Clinical Characteristics and Delayed Diagnosis of Pediatric Patients Presenting to the Emergency Department With a Newly Diagnosed Central Nervous System Tumor: A Single Institutional Experience.

BACKGROUND: Due to the varied symptomatology and inconsistent features on neurologic exam, central nervous system (CNS) tumors are difficult to diagnosis in a timely manner. OBJECTIVE: To determine the clinical, neurological, and neuroimaging features of newly diagnosed CNS tumors presenting to the emergency department (ED). METHODS: We evaluated a retrospective cohort of 121 consecutive patients presenting to a tertiary care pediatric ED over 7 consecutive years with newly diagnosed CNS tumors. Clinical symptomatology, neurologic findings reported by emergency room and neurology physicians, neuroimaging features, and time to diagnosis were analyzed. RESULTS: A total of 116 (48 female, median age 8.0 years (interquartile range, 4.4-12.6), 52% Hispanic) presented to the ED (64% self-referred) diagnosed with a brain tumor (54% posterior fossa, 24% embryonal, 24% low-grade glioma, 16% high-grade glioma) resulting in hospital admission in 92% of cases. Five were diagnosed with extradural spinal, clivus, or orbital apex tumors. Symptomatology or duration did not differ when stratified by demographics, location, or histologic subtype. Moderate degree of concordance was observed among neurologic examinations performed by ED physicians and neurologists. Delayed diagnosis (median delay = 3.5 [1-7] months) was seen in 14% of patients, 13 with primary brain tumors (11 hemispheric, 2 brain stem). Six children with delayed diagnosis of low-grade glial tumors had a nonfocal neurologic examination in comparison to 5 patients with abnormal examinations observed with primary spinal or extradural CNS tumors. Four patients with posterior fossa tumors (3 medulloblastoma, 1 ependymoma) had normal/near normal neurologic examination at presentation despite posterior fossa symptomatology related to increased intracranial pressure. CONCLUSIONS: Our series highlights the complexity of symptomology and neurologic findings in children presenting to the ED with newly diagnosed CNS tumors who may have a normal neurologic examination. Standardization of symptom assessment and focused neurologic examinations may lead to earlier neuroimaging and prevent delayed diagnosis.

Severe Photo-oxidative Injury from Over-the-Counter Skin Moisturizer: A Child Abuse Mimic.

BACKGROUND: The cutaneous manifestations of pathological conditions have been described to mirror findings commonly associated with child abuse. Although it is important for clinicians to report suspected abuse, vigilance is required to detect conditions that mimic abuse. Phytophotodermatitis, a phototoxic reaction to furocoumarin-containing plants, is a well-described mimicker of nonaccidental trauma. However, non-furocoumarin-containing chemicals may cause similar presentations through a process called auto-oxidation. Typically, these chemical reactions occur as a result of aero-oxidation or, less commonly, photo-oxidation. CASE REPORT: We report the first pediatric case of photo-oxidative contact dermatitis from an over-the-counter skin moisturizer. A 12-month-old Hispanic boy presented to the Emergency Department with an apparent scald burn over his anterior chest and left shoulder. Given the lack of apparent cause, a nonaccidental injury was suspected. He was admitted to the pediatric service under the consult of Dermatology and the child maltreatment team. Further history and clinical progression strongly suggested a photo-oxidation reaction from chemical components in a widely available over-the-counter skin moisturizer. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights an infrequently reported cause of pediatric contact dermatitis: a photo-oxidative reaction to chemical components in skin moisturizer. It is important for the clinician to be able to differentiate injuries secondary to nonaccidental trauma from conditions that mirror their presentation. The clinical features of this case mimicked child maltreatment and underscore the importance of an interdisciplinary team approach in the care of these children.

Rattlesnake envenomation with neurotoxicity refractory to treatment with crotaline Fab antivenom.

INTRODUCTION: Neurotoxicity following rattlesnake envenomation is reported with certain crotaline species. In some instances, crotaline Fab antivenom therapy that effectively halts progression of local tissue edema and hemotoxicity fails to reverse neurologic venom effects. CASE SERIES: A 50-year-old man presented following a rattlesnake envenomation to the left ring finger. He had swelling and pain in the affected hand and complained of dyspnea and dysphonia. Significant fasciculations were seen in the face, tongue, neck, trunk, and arms. The patient received crotaline Fab antivenom but continued to develop worsening respiratory distress. His respiratory insufficiency requiring ventilatory support appeared related to respiratory muscle incoordination as extremity motor function remained intact. Initial control of local edema progression and hematologic parameters was achieved with antivenom, but diffuse fasciculations involving the entire body worsened despite aggressive antivenom treatment. In another case, a 9-year-old boy was envenomated by a rattlesnake on the left thenar eminence. He presented with pain and swelling up to the forearm and fasciculations of the tongue, face, and upper extremities. The progression of edema was halted at the mid-bicep level and hematologic parameters normalized with crotaline Fab antivenom. However, fasciculations continued for two days despite antivenom treatment. CONCLUSION: We describe two cases of neurotoxicity following rattlesnake envenomation in which treatment with crotaline Fab antivenom adequately obtained initial control of local swelling and hematologic effects, but neurotoxic venom effects remained refractory to antivenom therapy. This phenomenon is anecdotally recognized following certain crotaline species envenomations.

Olfactory dysfunction: a sequela of pediatric blunt head trauma.

OBJECTIVE: To evaluate olfactory function in children with blunt head trauma. METHODS: Eligible subjects were consecutive children presenting at San Diego Children's Hospital Emergency Department or Trauma Service with blunt head trauma. Thirty-seven head injured children mean age 10.11+/-2.74 were evaluated; 36 healthy age and gender matched community children, mean age 10.08+/-2.99, served as controls. The medical record was reviewed for clinical measures related to head injury (HI). All children underwent olfactory assessment with the San Diego Children's Odor Identification Test (SDOIT). Olfactory event-related potentials were recorded on a subset of head injured and control children. RESULTS: Three of 37 head injured children had olfactory dysfunction. The head injured hyposmics had signs of more severe head injury represented by lower Glasgow Coma Scores (GCS), 10.33+/-5.51, when compared to their normosmic counterparts with mean GCS of 14.06+/-2.82. When stratifying the head injured children by clinical measures, lower Glasgow Coma Score, and abnormalities on head CT scan were associated with poorer olfactory performance. CONCLUSION: Children with blunt head injury may suffer post-traumatic olfactory impairment. More severe head injuries are more likely to produce olfactory deficits. In cases of significant head injury, cranial nerve I evaluation is imperative.