Hand, Foot, and Mouth Disease Associated With Transient Hyperphosphatasemia.

A majority of pediatric outpatient practice involves managing familiar diseases that present in familiar ways. Occasionally, a familiar disease presents uniquely, which adds a diagnostic challenge and enhances the clinical experience of the clinician. We describe an 18-month-old male who presented to the clinic with a familiar disease but with unique additional findings. The patient had a one-day history of rash, subjective fever, and several episodes of non-bloody diarrhea. The rash included petechial lesions across his abdomen, groin, back, arms, and legs, as well as vesicular lesions in the mouth and on the palms and soles. A tentative diagnosis of hand, foot, and mouth disease (HFMD) was made. However, the presence of petechiae prompted further laboratory evaluation, including a complete blood count (CBC) and comprehensive metabolic panel (CMP). The CBC was unremarkable, but the CMP revealed an abnormally high serum alkaline phosphatase (ALP) level of 1,353 U/L (normal range: 53-128 U/L). The patient was subsequently diagnosed with an atypical presentation of HFMD associated with transient hyperphosphatasemia (TH). TH is characterized by a benign increase in serum alkaline phosphatase levels with an absence of liver or bone diseases. TH is usually clinically silent. Clinicians should consider the possibility of TH in pediatric patients who are found incidentally to have an elevated ALP, especially with a concomitant viral infection. An awareness and understanding of TH will prevent unnecessary additional testing and avoid undue parental anxiety.

Bilateral Exertional Compartment Syndrome With Endoscopic Fasciotomy Surgical Intervention in a High School Athlete.

A 17-year-old female presented to the physical therapy clinic with bilateral lower leg pain that worsened with activity. The patient experienced numbness, tingling, and cramping along the lateral and posterior portions of her legs during basketball practice, and her symptoms had gradually worsened over the past eight months. She obtained minimal relief with conservative treatments such as stretching and rest. X-rays and MRI of the lower limbs were obtained six months after symptoms began and were unremarkable. Further evaluation included compartment pressure testing taken before and after exercise. The patient demonstrated diagnostic pressures indicative of compartment syndrome in two compartments bilaterally. The patient was subsequently diagnosed with exertional compartment syndrome. Exertional compartment syndrome is a cause of muscle pain that occurs due to increased tissue pressure within the confinement of the closed fascial space during exercise. Patients are often misdiagnosed or there is a significant delay in the correct diagnosis. The gold standard for diagnosis is measurement of intracompartmental pressures with the Stryker catheter. Clinicians should consider exertional compartment syndrome in active patients who present with generalized muscle pain or sensation deficits that worsen with activity and are relieved with rest. Surgical intervention is a reasonable intervention and the only definitive option for an athlete with chronic exertional compartment syndrome who wants to continue high-level competition. Endoscopic fasciotomies are the new preferred techniques compared to more invasive open surgeries, which require a full incision. Endoscopic fasciotomy has a quicker healing time and has been shown to be as effective at relieving compartment syndrome symptoms as invasive open techniques. After surgical intervention, the patient reported a 90% reduction in symptoms and had returned to full sport participation within two months.

Inconspicuous Presentation of Metastatic Neuroblastoma.

Neuroblastoma is a malignant tumor arising from nerve tissue that accounts for approximately 15 percent of pediatric cancer fatalities. Primary tumors most commonly arise in sympathetic nervous tissue of the abdomen and metastasize to the bone marrow, liver, and lymph nodes. This case report depicts a 3-year-old girl who presented with a recurring fever, runny nose, and a positive test for rhinovirus suggesting a simple case of the common cold. Further investigation, however, revealed stage 4 neuroblastoma. This patient experience emphasizes the importance of having a high level of suspicion to rule out more serious underlying pathology in a seemingly unremarkable patient presentation.

From LCME probation to compliance: the Marshall University Joan C Edwards School of Medicine experience.

The Joan C Edwards School of Medicine (Marshall University, Huntington, WV, USA) was placed on probation by the Liaison Committee on Medical Education (LCME) in June 2011. In the following 2 years, extensive changes were made to address the numerous citations that resulted in this probation. In October 2013, the LCME lifted probation. In this article, we detail the challenges and solutions identified relevant to our struggle with compliance.

Urticarial Vasculitis in a Teenage Girl.

This case involves a 13-year-old female who presented to the pediatrician for a routine check-up with complaints of a long history of intermittent diarrhea followed by a severe rash lasting for up to a week afterwards. The mother had described her daughter's condition to multiple physicians, several whom had seen her during flare-ups. The nonmigratory lesions resembled "hives" with a single lesion lasting for 48 to 72 hours and resolving into what her parent described as a bruise. They often diagnosed her daughter with urticaria and prescribed steroids, which did resolve the acute flare-ups. None of the physicians, however, focused on the disease's evolution and chronicity in an effort toward diagnosis and prevention. The patient was referred by her pediatrician to a dermatologist who diagnosed the patient with urticarial vasculitis. She was initially started on dapsone 25 mg and was increased over a period of months to a maintenance dose of 100 mg daily. She has had no recurrences in her cutaneous or systemic symptoms on this dose. She is closely monitored by her dermatologist on a regular basis with twice yearly complete blood counts. Several attempts have been made to discontinue the dapsone, resulting in a flare of her gastrointestinal symptoms. This patient suffered with this condition for almost 10 years. This is a reminder that spending extra time to think through a patient's problem early on may prevent years of suffering for patients and their families.