Screening Patterns in Abusive Abdominal Trauma

Background: Diagnosis of abusive abdominal trauma (AAT) is often clinically occult. Abdominal CT is the preferred method to diagnose abdominal injuries. However, due to risk of ionizing radiation, and cost, it is performed only in selected children. Recently, elevated liver enzymes were used to screen for occult AAT, but its accuracy is unknown due to inconsistent methodology and results. Objective: To determine the accuracy of elevated liver enzymes (transaminases) in the diagnosis of AAT and if pancreatic enzymes and clinical findings help in patients’ selection for abdominal CT. Methods: A retrospective (2011-2020) study on children younger than 3 years suspected of child abuse. The study group included children that had abdominal CT for suspected AAT, while the control group included similar number of children randomized from 5208 children evaluated for child abuse without an abdominal CT. Patients who had an incomplete medical record, were evaluated for cardiac arrest, or had a CT without contrast were excluded. Results: AAT is rare 0.6% (30/5434) in children suspected of child abuse. Transaminases were obtained in 99.1% of the AAT patients and 55.3% of the control cases. 93.1% (27/29) patients with abdominal injuries had elevated transaminases. The specificity and sensitivity for the transaminases in detecting positive abdominal CT was 93.3% and 90.0%, respectively. Only one additional case was identified with elevated pancreatic enzymes and negative transaminases. There was no clinical or imaging findings that could differentiate between patients with negative and positive abdominal CT scans. Based only on elevated transaminases, 11 CT scans need to be performed for a single positive study. Conclusion/Potential Impact: Transaminases have high sensitivity in predicting AAT. Universal use of transaminases in all children suspected of child abuse may result in 11 CT scans for one positive study. Therefore, more clinical judgement is necessary in selecting patients for CT.

Lessons in clinical reasoning ‒ pitfalls, myths and pearls: a case of recurrent pancreatitis

Objectives Cognitive biases can result in clinical reasoning failures that can lead to diagnostic errors. Autobrewery syndrome is a rare, but likely underdiagnosed, condition in which gut flora ferment glucose, producing ethanol. It most frequently presents with unexplained episodes of inebriation, though more case studies are necessary to better characterize the syndrome. Case presentation This is a case of a 41-year old male with a past medical history notable only for frequent sinus infections, who presented with recurrent episodes of acute pancreatitis. In the week prior to his first episode of pancreatitis, he consumed four beers, an increase from his baseline of 1–2 drinks per month. At home, he had several episodes of confusion, which he attributed to fatigue. He underwent laparoscopic cholecystectomy and testing for genetic and autoimmune causes of pancreatitis, which were non-revealing. He was hospitalized 10 more times during that 9-month period for acute pancreatitis with elevated transaminases. During these admissions, he had elevated triglycerides requiring an insulin drip and elevated alcohol level despite abstaining from alcohol for the prior eight months. His alcohol level increased after consumption of complex carbohydrates, confirming the diagnosis of autobrewery syndrome. Conclusions Through integrated commentary on the diagnostic reasoning process, this case underscores how overconfidence can lead to premature closure and anchoring resulting in diagnostic error. Using a metacognitive overview, case discussants describe the importance of structured reflection and a standardized approach to early hypothesis generation to navigate these cognitive biases.

DRESS syndrome (drug rash with eosinophilia and systemic symptoms): sometimes, not all signs are there

DRESS syndrome is a rare and potentially fatal multisystemic reaction that occurs two to six weeks after exposure to certain drugs. It is characterized by fever, eosinophilia, and skin rash. Case of a 37-year-old man, black, with gout (started allopurinol 4 weeks before). He arrived at the Emergency Room complaining of headache, fever, abdominal pain, and scattered maculopapular skin lesions. The conducted study showed elevated transaminases and C-reactive protein, hepatomegaly, and peri-hepatic adenomegalies. Allopurinol was stopped, but throughout hospitalization, liver, renal and neurological dysfunctions (with meningoencephalitis) worsened; it also appeared eosinophilia. A skin biopsy was performed, the possibility of DRESS syndrome was assumed, and methylprednisolone 2 mg/kg/day was started, with progressive improvement. The skin biopsy was compatible with DRESS. The described case reveals some peculiarities. Among the most relevant arethe late onset of eosinophilia and the difficulty in evaluating the rash due to the patient's skin tone and neurological manifestations (rare).

Liver Involvement in Children with COVID-19 and Multisystem Inflammatory Syndrome: A Single-Center Bulgarian Observational Study

SARS-CoV-2 infection may precede and cause various autoimmune and inflammatory diseases, including multisystem inflammatory syndrome in children (MIS-C). Therefore, we aimed to observe the clinical presentation and laboratory, instrumental and other constellations in children with MIS-C, including liver involvement. We present the outcomes from a single-center prospective observational study in which 89 children was included (60 with proven COVID-19, 10 symptomatic with confirmed COVID-19 contact and 19 diagnosed with MIS-C). Laboratory, instrumental, immunological, and clinical investigations were performed. Only 12% (n = 4) from the COVID-19 group (except the ICU cases), we found elevated AST and/or ALT (up to 100). All of the children with elevated transaminase were overweight or obese, presenting along with moderate COVID-19 pneumonia. The majority of children with MIS-C showed typical laboratory constellations with higher levels of IL-6 (120.36 ± 35.56 ng/mL). About half of the children in the MIS-C group (52%, n = 11) showed elevated transaminases. Eleven children (57.9%) presented with abdominal pain, eight (42.1%) with ascites, two (10.5%) with hepatosplenomegaly, and four (21.1%) with symptoms such as diarrhea. Mesenteric lymphadenitis was observed more often in patients with elevated LDH (327.83 ± 159.39, p = 0.077). Ascites was associated with lymphopenia (0.86 ± 0.80, p = 0.029) and elevated LDH. Hepato-splenomegaly was also more frequent in children with lymphopenia (0.5 ± 0.14, p = 0.039), higher troponin (402.00 ± 101.23, p = 0.004) and low ESR. Diarrhea was more frequent in patients with lower CRP (9.00 ± 3.44 vs. 22.25 ± 2.58, p = 0.04), and higher AST and ALT (469.00 ± 349.59 vs. and 286.67 ± 174.91, respectively, p = 0.010), and D-dimer (4516.66 ± 715.83, p = 0.001). Our data suggest that the liver can also be involved in MIS-C, presenting with typical laboratory and instrumental outcomes.

Leptospirosis in COVID-19 Positive Pregnancy: A Rare Case Report Mimicking Hellp Syndrome

Leptospirosis in pregnancy is often underdiagnosed and not commonly reported due to its unusual appearance and rarity. It looks like HELLP syndrome, obstetric cholestasis, viral hepatitis & pregnancy-related acute fatty liver. Miscarriages in the first trimester, stillbirths, and neonatal leptospirosis are serious complications that necessitate a high degree of concern, heightened sensitivity, and prompt diagnosis and treatment. We have one such incidence of leptospirosis in a COVID-19 positive pregnant female. A 21-year-old Primigravida with a predisposition of serious anaemia & thrombocytopenia, presented with fever, haematemesis, malena and sore throat at 38 weeks and 2 days gestation, during the COVID-19 pandemic. She had pallor, oedema, and haematuria on catheterization, rest all investigations were within normal limits. Proteinuria, haemolysis, low platelets, and elevated bilirubin were discovered during the investigation. Due to the lack of hypertension and elevated transaminases, the working diagnosis was atypical haemolysis, low platelets (HELLP) syndrome. The patient was tested for COVID-19 RT-PCR, came out to be positive and the fever spikes continued, leading to further investigations for Dengue, Malaria, Scrub Typhus, and Leptospirosis due to the ongoing Covid-19 pandemic. After the EIA (Enzyme Immunoassay) IgM antibody (confirmatory for Leptospirosis) tested positive for Leptospirosis, the decision to start Doxycycline was made. Meanwhile, the patient's CTG (Cardio tocograph) revealed signs of foetal distress, and a decision for an emergency LSCS was taken (Lower Segment Caesarean Section). The histology of the placenta after the section revealed normal findings. Doxycycline was initiated with a neonatal feeding regimen that was acceptable. On day two of life, the newborn had no indications of inherited leptospirosis and was removed from Neonatal Intensive Care. Within one week, the patient's symptoms had disappeared, and her biochemistry had went back to normal within 2 weeks.

Elevated liver enzymes of newly-diagnosed pediatric celiac patients- a prospective-observational study

ObjectivesCeliac disease clinical presentation is constantly changing. We set to determine the prevalence of elevated transaminases in newly diagnosed celiac patients, and to evaluate this sub-group of patients for associated clinical and laboratory findings and assess their natural course of disease following therapeutic diet initiation.MethodsWe conducted a prospective-observational study of all newly-diagnosed pediatric celiac patients, between August 2016 – April 2018, in a pediatric gastroenterology clinic. Clinical data, anthropometrics and blood test results were recorded at diagnosis and at three, six and twelve months of follow-up. We compared patients with normal and elevated transaminases at diagnosis. ALT threshold was set at 24 U/l.ResultsOf 125 newly-diagnosed celiac patients, 31 (24.8%) had elevated ALT at diagnosis; two (1.6%) with over 3xULN. Patients with elevated ALT at diagnosis were significantly younger (mean age 5.5 (SD- 3.4) vs 7.3 (SD- 3.7) years, p < 0.01) and more commonly presented with diarrhea (32.3% vs. 14.9%, p = 0.03). 80% of patients with elevated ALT levels, normalized their ALT within 3 months and all within one year. Following gluten free diet initiation, patients with elevated ALT had similar clinical course, growth, serology normalization rate, and laboratory results, compared to patients with normal ALT over a one year follow up. A single patient was simultaneously co-diagnosed with celiac disease and auto-immune hepatitis.ConclusionsClinically significant ALT abnormalities are rare among newly diagnosed pediatric celiac patients. Significant elevations failing to normalize on gluten free diet, should raise concern of a concomitant primary liver disease and warrant further investigations.

Enteral Ciprofloxacin or Levofloxacin for Ventilator-Associated Tracheobronchitis in Children

Introduction Pseudomonas aeruginosa is the most commonly isolated organism in children with ventilator-associated tracheobronchitis (VAT). Enteral treatment with ciprofloxacin or levofloxacin is sometimes employed, but supportive data are limited. The purpose of this study was to evaluate the effectiveness and safety of enteral ciprofloxacin and levofloxacin administration for VAT in children. Methods This was a retrospective review of electronic medical records for children less than 18 years of age who received enteral ciprofloxacin or levofloxacin for the treatment of VAT from January 2013 through January 2020 at an academic children’s hospital. Results Seventy-six children (median age 9.5, IQR 3.6-13.1 years), received ciprofloxacin or levofloxacin for VAT treatment during the study period. Median treatment duration was 8 (range 7-10) days. Most tracheostomy cultures (n=70/82, 85%) were polymicrobial, with P. aeruginosa most commonly isolated (n=67/224 organisms, 30%). Sixty-five children (86%) were successfully treated with an enteral fluoroquinolone. Antibiotics were changed or extended for two (3%) children. Ten (13%) children were prescribed antibiotics and eight (11%) required hospitalization for a lower respiratory tract infection within 30 days of completion of their fluoroquinolone course. Six (8%) patients received a seizure rescue medication, seven (9%) experienced emesis, and one (1%) had elevated transaminases. Tendonitis, tendon rupture and QTc prolongation were not observed. Conclusions The results of this study suggest enteral fluoroquinolones may be effective for the treatment of VAT in children. Further study is warranted to clarify the role of these agents in pediatric VAT.