Risankizumab-induced paradoxical pustular psoriasis.

A 45-year-old white woman established on risankizumab self-presented to our service with pustular psoriasis affecting 60% of her body surface area. No history of pustular psoriasis was described in the 22 years that she had been diagnosed with psoriasis. This, to our knowledge, is the first case of paradoxical pustular psoriasis associated with risankizumab.

Fat embolism syndrome in a child with muscular dystrophy.

Fat embolism syndrome is a relatively common complication of orthopedic trauma. Once thought to be rare in children, it probably occurs with a similar frequency as in adults, but is often subclinical. Clinically apparent fat embolism syndrome may exhibit neurologic, pulmonary, and cutaneous manifestations. It often resolves without sequelae if it is recognized promptly and supportive treatment is provided. We present a pediatric case of fat embolism syndrome and review the literature on its diagnosis and management in children.

Intraosseous infusion of resuscitative fluids and drugs: long-term effect on linear bone growth in pigs.

We studied the effects of intraosseous (IO) infusion of a standard fluid bolus and resuscitative drugs on long-term bone growth and epiphyseal closure in the "pediatric" swine model. Eighteen weanling pigs were randomly assigned to six groups as follows: three animals received two normal saline boluses, 20 mL/kg IO over 20 minutes; three received sodium bicarbonate, 1 mEq/kg IO; three received a 10% sodium bicarbonate infusion IO at maintenance rate over 1 hour; three received epinephrine 1:10,000, 0.1 mL/kg IO; three received an epinephrine infusion IO at 1 microgram/kg/min for 1 hour; and three received a dopamine infusion IO at 10 micrograms/kg/min for 1 hour. All infusions were given in the left hindleg; the right hindleg was used as a control. Lateral radiographs of the hind extremities were obtained at the beginning of the study and at 1 and 3 months after infusion. Linear radiographic measurements of the infused and control tibias were compared. At 6 months after infusion, the tibias were harvested, measured directly, and radiographed to determine the degree of epiphyseal closure. Analysis of variance for the first 3 months' data yielded a nonsignificant time-by-treatment interaction (P = .84) and a nonsignificant main effect for time (P = .22). Separate analysis of the direct measurements taken at 6 months revealed no difference in growth between experimental and control tibias. In addition, no radiographic difference in epiphyseal closure was noted between the two groups at the conclusion of the study, nor were any structural defects discovered. Intraosseous infusion of fluids and resuscitative drugs does not adversely affect subsequent bone growth and development in the swine model.

Recognizing an index case of type 1 neurofibromatosis.

Neurofibromatosis is a relatively common autosomal dominant disorder with variable penetrance. The disorder usually presents in childhood. Hallmarks of type 1 neurofibromatosis are café-au-lait macules and neurofibromas. Neurologic complications include mental retardation, learning disabilities and seizures. Tumors of the eighth cranial nerve, as well as other intracranial and spinal neoplasms, are the typical lesions in type 2 neurofibromatosis. Both forms of neurofibromatosis have a highly variable course and may result in progressive neurologic deterioration, disfigurement and impingement syndromes. In the 50 percent of cases that represent new mutations, diagnosis may be delayed if the physician is not familiar with the salient features of the disorder. Thorough initial evaluation, genetic counseling and close follow-up are important aspects of management.

Long-term local effects of intraosseous infusion on tibial bone marrow in the weanling pig model.

The weanling pig model was used to determine the long-term local effects, if any, on tibial bone marrow after intraosseous (IO) infusion of resuscitation fluid and drugs at standard dosages. One of six IO treatments (two normal saline boluses [20 mL/kg]; bolus sodium bicarbonate [1 mEq/kg]; 10% sodium bicarbonate infusion at a maintenance rate for 1 hour; bolus 1:10,000 epinephrine [0.01 mg/kg]; 1:10,000 epinephrine solution infusion, 1 microgram/kg/min for 1 hour; or dopamine infusion, 10 micrograms/kg/min for 1 hour) was randomly administered via the left tibia to 18 pigs at 4 weeks of age. The animals were subsequently followed for 3 months, after which marrow from the same space and peripheral blood were examined. Marrow from the right tibia of each animal served as control; untreated historic controls were also used for comparison. Examination of the marrow revealed normal cell differentials in all limbs in all groups. Overall cellularity was somewhat decreased in the experimental limbs of the normal saline bolus group when compared with same-animal control limbs, perhaps due to the pressure effect from rapid injection. Peripheral blood counts and differentials in these and all other animals were normal. The authors conclude that IO administration of commonly used resuscitative medications does not result in significant adverse effects in the tibial bone marrow in this model.

Neurogenic pulmonary edema: case reports and review.

Neurogenic pulmonary edema (NPE) is a relatively common though often subclinical complication of a variety of central nervous system insults (trauma, hemorrhage, seizures, etc.) in children and adults. The syndrome probably results from massive centrally mediated sympathetic discharge and generalized vasoconstriction, and often presents in the emergency department (ED). The symptoms are likely to be mistaken for aspiration pneumonia. Treatment consists of ventilatory support, including positive end-expiratory pressure, and aggressive measures to reduce intracranial pressure. We present four cases of NPE and review its recognition and emergent management.

Hemorrhagic shock and encephalopathy syndrome.

Hemorrhagic shock and encephalopathy syndrome (HSES) is a devastating symptom complex that affects previously healthy infants and is associated with significant mortality and neurologic morbidity. The syndrome was first reported less than ten years ago, and there continues to be debate regarding whether HSES actually represents a distinct clinical entity or instead is a manifestation of heat illness, occult sepsis or endotoxic shock, or perhaps toxic ingestion. Nevertheless, the signs and symptoms described as HSES present in a typical fashion in the emergency department with sudden onset of shock, encephalopathy, seizures, and coagulopathy. Even with the initiation of intensive support in the ED, the outcome is probably dismal. We describe a case of HSES and review the presentation, proposed etiologies, and management of this catastrophic illness.

Unusual cases of intussusception.

Intussusception occurs most commonly in the first five years of life and is classically associated with intense intermittent abdominal pain, vomiting, bloody mucoid diarrhea, and a palpable abdominal mass. These cardinal findings are frequently not present, however, particularly outside the usual age range. The emergency physician must therefore be vigilant in considering intussusception as a potential cause for intestinal obstruction in all patients, if ischemic complications are to be avoided. We present three cases of "unusual" intussusception, and provide a review of this entity and a guide to its consideration and work-up in the emergency department.

Intraosseous administration of digoxin: same-dose comparison with intravenous administration in the dog model.

Intraosseous access has become the method of choice for venous access in critically ill and injured children when more traditional methods are not immediately available. However, there is a paucity of information concerning drug levels achieved via the intraosseous route. We report initial data on the comparison of serum digoxin levels after administration of the drug to dogs through both the intraosseous and intravenous routes. These data indicate that intraosseous infusion of digoxin results in similar serum levels to those attained after IV administration, and may therefore afford a reliable means of initial digitalization.

Intraosseous administration of antibiotics: same-dose comparison with intravenous administration in the weanling pig.

STUDY OBJECTIVES: To assess the reliability of the intraosseous route of administration for delivery of a loading dose of broad-spectrum antibiotics in a pediatric animal model. DESIGN: Serum levels achieved within 90 minutes of equivalent intraosseous (IO) and IV bolus dosing of ceftriaxone, cefotaxime, and a combination of ampicillin and gentamicin were compared in the weanling pig. SUBJECTS: Twelve female weanling pigs were studied in the Animal Facilities Laboratory at the University of Mississippi Medical Center. INTERVENTIONS: Through a proximal tibial IO catheter, each anesthetized animal received one of the following: 50 mg/kg ceftriaxone, 50 mg/kg cefotaxime, or 300 mg/kg ampicillin followed immediately by 2.5 mg/kg gentamicin. Venous blood was obtained for antibiotic assay at 15, 30, 45, 60, and 90 minutes after IO injection. The animals were allowed to recover, and, after a one-week washout period, each received the same antibiotic and dose as before through a peripheral IV. Levels were assayed at the same intervals and IO versus IV were compared. MEASUREMENTS AND MAIN RESULTS: Comparable serum levels of all four antibiotics were achieved by the two routes. Gentamicin levels were statistically indistinguishable IO versus IV at all assay intervals. Ampicillin and cefotaxime levels achieved by the two routes were equivalent within one hour of dosing. Serum levels of ceftriaxone after IO administration paralleled those after IV dosing but remained significantly lower at all time intervals. CONCLUSIONS: In the weanling pig model, the IO route was used to deliver serum levels of broad-spectrum antibiotics comparable to those attained after IV administration. The data support the use of standard parenteral doses for IO administration. To overcome potential avid protein binding of ceftriaxone in the bone marrow, we recommend using ceftriaxone at its highest recommended IO loading dose. Consistent with many other medications that have been similarly tested, these data indicate that initial or empiric antibiotic coverage in hypodynamic and shock states in infants and young children need not await the establishment of traditional IV access.

Toxicity with dextromethorphan-containing preparations: a literature review and report of two additional cases.

Dextromethorphan-containing cold/cough preparations are frequently prescribed and bought over the counter for use in children. Although generally considered safe, dextromethorphan has been shown to cause CNS side effects, including hyperexcitability, increased muscle tone, and ataxia. Two deaths have been reported with intentional dextromethorphan overdose. A literature review, brief review of pharmacology, and report of two cases of adverse reactions to dextromethorphan-containing preparations are presented.

Pott's puffy tumor: a complication of frontal sinusitis.

In children sinusitis is a frequent complication of upper respiratory infections but an infrequently considered diagnosis. Although most sinus infections are resolved without complications, when complications do occur they can be serious or life threatening. The most common ones occur in the orbit, but CNS extension is not infrequent. Osteomyelitis and resulting subperiosteal abscess of the frontal bone--the so-called Pott's puffy tumor--is a less common, and perhaps less frequently recognized, serious complication of frontal sinusitis. This paper describes two patients with subperiosteal abscess resulting from frontal sinusitis, one with CNS and orbital extension. A brief literature review is presented, and presentation, diagnosis, and treatment are discussed.