Are We Over-Treating Insect Bite Related Periorbital Cellulitis in Children? The Experience of a Large, Tertiary Care Pediatric Hospital.

INTRODUCTION: Preseptal (periorbital) and orbital cellulitis are potentially catastrophic infections near the eye. Preseptal cellulitis is far more common, and although classically reported to be associated with dacrocystitis, sinusitis/upper respiratory infection, trauma/surgery, or infection from contiguous areas, it can also be associated with insect bites. The objective of this study was to determine the prevalence of insect bite-associated preseptal cellulitis and to compare clinical findings and outcomes of these patients with those having other causes for the condition. METHODS: Retrospective chart review of children with a final discharge diagnosis of periorbital cellulitis from January 2009 to December 2014 at a tertiary care children' hospital. RESULTS: 213 children were diagnosed with preseptal cellulitis during the 5-year study period, of whom 60 (28%) were associated with insect bites. Patients in the noninsect bite group more commonly had fever at presentation (P < 0.001), with increased white blood cell and C reactive protein values (both P < 0.001). No patient with insect bite-associated preseptal cellulitis presented with fever, and none underwent radiographic testing or computerized tomography; their mean age was also lower (P < 0.001) and length of stay was significantly shorter. CONCLUSIONS: This study suggests that children with preseptal cellulitis associated with insect bites could be candidates for oral antibiotic therapy with outpatient follow-up by.

Severe Allergic Contact Dermatitis From Temporary "Black Henna" Coloring of the Hair During Religious Cultural Celebrations: Three Different Cases, Same History.

Contact dermatitis after the application of temporary, paint-on, henna tattoos represents a well-known, potentially serious problem of active sensitization. We describe 3 cases involving 3 children of the same age who developed a severe contact dermatitis with massive face and neck swelling after application of black henna to their hair during "Purim" celebrations. All 3 cases had a history of having applied henna tattoos in the previous year with mild local reactions. Their reactions are presumed to be due to sensitization to para-phenylenediamine. Although reactions to henna are being increasingly reported, reactions of this severity seem to be rare and could lead to permanent skin changes.

Neuroleptic Malignant Syndrome Associated With Metoclopramide Use in a Boy: Case Report and Review of the Literature.

Neuroleptic malignant syndrome (NMS), an idiosyncratic reaction comprising muscular rigidity, altered level of consciousness, and autonomic dysfunction, is a rare but serious medical condition. It is most commonly precipitated by major tranquilizers such as butyrophenones, phenothiazines, and thioxanthines. Metoclopramide, a chlorbenzamide derivative with antidopaminergic properties, is widely used to treat nausea and emesis. We describe the first reported case of a boy who developed NMS in association with the use of this drug. A 13-year-old boy presented to the emergency department with a history of hyperthermia (42.6°C) and altered level of consciousness. He had recently had acute gastroenteritis and had been treated with metoclopramide 10 mg three times a day for 2 days. Vital signs were notable for hypotension, and physical examination revealed altered mental status with muscle rigidity. Laboratory testing revealed metabolic acidosis and increased prothrombin and partial thromboplastin times. He was actively cooled and received 3 rapid boluses, totaling 60 mL/kg, of isotonic crystalloids, for more than 20 minutes. Sepsis workup revealed no evidence of bacterial infection. He subsequently recovered fully and was discharged home with pediatric follow-up. This case represents the first description of NMS in association with metoclopramide in a healthy boy. It demonstrates the importance of considering this diagnosis early in the course of disease in patients with muscular rigidity, altered level of consciousness and autonomic dysfunction, and the need to rapidly respond to the physiological aberrations.

Clinical characterization of idiopathic intracranial hypertension in children presenting to the emergency department: the experience of a large tertiary care pediatric hospital.

BACKGROUND: Idiopathic intracranial hypertension (IIH) is a syndrome characterized by elevated intracranial pressure, without evidence of intracranial mass lesion or venous thrombosis on brain imaging. The syndrome occurs mainly in young, fertile, and overweight women but may present in any age group. The aim of this study was to report the presentation, course, and outcomes of older versus younger children presenting with IIH to the emergency department of our large tertiary care hospital during an 8-year period. METHODS: Retrospective chart review (January 2000-December 2008) of all patients younger than 17 years with IIH was performed on the basis of modified Dandy Criteria. The patients were analyzed according to age (<11 years and 11-17 years) and weight centile (<90%, 90%-97%, >97%). RESULTS: Ages ranged from 2 to 16.5 years (mean [SD], 9.71 [4.56] years). Thirty males (46.8%) and 33 females (53.2%) were identified: 30 were prepubertal with a male-female ratio of 1:0.56 and 33 were pubertal with a male-female ratio of 1:2 (P < 0.05). There were no significant differences between the 2 age groups in proportions of children in the 3 predefined weight categories The most common presenting symptom was headache (75%), which was significantly less common in the younger age group compared with the older group (P < 0.01). Papilledema was present in 51 patients (82.3%). Mean (SD) cerebrospinal fluid opening pressure was 378 (16) mm H2O. Findings of brain imaging (mostly computed tomographic scan), performed in all patients, were normal in 42 (67.7%); the most common finding in the remainder was swelling of the optic nerves. CONCLUSIONS: Our results indicate that IIH should be considered in any child with new-onset headache or visual disturbance, irrespective of age, sex, weight, or the presence of known predisposing factors. When IIH is suspected, neuroimaging should be performed promptly to exclude secondary causes of this condition because IIH in children remains a diagnosis of exclusion. Early diagnosis and prompt treatment for IIH can prevent potential visual loss.

Propofol for pediatric colonoscopy: the experience of a large, tertiary care pediatric hospital.

Successful colonoscopy includes full visualization of the terminal ileum, especially in inflammatory bowel disease when ileal biopsy is essential. In children, higher levels of anxiety and lack of cooperation often necessitate a deeper level of sedation. The aim of this study was to evaluate the effectiveness of propofol compared with midazolam and fentanyl for colonoscopy, and in accomplishing ileal and cecal intubation in particular. This was a retrospective cohort study comparing the rates of successful colonoscopy in patients receiving propofol with those receiving midazolam/fentanyl. Complete, successful, colonoscopy to the terminal ileum was achieved in 78% of propofol patients compared with 66% of the midazolam/fentanyl group (P=0.004). Endoscopy reaching the cecum, but not the terminal ileum, was achieved in 78% of propofol patients and 66% of midazolam/fentanyl patients. The use of propofol was associated with a statistically significant increase in the rate of successful colonoscopy reaching the terminal ileum.

Pediatric electrical burn injuries: experience of a large tertiary care hospital and a review of electrical injury.

A retrospective review of all patients admitted between February 2004 and December 2009, with a diagnosis of burns associated with electrocution, was conducted at The Hospital for Sick Children, Toronto, Ontario, Canada. Data regarding type of electrocution and associated burns were collected. Of the 36 patients identified, 31 (86%) were shocked by electrical current, and 5 (14%) by lightning. Most burns associated with current were first degree (58%). The upper limbs, most frequently the wrist and arm (n = 23), were injured in 26 patients, and the lower limb in 2 patients, whereas 3 patients suffered multiple sites of injury. Twenty-eight patients were treated conservatively with dressings and minor surgical interventions such as debridement and primary repair. The remainder required excision and/or grafting. Fasciotomy and/or escharotomy were performed in 2 patients, and no one required amputation. Burns associated with electrical injuries remain a worldwide problem, responsible for considerable morbidity and mortality. They can usually be prevented through simple safety measures. An effective prevention program would help address this problem.

Late presentation of massive pleural effusion from intrathoracic migration of a ventriculoperitoneal shunt catheter: case report and review of the literature.

We report an unusual case of ventriculoperitoneal (VP) shunt intrathoracic migration, associated with massive symptomatic hydrothorax. The VP shunt was inserted 10 years before presentation, after hemorrhagic hydrocephalus caused by prenatal intraventricular hemorrhage. The pleural fluid was drained via tube thoracostomy and the shunt was externalized, with full resolution of symptoms and signs. The patient was subsequently managed with shunt revision with drainage into the abdominal cavity. We review the 10 pediatric cases of cerebrospinal fluid hydrothorax reported in the literature and discuss the mechanism of shunt tip migration. Pleural effusion secondary to VP shunt insertion is a rare and potentially life-threatening occurrence, and it should be suspected in any patient with a VP shunt and respiratory distress.

Incidence of traumatic lumbar puncture: experience of a large, tertiary care pediatric hospital.

The objective of this study was to establish the incidence of traumatic or unsuccessful lumbar punctures (LPs) in the authors' institution. This is a prospective study. Traumatic LP was defined as >400 red blood cells (RBCs) and unsuccessful LP as failure to obtain cerebrospinal fluid (CSF) after the first LP attempt. A total of 127 CSF were recorded over 1 year. The incidence of a traumatic LP was 27/103 (26.2%) using the sitting position and 3/24 (12.5%) in infants and children using the lying position. In total, 33 (26%) CSF samples had 0 RBCs. The incidence of traumatic LP was 24% when the procedure involved one LP and 50% when more than one attempt was required. RBC count was significantly lower in cases requiring only one attempt (P = .0074). Incidence of traumatic LP was independent of physicians' experience, sedation use or time of procedure, suggesting an intrinsic factor as the cause of traumatic LPs.