What defines uncommon? What defines uncommon? What defines - PDF document

Unusual Presentations of Unusual Presentations of Unusual Presentations of Unusual Presentations of Common Infectious Diseases in Common Infectious Diseases in Common Infectious Diseases in Common Infectious Diseases in Kids Kids Kids Kids Denise Bratc Denis Denise Bratc Denis Bratcher, DO Bratcher, DO DO DO Professor, Pediatrics Professor, Pediatrics Professor, Pediatrics Professor, Pediatrics Ped Ped Pediatric In Pediatric In atric Infectious D atric Infectious D fectious Diseases fectious Diseases seases seases Children’s Mercy H Children’s Mercy H ildren’s Mercy Hospitals & ildren’s Mercy Hospitals & ospitals & Clinics ospitals & Clinics linics linics Kans Kansas City Kans Kansas City City, MO City, MO , MO , MO What defines uncommon? What defines uncommon? What defines uncommon? What defines uncommon?  "Uncommon manifestations of "Uncommon manifestations of common diseases are more common diseases are more common diseases are more common diseases are more common than common common than common manifestations of uncommon manifestations of uncommon diseases." diseases."  Series will address unusual Series will address unusual presentations of common pediatric presentations of common pediatric presentations of common pediatric presentations of common pediatric infections infections

Case #1 Case #1 Case #1 Case #1 13-year old previously healthy male presents with right ankle pain X4 presents with right ankle pain X4 days, fever, perioral cyanosis Seen in healthcare facilities X4—last 2 times with fever  symptomatic care Evaluated by team trainer who noted cyanosis & called 911 cyanosis & called 911 Noted to be cyanotic, hypotensive, tachypneic Case #1: Review of Case #1: Review of Systems Case #1: Review of Systems Case #1: Review of Systems Systems  Fever X2 days  Fever X2 days Fever X2 days Fever X2 days  Right ankle pain X4 days Right ankle pain X4 days  Perioral cyanosis Perioral cyanosis  Hypotension Hypotension  Respiratory distress  Respiratory distress Respiratory distress Respiratory distress

Case #1: Past Medical History Case #1: Past Medical History Case #1: Past Medical History Case #1: Past Medical History  Cleft palate repair  Cleft palate repair Cleft palate repair Cleft palate repair—infant infant infant infant  Myringotomy tubes Myringotomy tubes— —toddler toddler  No history skin/soft tissue infections No history skin/soft tissue infections  Family Hx: mother with history of Family Hx: mother with history of boils; currently healthy boils; currently healthy  Social Hx: lives with parents & sister, Social Hx: lives with parents & sister, 2 cats, 2 dogs; plays football, kick 2 cats, 2 dogs; plays football, kick boxes, & unloads trucks boxes, & unloads trucks Case #1: Physical Exam Case #1: Physical Exam Case #1: Physical Exam Case #1: Physical Exam  VS:38.6 VS:38.6 VS:38.6 ° C; HR 120; RR38; BP VS:38.6 C; HR 120; RR38; BP C; HR 120; RR38; BP C; HR 120; RR38; BP 76/42 76/42  General: General: ill ill- -appearing appearing, becoming , becoming somnolent somnolent  HEENT normal  HEENT normal   Heart rate/rhythm regular, no Heart rate/rhythm regular, no murmur; murmur; tachycardic; capillary refill murmur; murmur; tachycardic; capillary refill tachycardic; capillary refill tachycardic; capillary refill very delayed very delayed  Lungs Lungs poor aeration bilaterally poor aeration bilaterally

Case #1: Physical Exam Case #1: Physical Exam Case #1: Physical Exam Case #1: Physical Exam  Abdomen: Abdomen: Abdomen: full, distended Abdomen: full, distended full, distended, no full, distended, no , no , no HSM/masses HSM/masses   Extremities: Extremities: cool, poorly perfused, cool, poorly perfused, distal pulses not palpable; right distal pulses not palpable; right lower ext. tightly edematous with lower ext. tightly edematous with ecchymosis throughout ecchymosis throughout  Skin: Skin: Ecchymotic areas over lower Skin: Skin: Ecchymotic areas over lower Ecchymotic areas over lower Ecchymotic areas over lower extremities; bullous lesions over R extremities; bullous lesions over R ankle ankle  Neuro: Neuro: somnolent somnolent Case #1: Pertinent Laboratory Case #1: Pertinent Laboratory Case #1: Pertinent Laboratory Case #1: Pertinent Laboratory Evaluation Evaluation Evaluation Evaluation  CBC: CBC: WBC CBC: CBC: WBC WBC WBC 1,600 1,600 1,600 1,600 Differential Differential 21S/34B/38L/13M 21S/34B/38L/13M Hemoglobin Hemoglobin 15.5 15.5 Platelets Platelets 150,000 150,000  Electrolytes: Electrolytes: Sodium Sodium Sodium Sodium 151 151 151 151 Potassium Potassium 3.2 3.2 Chloride Chloride 105 105 Carbon Dioxide Carbon Dioxide 34 34

Case #1: Pertinent Laboratory Case #1: Pertinent Laboratory Case #1: Pertinent Laboratory Case #1: Pertinent Laboratory Evaluation Evaluation Evaluation Evaluation  BUN/Cre BUN/Cre 40/1.8 40/1.8 mg/dL mg/dL  Lactic Acid Lactic Acid 6.8 6.8 mmol/L’ mmol/L’  PT/PTT PT/PTT 18.4/87.6 18.4/87.6 secs secs  Fibrinogen Fibrinogen 499 mg/dL 499 mg/dL Case #1: What’s the Case #1: What’s the Diagnosis? Case #1: What’s the Case #1: What’s the Diagnosis? Diagnosis? Diagnosis?  Septic Shock  Septic Shock Septic Shock Septic Shock  Staphylococcus Staphylococcus  Meningococcus Meningococcus  Pneumococcus Pneumococcus  Pneumonia Pneumonia  Osteoarticular infection Osteoarticular infection  Endocarditis Endocarditis

Case #1: Further Evaluation Case #1: Further Evaluation Case #1: Further Evaluation Case #1: Further Evaluation  Patient was intubated and ultimately Patient was intubated and ultimately Patient was intubated and ultimately Patient was intubated and ultimately  placed on ECMO with cardiopulmonary placed on ECMO with cardiopulmonary failure failure  Blood cultures repeatedly revealed Blood cultures repeatedly revealed Methicillin Methicillin- -resistant resistant S. aureus S. aureus (MRSA) (MRSA)  Clindamycin Clindamycin- -susceptible; not inducibly susceptible; not inducibly- - resistant resistant   Echocardiogram: no vegetations or Echocardiogram: no vegetations or thrombi thrombi Case #1: Radiologic Evaluation Case #1: Radiologic Evaluation Case #1: Radiologic Evaluation Case #1: Radiologic Evaluation  CXR: diffuse bilateral alveolar  CXR: diffuse bilateral alveolar CXR: diffuse bilateral alveolar CXR: diffuse bilateral alveolar opacities throughout the lungs opacities throughout the lungs  CT Head: no acute intracranial CT Head: no acute intracranial abnormality abnormality  Ultrasound: Ultrasound:  Right lower extremity: thrombus Right lower extremity: thrombus within superficial femoral vein to within superficial femoral vein to the popliteal vein level the popliteal vein level

Case #1: Further Evaluation Case #1: Further Evaluation Case #1: Further Evaluation Case #1: Further Evaluation   Patient Patient initiallly initiallly managed with managed with vancomycin/clindamycin/oxacillin vancomycin/clindamycin/ i / li d i / li d i / i / oxacillin illi illi pending susceptibility confirmation pending susceptibility confirmation  Vancomycin MIC =1 from outside hospital Vancomycin MIC =1 from outside hospital  Blood cultures remained positive Blood cultures remained positive  Vanc Vanc levels optimized; clindamycin levels optimized; clindamycin continued continued  Rifampin and gentamicin added Rifampin and gentamicin added  All lines, except ECMO circuit, changed All lines, except ECMO circuit, changed Case #1: Further Evaluation Case #1: Further Evaluation Case #1: Further Evaluation Case #1: Further Evaluation  Bedside fasciotomies revealed  Bedside fasciotomies revealed Bedside fasciotomies revealed Bedside fasciotomies revealed extensive necrosis of muscles extensive necrosis of muscles throughout entire right lower throughout entire right lower extremity extremity  Ultimately above Ultimately above- -the the- -knee knee amputation required amputation required  Unable to wean from ECMO Unable to wean from ECMO support after lengthy course support after lengthy course