18-Month-Old with Lethargy and Accelerated Idioventricular Rhythm in Prehospital Setting: A Case Report.

INTRODUCTION: We report a case of accelerated idioventricular rhythm (AIVR) identified by Emergency Medical Services (EMS) monitoring of an infant presenting with lethargy and respiratory distress. Accelerated idioventricular rhythms are rare ventricular rhythms originating from the His-Purkinje system or ventricular myocytes, consisting of >3 monomorphic beats with gradual onset and termination.1 An AIVR is usually well-tolerated and does not require treatment, though sustained arrythmia may induce syncope, and the rhythm has been seen in newborn infants with congenital heart diseases.1 Monitoring ill children with ECG can identify such dysrhythmias in the prehospital setting. CASE REPORT: An 18-month-old male presented to their pediatrician with lethargy and respiratory distress, prompting activation of EMS. The patient was placed on a 4-lead ECG initially revealing monomorphic QRS complexes at a rate of 170 beats per minute (BPM). A 12-lead ECG was interpreted as sinus tachycardia by the paramedics who noted the QRS complexes were "getting taller and shorter" with a stable rapid heart rate. The clinician then noted a consistently wide tachycardia which spontaneously converted to a narrow complex tachycardia. The QRS pattern remained variable, with notation of variable R-wave height. After arrival to the emergency department, pediatric cardiology was consulted and interpreted the prehospital ECG findings as accelerated idioventricular rhythm. The patient experienced multiple occurrences of accelerated idioventricular rhythm during hospitalization without associated hypoxia or decreased perfusion. DISCUSSION: Accelerated idioventricular rhythm is relatively rare entity without underlying cardiac disease and most cases are asymptomatic or benign. In the pediatric population, AIVR is generally related to congenital heart defects, cardiac tumors, and cardiomyopathies. In the prehospital setting, continuous ECG monitoring should be a part of care by Advanced Life Support personnel in children with altered mental status, respiratory distress, unexplained syncope, or suspected arrhythmias and 12 lead ECG should be considered if there is any abnormality noted. While this patient did not experience persisting morbidity from AIVR, the potentially hazardous rhythm would not have been recognized without the astute observation, clinical management and persistent follow up of the prehospital clinicians.

Application of a complete blood count to screening lethargic and anorectic cats for pancreatitis.

BACKGROUND: Feline pancreatitis (FP) is an important health problem of cats. Its diagnostics is based on the combination of quantification of serum pancreatic lipase immunoreactivity (fPLI) and abdominal ultrasonography (AUS). These modalities allow for establishing highly specific diagnosis, however they are relatively expensive and time-consuming. On the other hand, a screening test of high sensitivity which would allow to rule out FP on the first visit without a considerable increase of costs would be clinically useful. To evaluate accuracy of nonspecific inflammatory biomarkers based on complete blood count (CBC) in diagnosing FP 73 client-owned cats with signs of lethargy and reduced appetite lasting for at least 2 days before presentation were enrolled in the cross-sectional study. They were examined with fPLI assay and AUS and classified as cats with very low risk of FP when fPLI ≤3.5 µg/L and AUS negative for FP, or as cats with increased risk of FP in the case of any other combination of results. Then, 7 various CBC measurements were measured in each cat and linked to the risk of FP using the multivariable logistic regression. RESULTS: Five CBC measurements turned out to be significantly associated with the risk of FP - total leukocyte count (WBC; crude odds ratio(ORcrude) = 12.2; CI 95%: 1.52, 98.5), total neutrophil count (ORcrude = 5.84; CI 95%: 1.22, 27.9), band neutrophil count (BNC; ORcrude = 6.67; CI 95%: 1.98, 22.4), neutrophil-to-lymphocyte ratio (ORcrude = 3.68; CI 95%: 1.25, 10.9), and eosinophil count (EC; ORcrude = 0.34; CI 95%: 0.12, 0.96). The model based on WBC, BNC, and EC proved to have at least fair diagnostic potential (area under ROC curve 82.7%; CI 95%: 72.8%, 92.5%). When WBC <  18 G/L, BNC <  0.27 G/L, and EC >  0.3 G/L was considered as a negative result, and any other combination as the positive result, the CBC model had high sensitivity (91.8%; CI 95%: 80.8%, 96.8%) at a relatively low specificity (58.3%; CI 95%: 38.8%, 75.5%). CONCLUSION: The combination of three CBC measurements is an immediately available and fairly accurate screening method for identification of lethargic and anorectic cats with increased risk of FP.

An evaluation of suspected cases of Hantavirus infection admitted to a tertiary care university hospital in Düzce, Turkey, between 2012 and 2018

Background/aim: Hantavirus is a rodent borne zoonosis caused by the members of the virus family Bunyaviridae, genus Hantavirus. In this study, we aimed to determine the role of peripheral blood leukocyte ratio in differential diagnosis of Hantavirus disease. Materials and methods: The medical records of patients at the Düzce University Medical Faculty were examined retrospectively. A total of 20 patients diagnosed with hantavirus infection confirmed by serologic tests were included in the study (Group 1). The other group consisted of 30 patients suspected of hantavirus infection but found negative (Group 2). Demographic, clinical and laboratory characteristics, neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), and lymphocyte/monocyte (LMR) ratios of both groups were compared. Results: As a result of the istatistics analysis, no difference was found between the groups' age, sex, and clinical complaints except lethargy-weakness (P = 0.004) and diarrhea (P < 0.001). Hemogram analysis showed a significant difference between the groups in terms of leukocyte, hemoglobin, hematocrit, platelet, mean platelet volume (P < 0.05) and PLR (P = 0.001) and LMR (P = 0.003) values from peripheral blood leukocyte ratios. Conclusion: In conclusion, NLR, PLR, and LMR ratios may be useful for clinicians in differential diagnosis of Hantavirus in patients presenting with similar symptoms of Hantavirus disease.

Expanding the clinical spectrum of mitochondrial 3-hydroxy-3-methylglutaryl-CoA synthase deficiency with Turkish cases harboring novel HMGCS2 gene mutations and literature review.

Mitochondrial 3-hydroxy-3-methylglutaryl-CoA synthase (mHS) deficiency is a very rare autosomal recessive inborn error of ketone body synthesis and presents with hypoketotic hypoglycemia, metabolic acidosis, lethargy, encephalopathy, and hepatomegaly with fatty liver precipitated by catabolic stress. We report acute presentation of two patients from unrelated two families with novel homozygous c.862C>T and c.725-2A>C mutations, respectively, in HMGCS2 gene. Affected patients had severe hypoketotic hypoglycemia, lethargy, encephalopathy, severe metabolic and lactic acidosis and hepatomegaly after infections. Surprisingly, molecular screening of the second family showed more affected patients without clinical findings. These cases expand the clinic spectrum of this extremely rare disease.

A 21st Century Problem: Cannabis Toxicity in a 13-Month-Old Child.

BACKGROUND: Cannabis is one of the most abused drugs worldwide, with more than 20 million users in the United States (US). As access to cannabis products increases with expanding US legislation and decriminalization of marijuana, emergency physicians must be adept in recognizing unintentional cannabis toxicity in young children, which can range from altered mental status to encephalopathy and coma. CASE REPORT: We report the case of a 13-month-old female presenting with self-limiting altered mental status and lethargy, with a subsequent diagnosis of tetrahydrocannabinol exposure on confirmatory urine gas chromatography-mass spectrometry. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Considering caretakers rarely report possible cannabis exposure, history-taking must review caretakers' medicinal and recreational drug exposures to prevent inadvertently missing the diagnosis. In the young child with altered mental status, prompt urine screening for cannabinoid detection can prevent further invasive and costly diagnostic investigations, such as brain imaging and lumbar puncture.

Listeria Meningitis in an Immunocompetent Child: Case Report and Literature Review

We present a case of a 23 month-old boy presenting with fever, irritability and diarrhea who subsequently developed symptoms of photophobia and lethargy. Cerebrospinal fluid culture grew Listeria monocytogenes. Immunology investigations were normal. This patient had a complete and uncomplicated recovery. Listeria meningitis is a rare presentation in immunocompetent children, but should be considered in the setting of diarrhea, failure to respond to cephalosporin therapy, or suspected immunodeficiency.

Food Protein-Induced Enterocolitis Syndrome: Proposals for New Definitions.

Acute food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated allergy and is characterized by repetitive profuse vomiting episodes, often in association with pallor, lethargy, and diarrhea, presenting within 1-4 h from the ingestion of a triggering food. In 2017, the international consensus guidelines for the diagnosis and management of FPIES were published. They cover all aspects of this syndrome, which in recent decades has attracted the attention of pediatric allergists. In particular, the consensus proposed innovative diagnostic criteria. However, the diagnosis of acute FPIES is still currently discussed because the interest in this disease is relatively recent and, above all, there are no validated panels of diagnostic criteria. We propose some ideas for reflection on the diagnostic and suspicion criteria of acute FPIES with exemplary stories of children certainly or probably suffering from acute FPIES. For example, we believe that new definitions should be produced for mild forms of FPIES, multiple forms, and those with IgE-mediated symptoms. Moreover, we propose two clinical criteria to suspect acute FPIES and to refer the child to the diagnostic oral food challenge.

Pyruvate Carboxylase Deficiency Type C: A Rare Cause of Acute Transient Flaccid Paralysis with Ketoacidosis.

Pyruvate carboxylase (PC) is a biotin-containing enzyme that is responsible for the adenosine triphosphate-dependent carboxylation of pyruvate to oxaloacetate, a key intermediate in the tricarboxylic acid cycle. PC deficiency (OMIM 266150) is a rare autosomal recessive metabolic disease, causing elevation of pyruvate, lactate, and alanine. Three types of PC deficiency have been described in the literature; A, B, and C. Type A PC deficiency, also called infantile or North American type, is characterized by infantile onset acidosis, failure to thrive, and developmental delay. The second subtype or type B, the neonatal or French form, presents usually in the neonatal period, mostly in the first 72 hours of life with severe lactic acidosis, truncal hypotonia, and seizures. The third type is called type C, is extremely rare with few cases published in the literature. In this case report, we present an 11-month-old girl who presented with acute flaccid paralysis, lethargy, and constipation with elevated ketones and lactate. She was confirmed genetically and biochemically to have PC deficiency type C. The patient's unusual presentation expands the clinical phenotype of this extremely rare disease.

Clinical and Laboratory Factors Associated with Severe Dengue: A Case-Control Study of Hospitalized Children.

Background: More than half of the hospitalizations because of dengue in Brazil occurred in children <15 years of age in 2007 and 2008, an unexpected change in the epidemiological pattern. We sought to determine clinical and laboratory parameters associated with severity. Methods: A case-control study was conducted in three pediatric hospitals in Rio de Janeiro, Brazil; 233 laboratory-confirmed dengue patients were included: 69 cases and 164 controls. Specific clinical and laboratory factors were assessed using univariate and multivariate logistic regression models. Results: Lethargy [adjusted odds ratio (ORa): 9.15, 95% confidence interval (CI): 3.08-27.12], dyspnea (ORa: 8.24, 95% CI: 3.27-20.72) and abdominal pain (ORa: 6.78, 95% CI: 1.44-31.84) were independently associated with severe dengue in children. Lethargy and dyspnea presented as early as 72 and 48 h, respectively, before shock. Conclusions: Abdominal pain and lethargy confirmed their role as warning signs, which along with dyspnea might be helpful in identifying cases progressing to severe dengue.

Relationship of time to presentation after onset of upper GI bleeding with patient characteristics and outcomes: a prospective study.

BACKGROUND AND AIMS: We performed a prospective multi-national study of patients presenting to the emergency department with upper GI bleeding (UGIB) and assessed the relationship of time to presentation after onset of UGIB symptoms with patient characteristics and outcomes. METHODS: Consecutive patients presenting with overt UGIB (red-blood emesis, coffee-ground emesis, and/or melena) from March 2014 to March 2015 at 6 hospitals were included. Multiple predefined patient characteristics and outcomes were collected. Rapid presentation was defined as ≤6 hours. RESULTS: Among 2944 patients, 1068 (36%) presented within 6 hours and 576 (20%) beyond 48 hours. Significant independent factors associated with presentation ≤6 hours versus >6 hours on logistic regression included melena (odds ratio [OR], 0.22; 95% CI, 0.18-0.28), hemoglobin ≤80 g/L (OR, 0.47; 95% CI, 0.36-0.61), altered mental status (OR, 2.06; 95% CI, 1.55-2.73), albumin ≤30 g/L (OR, 1.43; 95% CI, 1.14-1.78), and red-blood emesis (OR, 1.29; 95% CI, 1.06-1.59). Patients presenting ≤6 hours versus >6 hours required transfusion less often (286 [27%] vs 791 [42%]; difference, -15%; 95% CI, -19% to -12%) because of a smaller proportion with low hemoglobin levels, but were similar with regard to hemostatic intervention (189 [18%] vs 371 [20%]), 30-day mortality (80 [7%] vs 121 [6%]), and hospital days (5.0 ± 0.2 vs 5.0 ± 0.2). CONCLUSIONS: Patients with melena alone delay their presentation to the hospital. A delayed presentation is associated with a decreased hemoglobin level and increases the likelihood of transfusion. Other outcomes are similar with rapid versus delayed presentation. Time to presentation should not be used as an indicator for poor outcome. Patients with delayed presentation should be managed with the same degree of care as those with rapid presentation.

Acute intoxication due to Wisteria floribunda seed in seven young children.

BACKGROUND: Wisteria floribunda is a vine commonly found in Korea, Japan, and the USA. The objective of this observational study was to assess the toxicity of W. floribunda seeds in young children. METHODS: Of 28 children in a kindergarten who participated in a field trip, seven ingested W. floribunda seeds: six half of the seed and one a whole seed. These seven children were admitted to the Gachon University Gil Medical Center in Incheon, Korea. RESULTS: All of the children had vomiting within 4 h of ingesting the W. floribunda seed; the child who ingested a whole seed began to vomit 2 h after ingestion. By 5 h after ingestion, they all complained of abdominal pain and one child was lethargic. Leukocytosis was observed in all of the children. Abdominal pain and vomiting subsided in all of the children within 2 days after admission. The average duration of hospitalization was 3.1 days. CONCLUSIONS: W. floribunda seed ingestion induced gastrointestinal and neurologic symptoms in these young children. Given that the onset of vomiting was earlier in the child who ingested a whole seed than in the children who had ingested only a half, the amount of ingested seeds may be associated with the severity of the symptoms. Ingestion of half a raw W. floribunda seed can cause gastrointestinal symptoms in young children and even result in hospitalization.

Unintentional Marijuana Exposure Presenting as Altered Mental Status in the Pediatric Emergency Department: A Case Series.

BACKGROUND: Unintentional tetrahydrocannabinol (THC) exposure in pediatric patients can present as altered mental status. Altered mental status in a pediatric patient often leads to invasive diagnostic testing. CASE REPORT: The following cases describe 3 pediatric patients in Washington state who presented to a tertiary care children's hospital emergency department (ED) with altered mental status, later found to have urine toxicology screening positive for inactive THC metabolite (positive THC toxicology screen). Case 1 is a 6-year-old boy who presented with vomiting, lethargy, and hallucinations. Case 2 is a 5-year-old girl who presented with nausea, slurred speech, ataxia, and lethargy in the setting of a minor head injury. Case 3 is a 7-month-old boy who presented with vomiting and lethargy in the setting of a minor fall the day prior to ED evaluation. All children had extensive work-ups before the diagnosis was made; 2 were discharged home and 1 was admitted to the pediatric intensive care unit. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As access to marijuana increases with growing legalization, it is important to be familiar with state marijuana legislation, to consider and ask families about access to marijuana products as a potential contributor to altered mental status, and to be aware of potential caretaker reluctance regarding disclosure of marijuana use secondary to perceived stigma. Maintaining awareness of the clinical effects of THC exposure in children may limit invasive testing in a hemodynamically stable child with altered mental status.

Comparison of Lactic Acid Levels in Children with Suspected and Confirmed Intussusception.

BACKGROUND: Currently, no laboratory test can identify children with intussusception. Lactic acid is a marker of ischemia in gastrointestinal emergencies. OBJECTIVES: We present a case series comparing lactic acid levels in children with suspected and confirmed intussusception. METHODS: This is a prospective single case series of 39 patients who had suspected intussusception. Patients were eligible if they underwent abdominal ultrasound screening for suspected intussusception. Blood collected at the time of peripheral intravenous line placement was analyzed for lactic acid levels before ultrasound. RESULTS: Thirty-nine patients were enrolled; 16 were diagnosed with intussusception. Mean (± standard deviation) lactic acid levels were not significantly different between children with suspected (1.7 ± 0.69 mmol/L) and confirmed intussusception (1.93 ± 1.13 mmol/L). CONCLUSIONS: Lactic acid levels cannot identify children with intussusception.

Making the Quick Diagnosis: A Case of Neonatal Shock.

BACKGROUND: The work-up and initial management of a critically ill neonate is challenging and anxiety provoking for the Emergency Physician. While sepsis and critical congenital heart disease represent a large proportion of neonates presenting to the Emergency Department (ED) in shock, there are several additional etiologies to consider. Underlying metabolic, endocrinologic, gastrointestinal, neurologic, and traumatic disorders must be considered in a critically ill infant. Several potential etiologies will present with nonspecific and overlapping signs and symptoms, and the diagnosis often is not evident at the time of ED assessment. CASE REPORT: We present the case of a neonate in shock, with a variety of nonspecific signs and symptoms who was ultimately diagnosed with tachycardia-induced cardiomyopathy secondary to a resolved dysrhythmia. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights the diagnostic and therapeutic approach to the critically ill neonate in the ED, and expands the differential diagnosis beyond sepsis and critical congenital heart disease. Knowledge of the potential life-threatening etiologies of shock in this population allows the Emergency Physician to appropriately test for, and empirically treat, several potential etiologies simultaneously. Additionally, we discuss the diagnosis and management of supraventricular tachycardia and Wolff-Parkinson-White syndrome in the neonatal and pediatric population, which is essential knowledge for an Emergency Physician.

Simplified antibiotic regimens compared with injectable procaine benzylpenicillin plus gentamicin for treatment of neonates and young infants with clinical signs of possible serious bacterial infection when referral is not possible: a randomised, open-label, equivalence trial.

BACKGROUND: WHO recommends hospital-based treatment for young infants aged 0-59 days with clinical signs of possible serious bacterial infection, but most families in resource-poor settings cannot accept referral. We aimed to assess whether use of simplified antibiotic regimens to treat young infants with clinical signs of severe infection was as efficacious as an injectable procaine benzylpenicillin-gentamicin combination for 7 days for situations in which hospital referral was not possible. METHODS: In a multisite open-label equivalence trial in DR Congo, Kenya, and Nigeria, community health workers visited all newborn babies at home, identifying and referring unwell young infants to a study nurse. We stratified young infants with clinical signs of severe infection whose parents did not accept referral to hospital by age (0-6 days and 7-59 days), and randomly assigned each individual within these strata to receive one of the four treatment regimens. Randomisation was stratified by age group of infants. An age-stratified randomisation scheme with block size of eight was computer-generated off-site at WHO. The outcome assessor was masked. We randomly allocated infants to receive injectable procaine benzylpenicillin-gentamicin for 7 days (group A, reference group); injectable gentamicin and oral amoxicillin for 7 days (group B); injectable procaine benzylpenicillin-gentamicin for 2 days, then oral amoxicillin for 5 days (group C); or injectable gentamicin for 2 days and oral amoxicillin for 7 days (group D). Trained health professionals gave daily injections and the first dose of oral amoxicillin. Our primary outcome was treatment failure by day 8 after enrolment, defined as clinical deterioration, development of a serious adverse event (including death), no improvement by day 4, or not cured by day 8. Independent outcome assessors, who did not know the infant's treatment regimen, assessed study outcomes on days 4, 8, 11, and 15. Primary analysis was per protocol. We used a prespecified similarity margin of 5% to assess equivalence between regimens. This study is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12610000286044. FINDINGS: In Kenya and Nigeria, we started enrolment on April 4, 2011, and we enrolled the necessary number of young infants aged 7 days or older from Oct 17, 2011, to April 30, 2012. At these sites, we continued to enrol infants younger than 7 days until March 29, 2013. In DR Congo, we started enrolment on Sept 17, 2012, and continued until June 28, 2013. We randomly assigned 3564 young infants to either group A (n=894), group B (n=884), group C (n=896), or group D (n=890). We excluded 200 randomly assigned infants, who did not fulfil the predefined criteria of adherence to treatment and adequate follow-up. In the per-protocol analysis, 828 infants were included in group A, 826 in group B, 862 in group C, and 848 in group D. 67 (8%) infants failed treatment in group A compared with 51 (6%) infants in group B (risk difference -1·9%, 95% CI -4·4 to 0·1), 65 (8%) in group C (-0·6%, -3·1 to 2·0), and 46 (5%) in group D (-2·7%, -5·1 to 0·3). Treatment failure in groups B, C, and D was within the similarity margin compared with group A. During the 15 days after random allocation, 12 (1%) infants died in group A, compared with ten (1%) infants in group B, 20 (2%) infants in group C, and 11 (1%) infants in group D. An infant in group A had a serious adverse event other than death (injection abscess). INTERPRETATION: The three simplified regimens were as effective as injectable procaine benzylpenicillin-gentamicin for 7 days on an outpatient basis in young infants with clinical signs of severe infection, without signs of critical illness, and whose caregivers did not accept referral for hospital admission. FUNDING: Bill & Melinda Gates Foundation grant to WHO.