Enteric Duplication Cyst in a Patient with Suspected Milk-Protein Allergic Proctocolitis

INTRODUCTION: Gastrointestinal duplication cysts are rare congenital malformations that are typically discovered by routine prenatal ultrasound. These cysts can arise anywhere along the gastrointestinal tract but are most commonly found in the small intestine. Presenting symptoms vary, but often include: nausea, vomiting, abdominal pain or distention, obstruction, or a palpable mass. CASE DESCRIPTION: An exclusively breastfed eight-month-old female presented to the children’s hospital with severe microcytic anemia (hemoglobin concentration of 3.2 g/dL). Past medical history was significant for a six-month history of emesis and intermittent hematochezia. Around two months of age, she presented to the pediatrician due to intermittent loose, bloody stools, which were attributed to milk protein-induced proctocolitis. Dairy was removed from the mother’s diet, which reportedly provided some improvement. Iron deficiency anemia was diagnosed at four months of age when hemoglobin concentration was 8 g/dL and improved to 10.6 g/dL at six months after the initiation of iron therapy. Follow-up labs at eight months revealed severe microcytic anemia and prompted admission to the children’s hospital. Notably, medical history included a prenatal ultrasound concerning for bilateral ovarian cysts. Repeated postnatal images revealed decreased size of the cysts, and they were deemed insignificant. Upon admission, the patient was pale and tachycardic, but otherwise well appearing with a soft, non-tender, non-distended abdomen, normal bowel sounds, no palpable masses or hepatosplenomegaly. Ultrasound and CT of the abdomen showed bilateral abdominal mesenteric masses favoring mesenteric cysts. Exploratory laparotomy identified a ten cm bilobed retroperitoneal cystic mass and 80 cm of mesenteric duplication at the distal jejunum and proximal ileum closely adherent to native tissues with surrounding mucosal necrosis, ulceration, and hemorrhage. The native bowel could not be salvaged so resection and jejunoileostomy were performed. Hematochezia and anemia resolved after surgical recovery. DISCUSSION: This case demonstrates hematochezia, a relatively common pediatric complaint, which was suspected to be due to milk protein allergic proctocolitis and resulted in the missed diagnosis of a congenital enteric lesion. Unlike most cases of mesenteric duplication cysts, this patient had no palpable masses or abdominal distension. These lesions were detected by prenatal ultrasound but were dismissed postnatally. Severe microcytic anemia was the only sign of the severity of her illness and the need for prompt surgical management. Anatomic abnormalities discovered prenatally should be surveilled into infancy until they are resolved, corrected, or determined to be benign. Gastrointestinal duplication cyst(s) should be included in differential diagnoses for pediatric patients with unexplained hematochezia refractory to treatment.N

Factors Influencing Physician Treatment Strategies in Crotaline Snake Envenomation

BACKGROUND: Crotaline snake envenomation is a potentially serious medical condition that affects thousands of Americans each year. There continues to be variation in treatment practices by physicians in the United States despite guidelines establishing the use of antivenom and supportive care as the mainstays for treating crotaline snake envenomation. METHODS: This study sought to determine associations between physician treatment strategies, snake identification (ID), venom effects, bite location and patient presentation. A cross-sectional review of electronic medical records (EMR) for patients diagnosed with venomous snake bites from July 1, 2014 to August 31, 2019 was completed. Data collected from the EMR included: patient demographics, transfer information, length of hospital and ICU stays, snake ID, bite site, progression of local tissue effects, additional clinical and lab results, patient comorbidities and complications, and provider treatment strategy. RESULTS: Of the 83 patients who met inclusion criteria, 68 patients (81.9%) received antivenom. None of the 15 patients who were under observation (no antivenom) for treatment went to the ICU. These patients experienced the shortest hospital stays (H(2)=16.76, p<0.001). Hospital stays were longest for patients envenomated by an identified rattlesnake or cottonmouth compared to patients envenomated by an unknown snake or copperhead (H(2)=14.32, p<0.05). Rattlesnake envenomations used more vials of antivenom than copperhead envenomations (H(2)=8.76, p=0.01). In a regression model of treatment strategy, progression of local tissue effects was the only statistically significant predictor of receiving antivenom while other independent variables including snake ID, patient age, hemotoxicity, systemic symptoms, site of the snakebite, and patient comorbidities were not significant predictors. Lastly, there was a statistically significant association between treatment strategy and opioid prescription, with 77.9% of patients who received antivenom also receiving an opioid for pain management vs. 33.3% of patients under observation (no antivenom) who received opioids (Fisher Exact Probability Test, p=0.001). CONCLUSION: Envenomated patients are likely to be treated with antivenom if there was progression of local tissue effects. For patients in this study who were bitten by copperheads and unknown snakes, close observation without antivenom administration had favorable outcomes including shorter hospital stays and likely decreased hospital costs.N

Impact of the Filmarray® Meningitis/Encephalitis Panel On Clinical Practice In Pediatrics; A Multicentered Study

Background The FilmArray® Meningitis/Encephalitis Panel (MEP) is a rapid multiplex assay that tests cerebrospinal fluid (CSF) for 14 common central nervous system (CNS) pathogens, with results available in hours as opposed to days with the gold standard CSF culture. Current literature on the impact of MEP testing on length of stay (LOS) and antimicrobial use in pediatric patients is from only single site studies with variable results. Hypothesis MEP testing in pediatric patients would be associated with a decreased LOS, time on IV antibiotics, and time to narrowing antibiotics. Design/Methods We conducted a retrospective study of 5 sites. Inclusion criteria were children 0-18 years with lumbar puncture (LP) performed within 48 hours of presentation for suspected CNS infection between January 2015 and February 2019. Children with a neurosurgical history or immunosuppression were excluded. Collected data included demographics, presenting clinical features, laboratory and radiographic findings, antimicrobial use, and clinical outcomes. Mann-Whitney and Fisher’s exact test were used to compare continuous variables and categorical variables, respectively. A linear mixed model was used to analyze the effect of the MEP on LOS adjusting for clinical site, age, antibiotic pretreated LP, highest level of care, positive body fluid culture, CSF white blood cell count, and brain imaging consistent with meningitis/encephalitis. Results This study included 2,436 children, 833 received MEP testing. Patients in the MEP group were more likely to be younger, receive ICU level care, be unimmunized, have neurological symptoms at presentation, have a higher median CSF WBC count, or have received antibiotic treatment prior to LP (p=0.002, p\u3c0.0001, p\u3c0.0001, p\u3c0.0001, p\u3c0.0001, p=0.03, p\u3c0.0001). Patients in the MEP group were more likely to have abnormal head imaging, an infectious diseases consult, or a PICC line placed (p\u3c0.0001). In the univariate analysis the MEP group had a longer median LOS and this difference persisted after adjusting for the seven covariates (p\u3c0.0001, p=0.0017). There was no statistically significant difference in median total IV antibiotic time or median time to narrowing antibiotics (p=0.12, p=0.33). Conclusions Contrary to our hypothesis we found that patients who had MEP testing performed had a longer LOS, despite no difference being noted in the duration of IV antibiotics and time to narrowing antibiotics. Further analysis is needed to identify clinical scenarios in which MEP testing is most effective.https://digitalcommons.unmc.edu/chri_forum/1041/thumbnail.jp

ANTIVENOM OR OBSERVATION FOR PATIENTS WITH COPPERHEAD ENVENOMATION?

Retrospective cross-sectional review of treatment and outcomes in patients with crotawline snake bites