An adolescent with recurrent ankle swelling

A 14-year-old girl was admitted to our institute with a history of intermittent bilateral ankle swelling, and moderate but progressively worsening pain which has lasted for 2 years. The patient's history was unremarkable. She did not take medications and was not involved in any sports activity. She reported no fever, gastrointestinal symptoms, fatigue, weight loss, travels abroad or previous infections. She reported moderate pain at night, associated with a sense of heaviness, tightness and general discomfort, and with no response to ibuprofen. Physical examination was remarkable only for bilateral ankle non-pitting oedema, more evident on the left leg, with a thickened skinfold at the base of the second toe, and without redness, swelling or skin warming. The patient had been previously examined, and her foot and ankle X-rays, ultrasound (US) and MRI were all negative. Blood tests (white cell count, C reactive protein, erythrocyte sedimentation rate, albumin, antinuclear antibodies, creatinine, transaminase, creatine kinase, lactate dehydrogenase, thyroid function and glucose) and urinalysis were in the normal range. Her ocular assessment and echocardiogram were also normal. Question 1: Based on the clinical picture and laboratory tests, what is the most likely diagnosis? Deep venous thrombosis. Osteochondritis. Lymphoedema. Juvenile idiopathic arthritis. Question 2: Based on what you see infigure 1, what is the underlying cause? Recurrent bacterial lymphangitis. Primary lymphoedema. Tumour. Filariasis. Figure 1 Lymphoscintigraphy of the lower extremities showing insufficient deep lymphatic circulation in the left leg (red arrow, A) replaced by superficial drainage (B). Question 3: Which is the best diagnostic test to confirm the diagnosis? US scan. MRI. Lymphoscintigraphy. Reassurance and clinical follow-up. Question 4: What is the mainstay of management of this condition? Wait and see. Antibiotic course. Supportive therapy (ie, physical activity, elevation of extremities, pneumatic compression). Surgical intervention. Answers can be found on page 2

Six-year-old boy with a slow-onset persistent back pain

A 6-year-old boy was evaluated for a 6-week history of low back pain. Initially, the pain was exacerbated by movements, eventually showing a milder and fluctuating trend. History was unremarkable for previous traumatic events, fever or nocturnal pain. Physical examination revealed localised pain at palpation of the spinous processes at the lumbosacral level. Blood tests showed a normal blood count, negative C reactive protein (CRP) and erythrocyte sedimentation rate, normal lactic acid dehydrogenase (LDH) and creatine phosphokinase. A posterior-anterior radiograph of the lumbar spine resulted normal. An MRI scan revealed a lumbosacral transitional vertebra with bone oedema of the posterior arch until the spinous process. For better bone definition, a CT scan was performed (figure 1). Figure 1 CT scan of the transitional lumbosacral (L5) vertebra. Questions: Which causes of persistent low back pain should be ruled out in children under 10 years of age? Osteochondrosis Neoplasm Functional pain Infections What is the diagnosis in this patient? How is the diagnosis performed? How is this condition managed? Answers can be found on page 2

Unarousable child with a short bowel

Unarousable child with short bowel: A 4-year-old boy was admitted with progressive lethargy of a few hours' duration and no other symptoms. His medical history was relevant for short bowel syndrome (SBS), following neonatal volvulus, with residual bowel length of 23 cm and intact ileocecal valve. He had similar self-limiting episodes in the past, after weaning parenteral nutrition, especially after eating large meals. The day before, he had consumed a large amount of apples. Arterial blood gas (ABG) analysis showed metabolic acidosis with normal lactacidaemia (pH 7.09, pCO2 19 mm Hg, pO2 101 mm Hg, HCO3 5.8 mmol/L, BE -24, anion gap 29.4, chloride 116 mmol/L, L-lactate level 4 mmol/L). On admission, the child could be awakened, but he was confused with slurred speech (Glasgow Coma Scale 14), with a body temperature of 37 C°, a heart rate of 125 beats/min and a respiratory rate of 38 breaths/min. The abdomen was distended, without guarding and with normal bowel sounds. Blood glucose levels were normal, as well as white blood cell count, liver and kidney function test and C reactive protein. An abdominal ultrasound ruled out an intussusception. An abdominal X-ray was performed too (seefigure 1). Figure 1 Abdominal distension with gas and bloating. Questions: Which is the most likely diagnosis? Encephalitis D-lactic acidosis Dehydration with third space fluid collection and acidosis Hereditary fructose intolerance. How is this diagnosis confirmed? D lactic dosage Breath test for bacterial overgrowth Urine organic acid dosage Search for reductive substances in the stools. How should this patient be managed? Intravenous fluids to facilitate D-lactic excretion Restrict carbohydrates in the diet Intravenous bicarbonates Antibiotic treatment to reduce bowel bacterial overgrowth. Answers can be found on page 2

Evaporite sinkholes of the Friuli Venezia Giulia region (NE Italy)

Sinkholes are common in the Friuli Venezia Giulia (FVG) Region (NE Italy), where the presence of karstifiable rocks favours their occurrence accelerated by intense rainfalls. Their existence has been reported since the end of the 1800s along the Tagliamento Valley, in correspondence with the mantled evaporites (gypsum). Furthermore, tens of evaporite sinkholes have been documented on the reliefs adjacent to the village of Sauris and along the narrow W\u2013Eoriented valleys, where regional faults have played a major role in their spatial distribution. This paper reports for the first time an inventory of the sinkholes affecting the evaporites of the FVG Region. These phenomena were mapped and categorised using a genetic classification. The main output is an A0-format map, which incorporates a 1:50,000 scale Sinkhole Inventory Map (SIM). The SIM encompasses 552 sinkholes. The cover suffosion sinkholes are the most abundant, followed by bedrock collapses. There is a clear prevalence of the circular shape (65%) over other shapes. Diameters are 1\u2013140 m, with depths ranging 0.1\u201340 m with a mean value of 4.5 m. The SIM can motivate regional planning authorities to perform further investigations aimed to understand the geomorphological evolutions of these phenomena

Studi sul dialetto friulano. (1863)

Udine : Tip. G. Vatri, 1926 https://galileodiscovery.unipd.it/discovery/fulldisplay?context=L&vid=39UPD_INST:VU1&search_scope=MyInst_and_CI&tab=Everything&docid=alma99002002565020604

Procedural sedation for intra-articular corticosteroid injections in juvenile idiopathic arthritis (JIA) should be a standard of care.

N/

Cortical Thumb Sign.

N/