A Case of Lemierre-Like Syndrome in a Pediatric Patient.

Lemierre-like syndrome is a rare, systemic sequelae following a persistent oropharyngeal infection, leading to septic thrombophlebitis of the internal jugular vein (IJV). Lemierre syndrome is caused by the obligate anaerobic organism Fusobacterium necrophorum, innate to the oropharyngeal tract. Lemierre-like syndrome is due to infections caused by other organisms, including methicillin-resistant Staphylococcus aureus (MRSA). We are reporting a case of a five-month-old male who presented with one week of fever that was not alleviated by acetaminophen, bilateral otitis media, and left-sided cervical lymphadenopathy not alleviated with medical therapy. The patient's clinical course continued to deteriorate as he developed respiratory distress that progressed to acute respiratory failure requiring mechanical ventilation support. Extensive laboratory investigation ruled out the causes of primary and secondary immunodeficiencies. Blood cultures were positive for MRSA, and he was treated initially with vancomycin, then switched to linezolid per ENT recommendations, and ultimately needed daptomycin and ceftaroline therapy. A computed tomography (CT) scan of the neck and chest showed deep neck space infection, bilateral loculated pleural empyema, and mediastinitis. The patient required a decortication video-assisted thoracoscopic surgery (VATS), multiple drains, and a mediastinal washout to control the MRSA infection. This report emphasizes that the rapid progression and spread of septic thrombus can become detrimental to a patient's recovery and survival; therefore, it should be recognized early and treated promptly.

Rapidly Progressive Fatal Pneumococcal Meningitis in a Fully Immunized Child With a History of Facial Bone Fractures.

Meningitis is the inflammation of meninges either septic or aseptic depending on the source of infection. Typical signs and symptoms of meningitis in children include fever, headache, neck stiffness, nuchal rigidity represented by positive Kernig and Brudzinski signs, photophobia, nausea, vomiting, confusion, lethargy, and irritability. Bacterial meningitis is commonly caused by Streptococcus pneumoniae in children over the age of three months. Although there has been a decline in infections due to the introduction of the pneumococcal conjugate and pneumococcal polysaccharide vaccines, there are still reported cases of invasive pneumococcal infections mostly with non-vaccine serotypes. We report a fully immunized six-year-old male patient with a presentation of classic meningitis signs and symptoms who developed rapid progression of disease including sudden and dramatic change in physical exam and subsequent respiratory depression within 12 hours of admission. Our patient had a history of extensive traumatic facial bone fractures six months prior. Our case demonstrates a unique presentation of rapidly progressing pneumococcal meningitis due to a suspected complication of septic thrombophlebitis and subsequent brain herniation in a fully immunized patient six months after a severe traumatic facial injury.

Delayed Serotonin Syndrome and Non-cardiogenic Pulmonary Edema Following Bupropion Overdose in a Seven-Year-Old Female: A Case Report and Review of Literature.

Bupropion is an atypical antidepressant prescribed for depression and attention-deficit/hyperactivity disorder and to aid in smoking cessation. Bupropion overdose management is largely aimed toward common sequelae, including seizures, tachycardia, and QTc prolongation. In this case report, we identify a rare event of pediatric bupropion overdose with aforementioned common sequela and atypical features, including a delayed presentation of serotonin syndrome and non-cardiogenic pulmonary edema. This case follows a seven-year-old Caucasian female with autism spectrum disorder (ASD) who presented in status epilepticus following an accidental bupropion overdose and required multiple anti-seizure medications, endotracheal intubation, and admission to the pediatric intensive care unit (PICU). The patient's condition improved, and she was extubated 25 hours after admission and transitioned to high-flow nasal cannula therapy. On day 3 of admission, she became febrile and developed dyspnea with decreased breath sounds and intercostal retractions, tachycardia, a rigid abdomen and extremities with sporadic tremors, pulmonary edema, and a prolonged QTc interval. Targeted therapies were initiated, and following treatment, our patient showed remarkable improvement in the subsequent 24 hours and was discharged home five days after the initial presentation. This case identifies a delayed presentation of uncommon and serious complications of bupropion overdose, including pulmonary edema and serotonin syndrome, in a pediatric patient. Prompt investigation and identification of bupropion toxicity can help practitioners mitigate further complications during admission and reduce morbidity and mortality.

Recurrent Subglottic Stenosis in a 16-Month-Old Male in the Setting of Influenza A, Intubation, and Honey Consumption.

Recurrent episodes of subglottic stenosis are rare in the literature, and the etiologic causes are misunderstood but can be congenital, idiopathic, or iatrogenic in nature. Complications of intubation can result in subsequent inflammation and reactive processes. This case involves a 16-month-old male who suffered from a recurrent episode of subglottic stenosis in the setting of croup, influenza, and honey consumption. He had presented to the emergency department in respiratory distress after ingesting a home remedy of onion juice and honey. He had been discharged one day prior from the pediatric intensive care unit after four days of intubation and a seven-day hospital course with evidence of croup on imaging. He was readmitted, and subglottic edema and narrowing were confirmed via endoscopy, which prompted antibiotic treatment and close monitoring. After three days of monitoring and re-evaluation by bronchoscopy, the patient's condition began to improve, and no intubation was necessary. It is unclear what the cause of recurrent subglottic stenosis is due to the patient's clinical picture being clouded by a potential allergic reaction to honey versus an inflammatory reactive process post-intubation from the previous admission days prior. This case emphasizes the need for further research on the prevalence and etiology of recurrent subglottic stenosis and a deeper understanding of how to optimize diagnosis and treatment.

Invasive Sinusitis With Arcanobacterium haemolyticum and Fusobacterium necrophorum Complicated by Subdural Empyema in an Immunocompetent Adolescent Patient.

We are reporting a very rare case of an invasive infection with Arcanobacterium haemolyticum and Fusobacterium necrophorum that resulted in meningitis, cerebral edema, and subdural empyema secondary to upper respiratory infection (URI) and sinusitis in an immunocompetent adolescent patient. Our patient is a 17-year-old male with no significant medical history who presented to his pediatrician with a fever for three days, was diagnosed with a viral URI, and instructed to continue symptomatic care. Seven days later, the patient developed a headache, left-sided weakness, and continued to spike fever. The patient presented to the Emergency Center due to altered mental status, worsening left-sided weakness, and difficulty speaking. Head computed tomography (CT) scan showed small right-sided fluid collection with right-to-left midline shift and marked opacification of paranasal sinuses with air-fluid levels in frontal sinuses. The patient underwent an emergent craniotomy that revealed subdural empyema under high pressure and was started on vancomycin, cefepime, metronidazole, and levetiracetam. Six hours after his craniotomy, the patient developed fixed dilatation of his right-side pupil and a head CT scan showed developing ischemic changes and increased in his midline shift which prompted to emergent right decompressive craniectomy. The following day of his surgery, magnetic resonance imaging of the brain showed large acute infarctions of the right hemisphere, edema, and subfalcine herniation. Two brain death exams - 12 hours apart - were performed in which criteria for brain death were met. The patient's subdural empyema culture grew Fusobacterium necrophorum and Arcanobacterium haemolyticum.

Multimodal Management of Febrile Infection-Related Epilepsy Syndrome in a 17-Year-Old Male.

New-onset refractory status epilepticus (NORSE) is a clinical presentation, not a specific diagnosis, in which healthy people are suddenly struck by prolonged seizures that do not respond to at least two anti-seizure drugs and do not have a clear structural, toxic, or metabolic cause.Febrile infection-related epilepsy syndrome (FIRES) is considered a sub-category of NORSE. Our patient is a 17-year-old male admitted to the pediatric ward after a self-limited convulsive episode at home, noted to occur following five days of upper respiratory infection symptoms accompanied by fever. After multiple generalized tonic-clonic seizures necessitating treatment, he went into status epilepticus despite multiple antiepileptic drugs. The possibility of FIRES had been considered from the onset of refractory status epilepticus; as a result, an intensive multimodal treatment regimen was proactively implemented with some clinical improvement.

Calcium Channel Blocker Overdose Causes Acute Respiratory Distress Syndrome and Acute Kidney Injury in a 15-Year-Old Female.

Calcium channel blockers (CCBs) are among the most commonly prescribed cardiovascular medications in the adult population. Approximately 20% of adults with hypertension in the United States are prescribed dihydropyridine calcium channel blockers. Similarly, in the pediatric population, CCBs such as nifedipine and amlodipine are frequently prescribed in the non-emergent management of hypertension in children and adolescents. Despite the prevalence of CCB usage, the available literature on the management of calcium channel blocker toxicity in the pediatric population remains scarce. In the absence of formal guidelines, the management of CCB overdoses comes from case reports. This case identifies a 15-year-old Hispanic female who developed acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI) after an overdose of amlodipine. Our patient presented with profound, refractory hypotension requiring substantial inotropic support. She subsequently developed significant dyspnea, desaturating into the 80s with radiological evidence of ARDS requiring endotracheal intubation. After aggressive diuresis and electrolyte replacement, along with inotropic agents to maintain adequate blood pressure, our patient began to make significant clinical progress. With continued improvement and resolution of her AKI and ARDS, she was successfully weaned off ventilatory support and all infusions. Our patient was deemed medically appropriate for discharge 10 days after the initial presentation and was admitted to an inpatient psychiatric unit. Calcium channel blocker toxicity can pose considerable risks, as was seen with our patient. Prompt recognition and judicious management of CCB overdoses can mitigate associated morbidity and mortality, resulting in favorable outcomes for patients. The intention behind documenting this case is to contribute to the limited literature on the successful management of calcium channel blocker poisoning in the pediatric population.

Modified Whipple on an 18-month-old with traumatic pancreatic transection and duodenal rupture.

The emergence of the Whipple procedure revolutionized operative management of pancreatic disease since its introduction (Fernandez-del Castillo et al., 2012 [1]). This operation classically involves removal of the head of the pancreas along with the duodenum, gallbladder, a portion of the bile duct, and part of the stomach (Warshaw and Thayer, 2004; Evans et al., 2007 [2,3]). We report a beneficial outcome of a modified Whipple on a paediatric trauma patient post- motor vehicle accident (MVA). After Advanced Trauma Life Support (ATLS) was initiated and haemodynamic stability was achieved, exploratory laparotomy revealed pancreatic transection and duodenal rupture. Partial pancreaticoduodenectomy, pancreaticoduodenostomy, cholecystojejunostomy, and pyloric-sparing gastrojejunostomy were performed. Post-operative acute pancreatitis resolved with antibiotics and supportive care. While paediatric abdominal trauma does not typically warrant a Whipple, patients with severe injury to the pancreas and neighboring organs with major vascular injury may offer no other intra-operative choice (Adams, 2014; Thatte and Vaze, 2014; Debi et al., 2013 [[4], [5], [6]]). Our patient's growth was followed post-operatively. At a 20-year post-operative follow-up, he reported no further hospitalizations or complications such as diabetes, biliary stricture, gallstones, or growth retardation. We review the literature to expose the novelty of using a Whipple to treat paediatric abdominal trauma, and the advantages of a pylorus-preserving Whipple. Indications for damage control surgery and non-operative management were contrasted with those for definitive surgery to reconstruct the biliary tree to further elucidate why the latter option was chosen.

Ectopic subglottic thymic cyst: a rare cause of congenital stridor.

We describe the case of a 10-day-old boy who was brought to the hospital with stridor and respiratory distress. He was diagnosed with stenosis caused by a subglottic cyst. After the cyst was removed endoscopically, the patient's symptoms resolved. Pathology identified the cyst as ectopic thymic tissue. This case is noteworthy because we believe it represents the first reported instance of ectopic thymic tissue in the subglottis.

Juvenile xanthogranuloma: a rare cause of subglottic cyst and stenosis.

Only two cases of juvenile xanthogranuloma of the larynx have been previously reported in the literature. We report a new case, which occurred in an 18-month-old girl. The patient was brought to us for treatment of stridor and respiratory distress. During examination, she was found to have a subglottic mass. The lesion was treated with laser microlaryngoscopy, which relieved the patient's respiratory distress and obviated the need for tracheotomy. Pathologic examination of the mass revealed that it was consistent with a juvenile xanthogranuloma. Juvenile xanthogranuloma is generally a benign and self-limiting disease, but complications can occur when the space that the tumor occupies causes functional impairment.