A Giant Parathyroid Adenoma Presenting as Nausea, Vomiting, and Headaches in an Adolescent Male.

Primary hyperparathyroidism is rare in the pediatric population and is typically caused by a single parathyroid adenoma. Parathyroid adenomas are almost always small and not palpable on exam but can be evaluated by neck ultrasonography or 99 m Tc-sestamibi scan. Surgical resection is the only curative treatment. In this case, a 16-year-old male presents with a 10-day history of nausea, vomiting, and headaches and is found to have a highly elevated calcium and parathyroid hormone level and a cerebral calcification in his frontal lobe noted on computed tomography. He had a palpable mass over the region of his left inferior parathyroid gland which was surgically resected with histopathology revealing a giant parathyroid adenoma. Giant parathyroid adenomas are exceptionally rare in children and adolescents and are more likely to present with severe hypercalcemic crisis than smaller adenomas. As early symptoms are often nonspecific, awareness of this clinical entity is important. There are several reports of basal ganglia calcifications in the setting of parathyroid adenoma, but, to our knowledge, this is the first report of a patient with frontal lobe calcification.

Assessing and Improving WIC Enrollment in the Primary Care Setting: A Quality Initiative.

BACKGROUND AND OBJECTIVES: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides food and other resources to mitigate the harmful effects of food insecurity on child and maternal health. From a 2009 peak, nationwide WIC participation declined through 2020. Our objectives were to understand factors influencing WIC engagement and improve WIC enrollment through novel, primary care-based quality improvement interventions. METHODS: Plan-do-study-act cycles were implemented at a majority Medicaid-insured pediatric primary care clinic. Universal WIC screening at <5-year-old well-child visits was initiated, with counseling and referrals offered to nonparticipants. Clinic providers received WIC education. WIC screening, counseling reminders, and referrals were streamlined via the electronic health record. Families were surveyed on WIC participation barriers. Patient demographic data were analyzed for predictors of WIC participation. RESULTS: Mean new WIC enrollments increased significantly (42%) compared with baseline, with sustained special cause variation after study interventions. Provider WIC knowledge improved significantly at study end (P <.001). Rates of WIC screening, counseling, and referrals remained stable for >1 year after study interventions. The most common family-reported barriers to WIC participation were "Access problems" and "WIC knowledge gap." Factors associated with decreased WIC participation in multivariable analysis were increasing age (P <.001), and non-Medicaid insurance status (P = .03). CONCLUSIONS: We demonstrate feasible primary care-based screening, education, and referral interventions that appear to improve WIC enrollment. We identify knowledge gap and access problems as major potentially modifiable barriers to WIC participation. The expansion of similar low-cost interventions into other settings has the potential to benefit under-resourced children and families.

Diagnosis of Bacterial Tracheostomy-Associated Respiratory Tract Infections in Pediatric Patients.

OBJECTIVES: To identify demographic and clinical characteristics of children with fever and/or respiratory illness associated with a diagnosis of bacterial tracheostomy-associated respiratory tract infections (bTARTI). Secondary objectives included comparison of diagnostic testing, length of stay (LOS), and readmission rates between children diagnosed with bTARTI and others. METHODS: We performed a retrospective chart review of encounters over 1 year for fever and/or respiratory illness at a single academic children's hospital for children with tracheostomy dependence. Patient characteristics, features of presenting illness, and laboratory and imaging results were collected. Generalized linear mixed models were employed to study associations between patient characteristics, diagnosis of bTARTI, and impact on LOS or readmission rates. RESULTS: Among 145 children with tracheostomies identified, 79 children contributed 208 encounters. bTARTI was diagnosed in 66 (31.7%) encounters. Significant associations with bTARTI diagnosis included chest radiograph consistent with bacterial pneumonia (odds ratio [OR], 1.77; 95% confidence interval [CI], 1.50-2.08), positive tracheal aspirate culture (OR, 1.3; 95% CI, 1.05-1.61), higher white blood cell count (16.4 vs 13.1 × 103/µ; P = .03), change in oxygen requirement (OR, 1.14; 95% CI, 1.00-1.31), telephone encounter (OR, 1.41; 95% CI, 1.09-1.81), and living at home with family (OR, 1.42; 95% CI, 1.06-1.92). LOS for admitted patients with bTARTI was 2.19 times longer (CI, 1.23-3.88). CONCLUSIONS: In our single-center study, we identified several clinical and nonclinical factors associated with a diagnosis of bTARTI. Despite widespread use, few laboratory tests were predictive of a diagnosis of bTARTI. There is need for standardization in diagnosis.

A "Boil" Being the Clue to Think beyond Typical Bacterial Pathogens in Community-Acquired Pneumonia.

Empyema necessitans is an exceptionally rare complication of bacterial pneumonia in the pediatric population. It occurs when the infection extends from the lung parenchyma to the chest wall by forming a fistula, which leads to infection of the surrounding soft tissue. In this case, a 13-year-old boy is found to have empyema necessitans caused by Actinomyces meyeri, with a preceding clue to the diagnosis being that he was treated for a superficial chest wall abscess several weeks prior to developing significant respiratory symptoms. Providers should be aware of this entity as it requires obtaining cultures to identify the appropriate pathogen and avoid treatment failure as it has implications for antibiotic choice and length of therapy.

Clinical Characteristics and Health Outcomes of Neonates Reporting to the Emergency Department With Hypothermia.

OBJECTIVES: Although hypothermia has long been considered a sign of serious bacterial infection (SBI) in neonates, there is a lack of medical literature on this topic, and little is known about the prevalence of serious infection in these patients. Our primary objective was to assess the prevalence and type of serious infection in neonates with hypothermia. Our secondary objective was to describe the prevalence and type of significant pathology overall in this cohort. METHODS: We examined neonates (≤28 days old) evaluated in the emergency department and/or admitted to the hospital with hypothermia over a 3-year period. Demographics and relevant clinical data were extracted from the medical record. Fisher's exact test was used to determine differences in the prevalence of clinical and demographic characteristics in patients with and without a diagnosis of serious infection. RESULTS: Sixty-eight neonates met inclusion criteria, and 63 (93%) were admitted. Of those admitted to the hospital, 5 (7.9%) had a diagnosis of serious infection, including SBI (n = 4) and disseminated herpes simplex virus (n = 1). The types of SBI included urinary tract infection, septicemia, and meningitis. Eighty percent and 60% of neonates with hypothermia and diagnosed with serious infection had a temperature ≤34.4°C and ill appearance, respectively. Significant pathology was found in 9 (14.3%) patients and included both infectious and noninfectious diagnoses. CONCLUSIONS: Neonates presenting with hypothermia have a substantial risk for SBI or other significant pathology. This population merits further investigation; a multicenter prospective study should be conducted to better understand associations between risk factors and outcomes.

Recurrent Encephalopathy During Febrile Illnesses in a 6-Year-Old Boy.

Acute onset of encephalopathy is often due to infections or intoxications, but a high index of suspicion should exist for metabolic or autoimmune causes particularly in recurrent cases. A 6-year-old previously healthy Caucasian male presented with confusion and somnolence. He had several days of fever, myalgia, headaches, and rhinorrhea and was influenza-A positive. He was noted to have new urinary incontinence, inability to follow commands, and was responsive only to noxious stimuli. His neurological examination revealed bilateral ankle clonus. Laboratory results were significant for hypoglycemia and high anion gap metabolic acidosis. Cerebrospinal fluid was unremarkable and cultures remained negative. A magnetic resonance imaging (MRI) of the brain showed diffuse gray matter restricted diffusion. His presentation was attributed to acute influenza-A encephalitis. Four months later, he presented with emesis, abdominal pain, dehydration, and hypoglycemia. He subsequently developed dysarthria and confusion. A brain MRI was similar to his previous presentation. A repeat lumbar puncture was normal. A urine organic acid profile showed elevations of ketones and branched chain ketoacids, with mild elevations of N-acetylleucine and N-acetyl isoleucine. This pattern is consistent with maple syrup urine disease (MSUD). Genetic testing revealed that he is a heterozygote for 2 pathogenic variants in the BCKDHB gene (P200X and G278S), confirming MSUD. This case highlights the importance of broadening workup to include inborn errors of metabolism in cases of unexplained encephalopathy. Providers should be aware that diseases such as MSUD can occur in intermittent forms that may not be detected until early childhood.