Mercury Intoxication as a Rare Cause of Membranous Nephropathy in a Child.

In adults, membranous nephropathy is the second most common cause of nephrotic syndrome. In contrast, minimal change disease and focal segmental glomerulosclerosis constitute the most common forms of nephrotic syndrome in children, while membranous nephropathy accounts for <5% of cases. In adults, causes of membranous nephropathy include autoantibodies directed against phospholipase A2 receptor and thrombospondin type 1 containing 7A, various infections, environmental toxicities, autoimmune disorders, malignancies, and other secondary forms. The most common causes of secondary membranous nephropathy in children are infections, autoimmune diseases, and neoplasia. We discuss an unusual presentation of new-onset membranous nephropathy due to mercury toxicity in a 14-year-old male with reflux nephropathy. This case underscores the importance of a high index of suspicion for uncommon causes of nephrotic syndrome in pediatric patients with membranous nephropathy.

Safety and efficacy of milk and molasses enemas compared with sodium phosphate enemas for the treatment of constipation in a pediatric emergency department.

OBJECTIVES: The purpose of this study was to determine the safety and efficacy of routine milk and molasses enemas (MME) compared with sodium phosphate enemas for the treatment of constipation in the pediatric emergency department (ED). A secondary objective included the identification of factors associated with enema selection in the pediatric ED. METHODS: This study was approved by the University of Texas Southwestern Medical Center Institutional Review Board. The study design was a retrospective comparative chart review. Medical records of patients who presented to the ED and received either MME or sodium phosphate enema for constipation between November 1, 2007, and November 1, 2008, were identified and reviewed for data collection. The following data were collected to determine safety and efficacy: baseline demographics, chief complaint, medical history, radiographic imaging, enema type, treatment dose, adverse effects, improvement in symptoms, time until defecation, failure of initial therapy requiring additional intervention, and time from treatment until disposition. RESULTS: Both treatment groups had similar baseline characteristics. No statistically significant differences in treatment effect were noted between MME and sodium phosphate enemas. Several clinically significant trends were noted including the need for additional rectal treatment after administration of sodium phosphate enemas versus oral therapy after MME. In addition, there were 6 cases of treatment failure with sodium phosphate enemas versus 1 case with MME. CONCLUSIONS: No statistically significant differences were found between MME and sodium phosphate enemas. Based on our results, the 2 treatment options were found to be equally safe and effective.

Crotalidae polyvalent immune Fab for the treatment of pediatric crotaline envenomation.

Crotaline snakebites occur frequently in children, often resulting in significant morbidity. Crotalidae Polyvalent Immune Fab antivenom (FabAV) became available for clinical use in the US in 2000 and is currently the standard of care for the treatment of crotaline envenomation. The pediatric emergency care provider should be familiar with FabAV because its judicious use in affected children can greatly decrease morbidity caused by crotaline snakebites. This article will review the use of FabAV for the treatment of pediatric crotaline envenomation.

Rattlesnake envenomation with neurotoxicity refractory to treatment with crotaline Fab antivenom.

INTRODUCTION: Neurotoxicity following rattlesnake envenomation is reported with certain crotaline species. In some instances, crotaline Fab antivenom therapy that effectively halts progression of local tissue edema and hemotoxicity fails to reverse neurologic venom effects. CASE SERIES: A 50-year-old man presented following a rattlesnake envenomation to the left ring finger. He had swelling and pain in the affected hand and complained of dyspnea and dysphonia. Significant fasciculations were seen in the face, tongue, neck, trunk, and arms. The patient received crotaline Fab antivenom but continued to develop worsening respiratory distress. His respiratory insufficiency requiring ventilatory support appeared related to respiratory muscle incoordination as extremity motor function remained intact. Initial control of local edema progression and hematologic parameters was achieved with antivenom, but diffuse fasciculations involving the entire body worsened despite aggressive antivenom treatment. In another case, a 9-year-old boy was envenomated by a rattlesnake on the left thenar eminence. He presented with pain and swelling up to the forearm and fasciculations of the tongue, face, and upper extremities. The progression of edema was halted at the mid-bicep level and hematologic parameters normalized with crotaline Fab antivenom. However, fasciculations continued for two days despite antivenom treatment. CONCLUSION: We describe two cases of neurotoxicity following rattlesnake envenomation in which treatment with crotaline Fab antivenom adequately obtained initial control of local swelling and hematologic effects, but neurotoxic venom effects remained refractory to antivenom therapy. This phenomenon is anecdotally recognized following certain crotaline species envenomations.

Adequacy of surveillance to detect endemic rubella transmission in the United States.

BACKGROUND: Reported rubella cases in the United States are at the lowest numbers since the introduction of vaccine, suggesting that endemic transmission may have been interrupted. It is necessary to validate that the observed absence of rubella is due to the disappearance of disease rather than a failure of rubella surveillance. METHODS: Adequate rubella surveillance to detect ongoing transmission is characterized by evidence that rubella investigations are being conducted, detection of importations, and lack of spread from confirmed cases. We reviewed rubella surveillance data and activities from 5 sources: (1) data reported to the national surveillance system; (2) a survey of health departments and public health laboratories, including questions regarding any links between measles and rubella surveillance; (3) enhanced rubella surveillance activities in California and in New York City; (4) sentinel surveillance along the US-Mexico border; and (5) case detection in 8 large health maintenance organizations (HMOs). RESULTS: During 2002-2004, 35 cases of rubella were reported to the national system, including 12 (34%) imported cases. The 39 programs that responded to our survey reported conducting 1482 investigations for rubella; according to another national survey, 1921 investigations were conducted for measles. Forty-one laboratories responded to our survey and reported conducting 6428 tests for acute rubella. No previously undetected (or unreported) cases of rubella or congenital rubella syndrome were identified by our survey or reviews of surveillance in California, New York, and along the US-Mexico border, and no additional cases were detected in the HMO database. CONCLUSIONS: No previously unrecognized spread cases or outbreaks of rubella were detected. Surveillance in the United States is sufficiently sensitive to identify indigenous cases of rubella, if they were occurring, supporting the contention that rubella has been eliminated from the United States.

Cluster of Acute Toxicity from Ingestion of Synthetic Cannabinoid-Laced Brownies.

INTRODUCTION: Synthetic cannabinoid receptor agonists (SCRAs) are emerging designer drugs of abuse. Most reports on the health effects of these drugs are case reports. Unlike SCRAs, marijuana has classically been used via many routes of exposure including oral, such as in brownies. We report on 11 symptomatic patients who unknowingly ingested brownies laced with analytically confirmed SCRA and presented with mostly neuropsychiatric and cardiovascular symptoms. CASE SERIES: All 11 patients were taken to the ED within 1 h of exposure with the onset of various symptoms. There were five males and six females, age range 20-57 years. Neuropsychiatric and cardiovascular symptoms predominated: memory impairment (91 %, 10/11) and inappropriate giggling (36 %, 4/11). All the patients had light-headedness, perioral and facial numbness and tingling sensation, dry mouth, difficulty focusing/blurring of vision, and sluggishness. No patient had depressed consciousness. Two patients had heart rates >100, and 4 of 11 (36 %) had BP >140/80. One patient had chest pain. All the symptoms were completely resolved 4 h following their onset except two patients who had ongoing weakness and fatigue. All patients had negative urine drugs of abuse immunoassays and ethanol, acetaminophen, and salicylate concentrations, as well as normal electrocardiograms (ECGS) and metabolic panels. The SCRA was confirmed to be AM-2201. All the patients were discharged from the ED in stable condition within 10 h of the exposure. CONCLUSION: Oral exposure of 11 patients to brownies laced with analytically confirmed SCRA resulted in neuropsychiatric and cardiovascular symptoms. This series reflects that like marijuana, oral exposures to SCRAs can lead to symptoms.

Diagnosis of Streptococcus pneumoniae lower respiratory infection in hospitalized children by culture, polymerase chain reaction, serological testing, and urinary antigen detection.

A prospective study of 154 consecutive high-risk hospitalized children with lower respiratory infections was conducted to determine the clinical utility of a pneumolysin-based polymerase chain reaction (PCR) assay compared with blood and pleural fluid cultures and serological and urinary antigen tests to determine the incidence of Streptococcus pneumoniae. Whole blood, buffy coat, or plasma samples from 67 children (44%) tested positive by PCR. Sensitivity was 100% among 11 promptly tested culture-confirmed children and specificity was 95% among control subjects. Age, prior oral antibiotic therapy, and pneumococcal nasopharyngeal colonization did not influence PCR results, whereas several surrogates of disease severity were associated with positive tests. Although serological and urinary antigen tests had comparable sensitivity, specificity varied among infected children, and statistical agreement among all assays was limited. These findings support the use of PCR tests to evaluate the protective efficacy of pneumococcal conjugate vaccines and to identify promptly children with pretreated or nonbacteremic pneumococcal lower respiratory infections.

Benzonatate toxicity in a teenager resulting in coma, seizures, and severe metabolic acidosis.

We report a benzonatate overdose in a teenager resulting in life-threatening toxicity to increase awareness of this overdose, and discuss recent pediatric warnings and labeling information provided by the US Food and Drug Administration (FDA). After an overdose of benzonatate, a 13-yr-old female presented to our emergency department with coma, seizures, hypotension, prolonged QT interval on electrocardiogram, and metabolic acidosis. Benzonatate is an antitussive medication with sodium channel-blocking properties and local anesthetic effects on the respiratory stretch receptors due to a tetracaine-like metabolite. Overdose is reported to cause coma, seizures, hypotension, tachycardia, ventricular dysrhythmias, and cardiac arrest. The FDA recently issued a Drug Safety Communication warning that accidental benzonatate ingestion in children younger than 10 years of age have increased risk of death and added the new information to the Warnings and Precautions section of benzonatate's label.

Cheese: an old drug in a new wrapper.

BACKGROUND: An unexpected outbreak of "cheese" heroin, which contained diphenhydramine and usually acetaminophen, began in Dallas around 2004. Onset occurred among youths living in neighborhoods populated by first-generation Hispanic immigrants. Little was known about the problem or the social strengths and deficits of these youth, who were primarily inhalers ("snorters") but at risk of transitioning to injection. METHODS: Multiple data sources were used, including surveys, data from emergency departments, law enforcement, treatment programs, and coroner, and interviews with users and key informants. RESULTS: Among heroin users under age 20, overdose deaths peaked in 2006, the school survey responses to using "cheese" heroin peaked in 2007, and treatment admissions peaked in 2008. Hispanic youth entering treatment were less likely to be injectors and report fewer problems than their Anglo counterparts and they were more likely to live with their families and to be supported by them. Sixty percent of the Hispanic youth had been in treatment previously and only 53% completed treatment. Cocaine and/or benzodiazepines were involved in 32% of the adolescent heroin deaths. CONCLUSIONS: The timely use of multiple data sources enabled this outbreak to be quickly identified and monitored, and the Cheese Heroin Task Force used the collected data to help respond to the problem, although retention in treatment and readmissions remained problematic. Cultural problems including immigration status, language, and misunderstandings about the nature of treatment were barriers to successful treatment outcomes. Completion of treatment as an inhaler is critical to reducing the likelihood of transitioning to injection.

A pilot pharmacokinetic study of tricyclic antidepressant ovine Fab for TCA poisoning in children.

CONTEXT: A pilot study of tricyclic antidepressant (TCA)-specific antibody fragments (TCA Fab) in TCA-intoxicated adults showed a marked increase in serum total TCA concentrations following TCA Fab infusion with no worsening signs of TCA toxicity. TCA Fab pharmacokinetics (PK) was not described in this adult study. The objective of this study was to evaluate the PK of TCA Fab in children with TCA poisoning. METHODS: This was an open-label, single-center, dose escalation pilot trial of three patients. Inclusion criteria were documented TCA ingestion with at least one serious complication (QRS prolongation, dysrhythmia, hypotension, seizure, or coma). Patients were assigned to either a low-dose intravenous TCA Fab regimen (15, 30, and 60 mg/kg) or a high-dose regimen (30, 60, and 120 mg/kg) as needed to reverse TCA toxicity. Following the administration of TCA Fab, samples of blood and urine were obtained for PK evaluations. The outcomes of interest were serum and urine TCA concentrations (free and total), serum and urine Fab concentrations, improvement or worsening of TCA toxicity, and adverse effects. RESULTS: Three study patients were 11, 11, and 14 years of age. Two patients received 15 mg/kg of TCA Fab and one patient received a total of 90 mg/kg of TCA Fab (30 + 60 mg/kg). Serum-bound TCA increased significantly following TCA Fab administration with concomitant enhanced urinary elimination. Serum-free TCA concentrations were minimal to undetectable. Fab data were available for two patients. The serum TCA Fab area under the curve was 306.12 mg/L/h for the 15 mg/kg dose and 2,198.10 mg/L/h for the 90 mg/kg dose of TCA Fab. Maximum Fab concentrations correlated with maximum bound TCA in serum. The volume of distribution (V(D)) of TCA Fab was 0.2-0.3 L/kg. The clearance was 0.036-0.05 L/kg/h and the elimination half-life was 4 h. No adverse effects were observed. CONCLUSION: The limited PK data from this study are consistent with binding of TCA to TCA Fab and redistribution of TCA from the tissue to serum with subsequent enhanced urinary excretion of TCA. No toxic effects were observed with increased total TCA concentrations and no adverse effects were observed following TCA Fab administration. The small number of patients in this pilot study does not allow for safety or efficacy conclusions.

Opisthotonic posturing with neuromuscular irritability attributable to 4-aminopyridine ingestion by a healthy pediatric patient.

INTRODUCTION: 4-Aminopyridine (4-AP) is a potassium channel blocker used to increase muscle strength in the treatment of demyelinating diseases such as multiple sclerosis. We describe a case of ingestion by an 8-month-old child that resulted in severe but transient symptoms. CASE REPORT: An 8-month-old boy was found with greenish saliva, and a capsule with green 4-AP powder was missing. On arrival to an emergency department, he was jittery, tachycardic, and tachypneic. Activated charcoal, a cathartic, and midazolam (0.5 mg/kg) were administered before transfer to a tertiary pediatric hospital. On arrival, the infant remained tachycardic and tachypneic. His eyes deviated upward and he was noted to have 3+ deep tendon reflexes bilaterally. He was administered 0.9% normal saline (20 mL/kg) for a wide pulse pressure with low diastolic blood pressure. The patient developed dramatic opisthotonic posturing and vermiform tongue fasciculations. The symptoms responded well to repeated intravenous doses of benzodiazepines. In this case, we used 2 doses of lorazepam (0.05 mg/kg each). During opisthotonic posturing, an electroencephalogram performed in the intensive care unit revealed no evidence of seizure activity. Within 20 hours after admission, the patient became asymptomatic. CONCLUSION: This case is, to our knowledge, the first documented pediatric 4-AP ingestion. Clinical signs and symptoms are described as well as the response to therapy with benzodiazepines. The electroencephalogram performed while the patient was symptomatic was negative for seizures.