal plasma viral RNA load during pregnancy, and advanced maternal HIV disease.

Congenital Coccidioidomycosis: A Case Report and Review of the Literature.

Coccidioidomycosis in neonates is rare and the acquisition of disease in this age group is not well understood. Congenital coccidioidomycosis is very rare, usually associated with coccidioidal placentitis. Only a handful of cases of congenital coccidioidomycosis have been described in the literature. We describe an infant with congenital coccidioidomycosis delivered by cesarean section to a mother who was diagnosed with disseminated disease in the second trimester and summarize the available literature on congenital coccidioidomycosis.

Disseminated Coccidioidomycosis in an Adolescent With Crohn's Disease.

Coccidioidomycosis is a systemic mycosis caused by Coccidioides immitis/posadasii. This dimorphic fungus is endemic to the Southwestern United States, particularly in California and Arizona. Most infections are asymptomatic or mild, but around 5% of patients develop complicated pulmonary infection, and approximately 1% may progress to disseminated disease. We present the case of an adolescent male with Crohn's disease who received the integrin inhibitor, vedolizumab, and developed disseminated coccidioidomycosis. This case underscores the importance of considering severe and/or disseminated coccidioidomycosis in immunosuppressed children. In our case, clinical suspicion and bronchoscopy helped confirm the diagnosis and facilitate appropriate evaluation and treatment.

E-cigarette or Vaping Product Use-Associated Lung Injury Complicated by Pulmonary Aspergillosis.

Since the initial reports regarding the nationwide outbreak of e-cigarette or vaping product use-associated lung injury (EVALI) in August 2019 by the Centers for Disease Control and Prevention, a clear link has been established between EVALI and tetrahydrocannabinol (THC)-containing product use. We report a case of invasive pulmonary aspergillosis (IPA) as a complication of EVALI in an immunocompetent adolescent that resulted in a fatal outcome. We encourage physicians that are considering the diagnosis of EVALI be cognizant of the increased use of THC and other potential contaminants in vaping cartridges. IPA can be a fatal disease and early aggressive treatment is necessary.

Effect of the Coronavirus Disease 2019 (COVID-19) Pandemic on Pediatric Resident Well-Being.

OBJECTIVES: This study aims to identify factors specific to the COVID-19 pandemic that affect resident physicians' well-being, identify potential sources of anxiety, and assess for depression and stress among residents. METHODS: A cross-sectional survey was performed in April 2020 that evaluated resident perceptions about COVID-19 pandemic, its impact on their personal lifestyle, and coping mechanisms adopted. The respondents also completed the Beck Depression Inventory-II (BDI-II) and Cohen Perceived Stress Scale (PSS-10). RESULTS: Of 37 residents, 29 completed the survey for a response rate of 78%. We found that 50% of residents harbored increased anxiety due to the pandemic and reported fears of spreading disease. Factors that negatively impacted their well-being included social isolation from colleagues (78%), inability to engage in outdoor activities (82%), and social gatherings (86%). Residents expressed concern about the effect of the COVID-19 pandemic on their didactic education and clinical rotations. The mean PSS-10 total score was 17 (SD = 4.96, range = 0-33) and the mean BDI-II total score was 6.79 (SD = 6.00). Our residents adopted a number of coping mechanisms in response to COVID-19. CONCLUSIONS: We identified factors specific to the COVID-19 pandemic that adversely affected resident physician well-being. Trainees were concerned about the risk of developing COVID-19 and spreading this to their family. Residents also harbored anxiety regarding the effect of COVID-19 on their education. Lifestyle changes including social isolation also resulted in a negative effect on resident well-being. Developing strategies and resources directed to addressing these concerns may help support well-being and alleviate stress and anxiety.

Abatacept in the Treatment of Juvenile Dermatomyositis-Associated Calcifications in a 16-Year-Old Girl.

Calcinosis is a feared complication of JDM that may be seen in up to 40% of children with JDM. It is associated with negative impact on the patients' quality of life due to weakness, functional disability, joint contractures, muscle atrophy, skin ulcers, and secondary infections. Calcinosis can present as superficial nodules or plaques, larger nodular deposits extending into deeper tissue layers, accumulation of calcifications along the fascial planes of muscles or tendons, or an exoskeleton of calcium leading to limitations in mobility and joint contractures. Currently, there are no known effective treatments for calcinosis and current therapy is based on anecdotal retrospective studies and cases series. We report the case of a child with JDM-associated calcinosis with extensive intramuscular calcifications who failed conventional therapies but demonstrated improvement as evident by decrease in calcinosis and improved physical function with use of abatacept. We found that use of abatacept was associated with improvement in functional outcome and recurrence did not occur. This case suggests use of abatacept as a safe and effective treatment option for calcinosis due to JDM. Furthermore, large-scale clinical studies are needed to validate our findings and to evaluate the long-term outcomes.

Evaluation of Pediatric Surgical Site Infections Associated with Colorectal Surgeries at an Academic Children's Hospital.

Appropriate use of antibiotic prophylaxis (AP) is a key measure for the prevention of surgical site infections (SSI) in colorectal surgeries; however, despite the presence of national and international guidelines, compliance with AP recommendations remains low. The purpose of this study is to evaluate compliance with recommendations for the use of AP in children undergoing colorectal surgeries and to evaluate the effectiveness of antibiotics in the prevention of SSI. We collected demographic and clinical characteristics of patients who underwent colorectal surgeries, as well as microbiological and antimicrobial susceptibility data for patients who developed SSI. AP data were collected and compared with national guidelines. Antibiotic dosing and duration were most frequently in concordance with national guidelines, while antibiotic timing and selection had the lowest rates of compliance. Twelve of the 192 colorectal procedures evaluated resulted in SSI. Only 2 of the 12 children with SSI received appropriate AP for all four categories evaluated. Eight cases that resulted in SSI were due to organisms not covered by the recommended AP. We identified multiple areas for the improvement of AP in children undergoing colorectal surgery. A multidisciplinary approach to development of standardized protocols, educational interventions, and EHR-based algorithms may facilitate or improve appropriate AP use.