Acute Appendicitis in Children and Adolescents: Factors Associated with Perforation and the Causative Organism

PURPOSE: This study aimed to determine which factors are related to perforated appendicitis. We also conducted a survey to identify the causative organism. METHODS: From January 2011 to December 2014, 569 pediatric patients (322 male) younger than 19 years old who underwent an appendectomy due to acute appendicitis at Hallym University Sacred Heart Hospital were enrolled. Patients' medical records were reviewed retrospectively to determine their clinical manifestations, laboratory and imaging results, and pathogens. RESULTS: About 127 patients (22%) had perforated appendicitis. The rate of perforated appendicitis in preschool, late childhood, and adolescent ages were 50%, 27%, and 16.8%, respectively. The risk factors of perforation were high C-reactive protein levels and the presence of appendiceal fecalith (P <0.001). Of the 24 samples of peritoneal fluid and periappendiceal pus that were collected intraoperatively, 16 were culture positive. The most common pathogen was Escherichia coli (n=10), and others were Pseudomonas aeruginosa , Streptococcus spp., and Staphylococcus spp. CONCLUSIONS: The perforation rate of appendicitis among patients younger than 5 years old was 50%, and this decreased in proportion with age. Clinicians should be aware of the possibility of perforation when patients with appendicitis have high C-reactive protein levels or the presence of appendiceal fecalith on imaging.

New Provisional Classification of Juvenile Idiopathic Arthritis Applying Rheumatoid Factor and Antinuclear Antibody

OBJECTIVE: Previous classification systems for juvenile idiopathic arthritis (JIA) were based on the number of joints involved and did not categorize homogenous disease entities. Therefore, JIA patients were reclassified retrospectively by applying rheumatoid factor (RF) and antinuclear antibody (ANA), which have been proven to constitute a homogenous disease entity. METHODS: The medical records of JIA patients were investigated retrospectively and reclassified into six categories using the new provisional classification. The nomenclature was based on Dr. Martini's proposal in the 23rd European Paediatric Rheumatology Congress (2016) at Genoa, Italy. New categories included systemic JIA (sJIA), RF-positive JIA (RF-JIA), early-onset ANA-positive JIA (eoANA-JIA), enthesitis/spondylitis-related JIA (ESR-JIA), “other JIA”, and “unclassified JIA”. RESULTS: Of a total of 262 JIA patients, 71 (27.1%) were reclassified as sJIA, 31 (11.8%) as RF-JIA, 22 (8.4%) as eoANA-JIA, 63 (24.0%) as ESR-JIA, 65 (24.8%) as “other JIA”, and 10 (3.8%) as “unclassified JIA”. A comparison of RF-JIA, eoANA-JIA, and ESR-JIA revealed significant differences in the gender ratio, age of disease onset, and the cumulative number and type of joints involved among the three groups. “Other JIA” comprised a significant proportion (24.8%) and warrants the need for further classification. The characteristics of the RF-positive patients were comparable to those of the anti-cyclic citrullinated peptide antibody-positive patients. The ANA positivity was lower (28.2%) than that in Western studies but showed similar clinical features. CONCLUSION: This is the first study applying RF and ANA to classify JIA without considering the joint counts. The six new categories include sJIA, RF-JIA, eoANA-JIA, ESR-JIA, “other JIA,” and “unclassified JIA”.

Acute Pulmonary Embolism Associated with Transposition of the Inferior Vena Cava in a 14-year-old Boy

Idiopathic venous thromboembolism (VTE) and pulmonary embolism (PE) are relatively infrequent in the pediatric population but are almost always associated with an underlying disease or risk factors, such as congenital or acquired coagulation abnormalities, autoimmune disorders, or malignancies. In the pediatric emergency department, VTE, and particularly, PE, are often less considered in differential diagnoses because of their low incidence. On the other hand, a delayed diagnosis can result in serious morbidity and mortality. Therefore, even if there are no well-known risk factors, it is important to consider the possibility of PE, whenever there are suspicious symptoms and signs. The transposition of the inferior vena cava (IVC) is one of the major anatomical variants among the spectrum of IVC malformations. Although most IVC malformations are clinically silent and are discovered incidentally on radiographs, they are associated with PE in rare cases. In the pediatric population, no cases of transposition of the IVC that was discovered by acute PE have been reported. We report a case of acute PE associated with a transposition of the IVC in a 14-year-old boy without intra-cardiac anomalies or coagulation abnormalities.

An Unusual Cause of Acute Maxillary Sinusitis in a 9-year-old Child: Odontogenic Origin of Infected Dentigerous Cyst with Supernumerary Teeth

Acute maxillary sinusitis is a common disorder affecting children. Untreated acute sinusitis can develop into chronic sinusitis, and complications, such as orbital cellulitis or abscess, can occur. Maxillary sinusitis of odontogenic origin is not a well-recognized condition and is frequently missed in children. As an odontogenic source of sinusitis, the dentigerous cyst is one of the most prevalent types of odontogenic cysts, and it is associated with the crown of an unerupted or developing tooth. This report concerns a nine-year-old boy who was diagnosed with maxillary sinusitis originating from a dentigerous cyst with supernumerary teeth. The boy visited our pediatric clinic presenting with rhinorrhea and nasal obstruction and was initially diagnosed with maxillary sinusitis only. With antibiotic treatment, his symptoms seemed to improve, but after 2 months, he came to our clinic with left facial swelling with persistent rhinorrhea and nasal obstruction. Radiographic examinations of the sinuses were performed, and he was diagnosed with maxillary sinusitis originating from a dentigerous cyst with supernumerary teeth. After a surgical procedure involving the removal of the dentigerous cyst with supernumerary teeth, the symptoms of sinusitis gradually diminished. There are only very few cases in the pediatric medical literature that remind us that odontogenic origin can cause maxillary sinusitis in children. Our patient can act as a reminder to general pediatricians to include dentigerous cysts in the differential diagnosis of maxillary sinusitis.