Severe myxedema coma and pericardial effusion in a child with Down syndrome: the importance of adherence to levothyroxine therapy.

BACKGROUND: Myxedema coma is a rare, but life-threatening endocrinological emergency. Myxedema is characterized by altered mental status, and is accompanied by hypotension, bradycardia, hypothermia, bradypnea, hyporeflexia, hyponatremia, and hypoglycemia, all stemming from reduced metabolism due to severe hypothyroidism. Additionally, patients may exhibit signs of low cardiac output, edema in the extremities, peripheral circulatory disturbances, shock, and the development of pericardial and pleural effusions, ultimately leading to confusion and coma. We present a successfully treated case of severe myxedema coma with recurrent pericardial effusion and hypotensive shock. This case is characterized by an unusual clinical presentation and required a distinct treatment strategy highlighting its exceptional rarity. CASE: A 2-year-old boy with Down syndrome presented with recurrent pericardial effusion attributed to medication non-adherence. The critically-ill patient, experiencing a severe cardiogenic shock required mechanical ventilation and inotropic infusions in the pediatric intensive care unit. Elevated thyroid stimulating hormone (TSH), and low free T4 (fT4) and free T3 (fT3) levels prompted consideration of myxedema coma. Upon reviewing the patient's medical history, it was ascertained that he had an ongoing diagnosis of primary hypothyroidism, and exhibited non-adherence to the prescribed treatment regimen and failed to attend scheduled outpatient clinic appointments for follow-up assessments. The treatment plan, devised by the pediatric endocrinology team, included the peroral administration of L-thyroxine (L-T4) at a dose of 50 micrograms per day. After beginning regular oral L-T4 treatment, a gradual improvement in the patient's condition was observed. Notably, by the 15th day of oral therapy, the patient had made a full recovery. Contrary to the recommended intravenous treatment for myxedema coma, this patient was successfully treated with oral levothyroxine, due to the unavailability of the parenteral form in Türkiye. CONCLUSIONS: This case report presents an instance of non-adherence to L-T4 therapy, which subsequently progressed to severe myxedema coma. Changes in neurologic status and hemodynamic instability in a patient with a history of hypothyroidism should raise the concern of nonadherence and, though rare, myxedema coma should be in the differential diagnosis.

Importance of lactate/albumin ratio in pediatric nosocomial infection and mortality at different times.

Aim: To evaluate the lactate/albumin ratio and its relation to mortality in children with nosocomial infections. Materials & methods: One hundred six children were included in this study. Blood gas and albumin levels were analyzed at the first, 24th and 48th h. Results: The types of detected microbial agents, signs of sepsis, development of septic shock and mortality rates were different. The first-, 24th- and 48th h lactate levels of the children who died were higher than those of the living children, but the albumin levels were lower. The highest area under the curve value for the lactate/albumin ratio was detected at the 24th h. Conclusion: Lactate/albumin ratio can be used to predict mortality in children with nosocomial infections.

Cardiac failure in a child with tuberculous meningitis as a complication of Paroxysmal sympathetic hyperactivity.

BACKGROUND: Paroxysmal sympathetic hyperactivity (PSH) is a disorder due to the loss of regulation of autonomic activity. The most common condition predisposing to the development of PSH is traumatic brain injury (TBI), followed by anoxic brain injury, stroke, tumors, and infections. Awareness about the condition and early recognition is important to avoid life threatening complications. CASE: We report a 4-year-old child with tuberculous meningitis with symptoms of PSH who developed cardiac failure. PSH episodes were treated with beta blocker, benzodiazepine, morphine, dexmedetomidine, baclofen, and tizanidine. Three weeks after readmission PSH episodes decreased and the patient was transferred to the general ward. CONCLUSIONS: PSH assessment tool has benefits such as monitoring the patient, evaluating response to treatment and early diagnosing PSH patients.

First Successful Organ Procurement From a Pediatric Patient With a Nonpulsatile Ventricular Assist Device.

Left ventricular assist devices have become an important therapeutic option as a mechanical circulatory support system in the treatment of end-stage heart failure. Organ transplants from brain dead donors on mechanical circulatory support are rare. In the literature, many successful solid-organ transplants have been reported using these donors. However, to our knowledge, this is the first report of successful solid-organ transplant from a child donor with a nonpulsatile ventricular assist device.

Influenza Virus Associated Pediatric Acute Respiratory Distress Syndrome: Clinical Characteristics and Outcomes.

BACKGROUND AND OBJECTIVE: The aim of this multicenter retrospective study was to determine the clinical characteristics, treatment approaches and the course of pediatric acute respiratory distress syndrome (PARDS) which developed associated with the influenza virus in the 2019-20 season. METHODS: Patients included 1 month to 18 years who were diagnosed with PARDS associated with the influenza virus in the 2019-20 season. RESULTS: Sixty-seven patients were included in the study. The mean age of the patients was 64.16 ± 6.53 months, with 60% of the group <5 years. Influenza A was determined in 54 (80.5%) patients and Influenza B in 13 (19.5%). The majority of patients (73.1%) had a comorbidity. Fifty-eight (86.6%) patients were applied with invasive mechanical ventilation, Pediatric Acute Lung Injury Consensus Conference classification was mild in 5 (8.6%), moderate in 22 (37.9%) and severe in 31 (52.5%) patients. Ventilation was applied in the prone position to 40.3% of the patients, and in nonconventional modes to 24.1%. A total of 22 (33%) patients died, of which 4 had been previously healthy. Of the surviving 45 patients, 38 were discharged without support and 7 patients with a new morbidity. CONCLUSION: Both Influenza A and Influenza B cause severe PARDS with similar characteristics and at high rates. Influenza-related PARDS cause 33% mortality and 15.5% morbidity among the study group. Healthy children, especially those aged younger than 5 years, are also at risk.