Congenital Syphilis Misdiagnosed as Suspected Nonaccidental Trauma.

Congenital syphilis (CS) is a preventable infection, yet the incidence has surged to the highest rates in 20 years. Because 50% of live-born infants with CS are asymptomatic at birth, there is an increasing likelihood that pediatric providers will encounter older infants whose diagnoses were missed at birth, emphasizing the importance of timely prenatal screening and treatment. We present one such case of an infant admitted twice at 3 and 4 months of age with long bone fractures and suspected nonaccidental trauma. On her second presentation, several additional symptoms prompted evaluation for and eventual diagnosis of CS. In this case, it is demonstrated that an isolated long bone fracture can be a first presentation of CS, with other classic findings possibly appearing later. Pediatric providers should be familiar with the varied presentations of CS in older children, including the radiographic findings that we describe. The rising rates of CS reveal deficiencies in our current strategy to prevent CS and, thus, we recommend reconsideration of universal syphilis screening in the third trimester and at delivery, with timely treatment to prevent CS during pregnancy.

International travel is a risk factor for extended-spectrum ß-lactamase-producing Enterobacteriaceae acquisition in children: A case-case-control study in an urban U.S. hospital.

BACKGROUND: Extended-spectrum ß-lactamase-producing Enterobacteriaceae (ESBL) infections are increasing in both adults and children. The aim of this study was to describe the epidemiology of children with ESBL in an ethnically-diverse population, to determine what proportion of these infections were community-onset, and to identify risk factors predisposing children to ESBL acquisition. METHODS: A case-case-control study of children aged 0-18 years was conducted from 2012 to 2014. Patients with ESBL (detected via VITEK2) were matched 1:1:5 (based on age, sex, specimen source, and healthcare setting) with non-ESBL and uninfected controls. Data on prior antibiotic and healthcare exposure, international travel, prior urinary tract infection (UTI), comorbid gastrointestinal (GI), genitourinary (GU), neurologic, and immunocompromising conditions were collected and compared. RESULTS: Seventy-six patients were identified with 85 ESBL infections, of which 77 (91%) were E. coli. ESBL was isolated most frequently from urine (n = 72, 85%). Most infections were community-onset (n = 76, 89%) and were managed in the ambulatory setting (n = 47, 62%). On multivariate analysis, international travel (p < 0.001, OR 8.93; CI 2.92-27.78), comorbid GI condition (p = 0.002, OR 2.65, CI 1.36-5.15), Asian race (p = 0.005, OR 2.56, CI 1.34-4.89) and prior UTI (p < 0.001, OR 8.06, CI 3.47-18.87) were significant risk factors for ESBL. CONCLUSION: Most ESBL infections in this study were community-onset. To our knowledge, this is the first description of international travel as a risk factor for ESBL acquisition in children in the United States.

Higher Rates of Misdiagnosis in Pediatric Patients Versus Adults Hospitalized With Imported Malaria.

OBJECTIVES: Despite the availability of effective antimalarial prophylaxis, imported adult and pediatric malaria occurs in the United States, and this can pose diagnostic issues. We examined the clinical characteristics and diagnostic challenges of imported malaria requiring adult or pediatric inpatient admission at Montefiore Medical Center in the Bronx which provides care for a large population of immigrants from malaria endemic areas. STUDY DESIGN: We conducted a retrospective single center review of patients admitted with a diagnosis of malaria at Montefiore Medical Center from 2005 through 2012. We extracted historical, clinical, and laboratory values from the electronic medical record and patient charts. RESULTS: We identified 95 patients who were diagnosed and hospitalized with malaria from 2005 to 2012, 33 (35%) of them were children and 17 (18%) were with severe malaria. Most patients contracted malaria while visiting friends and relatives in West Africa. Only 38% of travelers took prophylaxis, and fewer than half reported taking it as prescribed. Misdiagnosis by emergency room or primary care doctors was observed in almost one quarter of all of the patients. Misdiagnosis occurred significantly more frequently in children (43%) compared to adults (13%) (P = 0.002). Pediatric patients were more likely to present with abdominal pain (42% vs. 15%; P = 0.005). CONCLUSIONS: Pediatric patients admitted for imported malaria at Montefiore Medical Center had a higher rate of misdiagnosis and presented with more gastrointestinal symptoms than hospitalized adults. By describing the clinical characteristics of patients with imported malaria, we hope to improve diagnostic accuracy by health care workers and raise awareness that friends and relatives may require more intensive pretravel counseling.

Laparoscopic vs open surgical approach for intussusception requiring operative intervention.

PURPOSE: Laparoscopy has recently been used to treat intussusception that cannot be reduced radiologically. The effectiveness and practical nature of this approach has been questioned. METHODS: This study retrospectively analyzed the authors' experience with this laparoscopic approach and compared this to the conventional open laparotomy procedure. RESULTS: Sixteen patients were treated via laparoscopy, with 2 of these requiring conversions to an open procedure (12.5%). Twenty-five patients underwent an open reduction. Operative time was not significantly different (P = .698) between the laparoscopic (49.56 +/- 26.40 minutes) and open groups (45.00 +/- 24.74). Length of stay, however, was significantly reduced (P = .005) in the laparoscopic group (3.00 +/- 1.31 days) compared to the open group (4.52 +/- 1.98). Total hospital charges were lower in the laparoscopic group ($8171 +/- 2595) compared to the open group ($11,672 +/- 5466); this difference was not significant (P = .088). There were no significant differences in intra- or postoperative complication rates (P = .637) between the 2 approaches. CONCLUSIONS: Although there remains a group who will require a conversion to an open procedure, the laparoscopic approach should be considered a safe and effective option for all children who do not respond to a radiological reduction.