Clinical Presentation Of Children Research Articles

Approach to the patient with Childhood Interstitial and Diffuse Lung Disease.

Childhood Interstitial and Diffuse Lung Disease (chILD) encompasses a group of rare, chronic lung disorders in infants and children with overlapping clinical features but diverse etiologies. The clinical presentation of chILD is of chronic or recurring respiratory signs and symptoms, often including increased work of breathing and hypoxia, with diffuse radiographic abnormalities on chest imaging. Recognition can be challenging since some clinical features overlap with those of more common pediatric respiratory diseases including asthma and recurrent viral infections, among others. chILD should be considered as an underlying diagnosis when a patient's respiratory symptoms seem disproportionate to the clinical scenario and/or persist. The diagnostic process involves multiple steps and is tailored to the individual patient. Nearly all children will undergo imaging and pulmonary function testing, many will undergo bronchoscopy with bronchoalveolar lavage, many will receive genetic testing, and some will require lung biopsy. Treatment includes preventive care, evaluation for comorbidities, pharmacotherapy according to diagnosis, and ongoing disease surveillance, including revisiting genetic and histopathologic results as new clinical information becomes available and as our understanding of these rare disorders improves. The purpose of this review is to provide a broad approach to the diagnosis and management of patients with chILD.

Molecular characterization of SARS-CoV-2 Omicron clade and clinical presentation in children

Since its emergence, SARS-CoV-2 Omicron clade has shown a marked degree of variability and different clinical presentation compared with previous clades. Here we demonstrate that at least four Omicron lineages circulated in children since December 2021, and studied until November 2022: BA.1 (33.6%), BA.2 (40.6%), BA.5 (23.7%) and BQ.1 (2.1%). At least 70% of infections concerned children under 1 year, most of them being infected with BA.2 lineages (n = 201, 75.6%). Looking at SARS-CoV-2 genetic variability, 69 SNPs were found to be significantly associated in pairs, (phi < − 0.3 or > 0.3 and p-value < 0.001). 16 SNPs were involved in 4 distinct clusters (bootstrap > 0.75). One of these clusters (A23040G, A27259C, T23617G, T23620G) was also positively associated with moderate/severe COVID-19 presentation (AOR [95% CI] 2.49 [1.26–4.89] p-value: 0.008) together with comorbidities (AOR [95% CI] 2.67 [1.36–5.24] p-value: 0.004). Overall, these results highlight the extensive SARS-CoV-2 Omicron circulation in children, mostly aged < 1 year, and provide insights on viral diversification even considering low-abundant SNPs, finally suggesting the potential contribution of viral diversification in affecting disease severity.

Technology-Assisted Parenting Intervention Plus Therapist Coaching: A Pilot Randomized Trial in a Community Practice Setting

ABSTRACT Disruptive behaviors are the most common clinical presentation in children and adolescents, particularly among disadvantaged youth referred to community mental health clinics (CMHCs). When left unaddressed, disruptive behaviors can increase the risk of adverse mental health outcomes. While parenting interventions are known to be efficacious and efficient treatment approaches, there are many barriers to involvement in such programs, particularly for disadvantaged populations. This pilot randomized controlled trial evaluated a technology-assisted parenting intervention (Parenting Wisely, PW) with therapist coaching compared to treatment as usual (TAU) at a CMHC. Participants included 53 caregiver-adolescent dyads and 13 clinicians recruited from a CMHC. Dyads randomized to PW + therapist coaching received a multi-component intervention that utilized a technology-assisted parenting program alongside therapist coaching sessions. Feasibility/acceptability assessments were conducted and preliminary findings on parenting outcomes and adolescent behavior outcomes were collected at 3- and 6-months post-baseline. Qualitative and quantitative results supported the feasibility and acceptability of the parenting PW + therapist coaching intervention as evidenced by caregiver engagement, therapist adherence, lack of treatment withdrawals, and satisfaction ratings. Exploratory analyses did not show differences between treatment conditions for parenting and adolescent behavioral outcomes. PW + therapist coaching may be better suited for early adolescents, who are at a critical period when disruptive behavior patterns are not yet ingrained, and parents have more authority and opportunity to address family interactions. Next steps for further evaluation include testing the effectiveness, predictors, moderators, and mechanisms of treatment outcomes of PW + therapist coaching as an adjunct to usual care.

Unusual pediatric lung infections: imaging findings

Pediatric lung infections continue to be a leading cause of pediatric morbidity and mortality. Although both pediatric and general radiologists are familiar with typical lung infections and their imaging findings in children, relatively rare lung infections continue to present a diagnostic challenge. In addition, the advances in radiological imaging and emergence of several new lung infections in recent years facilitated the need for up-to-date knowledge on this topic. In this review article, we discuss the imaging findings of pediatric lung infections caused by unusual/uncommon and new pathogens. We review the epidemiological, clinical, and radiological imaging findings of viral (coronavirus disease 2019, Middle East respiratory syndrome, bird flu), bacterial (Streptococcus anginosus, Francisella tularensis, Chlamydia psittaci), and parasitic lung infections (echinococcosis, paragonimiasis, amoebiasis). Additional disorders whose clinical course and imaging findings may mimic lung infections in children (hypersensitivity pneumonitis, pulmonary hemorrhage, eosinophilic pneumonia) are also presented, to aid in differential diagnosis. As the clinical presentation of children with new and unusual lung infections is often non-specific, imaging evaluation plays an important role in initial detection, follow-up for disease progression, and assessment of potential complications.Graphical

Obesity and Outcomes of Kawasaki Disease and COVID-19–Related Multisystem Inflammatory Syndrome in Children

ImportanceObesity may affect the clinical course of Kawasaki disease (KD) in children and multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19.ObjectiveTo compare the prevalence of obesity and associations with clinical outcomes in patients with KD or MIS-C.Design, Setting, and ParticipantsIn this cohort study, analysis of International Kawasaki Disease Registry (IKDR) data on contemporaneous patients was conducted between January 1, 2020, and July 31, 2022 (42 sites, 8 countries). Patients with MIS-C (defined by Centers for Disease Control and Prevention criteria) and patients with KD (defined by American Heart Association criteria) were included. Patients with KD who had evidence of a recent COVID-19 infection or missing or unknown COVID-19 status were excluded.Main Outcomes and MeasuresPatient demographic characteristics, clinical features, disease course, and outcome variables were collected from the IKDR data set. Using body mass index (BMI)/weight z score percentile equivalents, patient weight was categorized as normal weight (BMI &amp;amp;lt;85th percentile), overweight (BMI ≥85th to &amp;amp;lt;95th percentile), and obese (BMI ≥95th percentile). The association between adiposity category and clinical features and outcomes was determined separately for KD and MIS-C patient groups.ResultsOf 1767 children, 338 with KD (median age, 2.5 [IQR, 1.2-5.0] years; 60.4% male) and 1429 with MIS-C (median age, 8.7 [IQR, 5.3-12.4] years; 61.4% male) were contemporaneously included in the study. For patients with MIS-C vs KD, the prevalence of overweight (17.1% vs 11.5%) and obesity (23.7% vs 11.5%) was significantly higher (P &amp;amp;lt; .001), with significantly higher adiposity z scores, even after adjustment for age, sex, and race and ethnicity. For patients with KD, apart from intensive care unit admission rate, adiposity category was not associated with laboratory test features or outcomes. For patients with MIS-C, higher adiposity category was associated with worse laboratory test values and outcomes, including a greater likelihood of shock, intensive care unit admission and inotrope requirement, and increased inflammatory markers, creatinine levels, and alanine aminotransferase levels. Adiposity category was not associated with coronary artery abnormalities for either MIS-C or KD.Conclusions and RelevanceIn this international cohort study, obesity was more prevalent for patients with MIS-C vs KD, and associated with more severe presentation, laboratory test features, and outcomes. These findings suggest that obesity as a comorbid factor should be considered at the clinical presentation in children with MIS-C.

Clinical Presentation and Co-Detection of Respiratory Pathogens in Children Under 5 Years with Non-COVID-19 Bacterial and Viral Respiratory Tract Infections: A Prospective Study in Białystok, Poland (2021-2022).

BACKGROUND Respiratory tract infections (RTIs) in children often involve a complex interplay between viruses and bacteria. This study aimed to evaluate clinical presentation in children under 5 years old diagnosed with non-COVID-19 bacterial and viral respiratory tract co-infections between October 2021 and May 2022 in Białystok, Poland. MATERIAL AND METHODS We recruited 100 children under 5 years with RTIs who tested negative for SARS-CoV-2. Nasopharyngeal swabs were screened for 19 viruses and 7 bacterial strains using molecular assays. RESULTS Viral pathogens were detected in 71% of patients and bacterial pathogens were detected in 59%. The most common pathogens were Haemophilus influenzae (n=48), rhinoviruses (n=32), and Streptococcus pneumoniae (n=30). Single pathogens were detected in 36%, dual in 37%, triple in 15%, and quadruple in 2%. Bacterial pathogens were co-detected with viruses in 40 cases, mostly with rhinoviruses (n=15). Two different viruses were found in 14 children and the most common co-detection was adenovirus with rhinovirus (n=5); dyspnea (63% vs 11%) and wheezing (75% vs 22%) were more common in children with human bocavirus. Fever was a common symptom in children with human adenovirus (88% vs 58%). Detection of bacteria and multiple detections were more common in day-care attendees, but were not associated with clinical picture of RTI. CONCLUSIONS Consistent with previous studies, we found a high prevalence of rhinoviruses, despite ongoing implementation of non-pharmaceutical interventions to contain the COVID-19 pandemic. Co-detection of 2 different respiratory pathogens was frequent, but we found no evidence that this was associated with the severity of infections.

Management of febrile neutropenia in immunocompetent children and youth.

Febrile neutropenia is a common clinical presentation in children that can be associated with invasive bacterial infection (IBI). However, in otherwise healthy children and youth with fever and neutropenia, the risk for IBI is low, with most cases being caused by viral infections. Well-appearing, non-oncologic, and presumed immunocompetent children aged 6 months to 18 years experiencing a first episode of neutropenia, with no additional risk factors, typically do not require empiric antibiotics. However, a thorough assessment, including complete history and physical exam, is indicated, and a blood culture should be performed when the absolute neutrophil count is <0.5 × 109/L. Close follow-up, a repeat complete blood count, and strong anticipatory guidance are recommended.

0787 Sleep Problems and Sleep Disorders in Children with Rubinstein-Taybi Syndrome

Abstract Introduction Rubinstein-Taybi syndrome (RSTS) is a genetic condition which characterized by distinctive facial features, broad and angulated thumbs and halluces, short stature, and moderate-to-severe intellectual disability. Sleep problems have been reported in children with RSTS. However, most studies were case reports in adult population. There is limited information on details about sleep problems in children with RSTS. The purpose of this study was to: (1.) Describe the demographics, clinical presentation of children with RSTS; (2.) Describe polysomnographic findings, sleep diagnoses and treatments of children with RSTS. Methods A retrospective study was performed in patients with RSTS (ages 0-20 years) who underwent polysomnography at Cincinnati Children’s Hospital Medical Center from January 1, 2000 to October 31, 2022. Demographics, clinical presentation, polysomnographic findings, diagnoses and treatments were reviewed. Descriptive statistics were utilized. Results Thirteen children with RSTS were included, 69% were male (N=9). The median age was 6.3 years (range 13 days to 12.6 years). The most common presenting symptoms included snoring (N=9, 69.2%), pauses of breathing (N=6, 46.2%) and nighttime awakenings (N=5, 38.5%). The age of onset of sleep symptoms ranged from birth to 5 years. From polysomnographic findings, the most common diagnosis was obstructive sleep apnea (OSA) (N=11, 84.6%) with obstructive apnea-hypopnea index ranging from 2.8 to 72.7/h, (mild, N=3; moderate, N=3; severe; N=5). All children with mild OSA (N=3) were treated with medications, while children with moderate-to-severe OSA were managed with PAP therapies (N=4), supplemental oxygen (N=3), and surgeries (N=3). Other diagnoses included central sleep apnea (N=2) and periodic limb movement disorder (N=2), which were treated with supplemental oxygen and iron supplements, respectively. Conclusion The most common presenting sleep symptoms in children with RSTS were snoring, pauses of breathing and nighttime awakening. The age of onset of symptoms was variable, but usually occurred during infancy through childhood. OSA was the most common diagnosis in these populations. Physicians should recognize the early signs and symptoms of sleep problems in children with RSTS to allow early diagnosis and appropriate treatment. Support (if any) Cincinnati Children's Hospital Research Fund

Imaging of Right Lower Quadrant Pain in Children and Adolescents: AJR Expert Panel Narrative Review.

Right lower quadrant (RLQ) pain is a common clinical presentation in children, and accurate clinical diagnosis remains challenging given that this nonspecific presentation is associated with numerous surgical and nonsurgical conditions. The broad differential diagnosis varies by patient age and sex. Important considerations in the selection of a diagnostic imaging strategy include the sequencing, performance, and cost of tests. This article provides a comprehensive narrative review of the diagnostic imaging of RLQ pain in children and adolescents, including a discussion of the complementary roles of ultrasound, CT, and MRI; description of key imaging findings based on available evidence; and presentation of salient differential diagnoses. Subspecialized pediatric emergency medicine and surgical perspectives are also provided as further clinical insight into this common, but often challenging, scenario. Finally, the current status of imaging of RLQ pain in children and adolescents is summarized on the basis of expert consensus.

Clinical Presentation of Children with COVID-19 admitted to Pediatric Intensive Care Unit: Single Center Experience

Coronavirus disease of 2019 (COVID-19) infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) among children is mostly a mild disease yet it may cause life threatening direct histopathological lung injury and indirect immune dysregulation with hyperimmune response that causes multi inflammatory disease.

Complete and incomplete Kawasaki disease: Clinical differences and coronary artery outcome from a national prospective surveillance study in Switzerland.

The aim of this national prospective surveillance study was to compare the clinical presentation, laboratory findings, treatment, and coronary artery outcome in patients with incomplete and complete Kawasaki disease (KD). Between March 2013 and February 2019, children with a diagnosis of complete and incomplete KD were reported by the Swiss Paediatric Surveillance Unit and prospectively enrolled. Clinical data, laboratory values, treatment, and echocardiographic features were collected at diagnosis and 1 year of follow-up. Data were compared between children with complete or incomplete KD. A total of 351 questionnaires were registered from children with a diagnosis of KD. Of them, 219 (62.4%) children had complete KD, and 132 (37.6%) children had incomplete KD. Children with incomplete KD were younger and had a longer-lasting fever; however, there were no differences in the level of C-reactive protein. All but four children received intravenous immunoglobulin treatment, whereas 14% of children were treated with corticosteroids. Children with incomplete KD were more often treated with corticosteroids than children with incomplete KD (p = 0.01). At diagnosis, 39 (11.1%) patients had only coronary artery dilation and 57 (16.2%) had at least one coronary artery aneurysm. There were no differences in coronary artery involvement between the two groups. At follow-up, 273 of 294 (92.8%) patients had no coronary artery involvement, with no difference between the two groups (p = 0.609). The overall incidence of coronary artery aneurysms at diagnosis was 16.2%. At follow-up, most coronary artery aneurysms had regressed, and coronary artery aneurysms were present in only 5.8% of the patients. Coronary artery aneurysms were slightly more frequent in patients with incomplete KD at follow-up (p = 0.039) but not at diagnosis (p = 0.208). Although the clinical presentation in children with incomplete and complete KD differs, the absence of coronary artery involvement does not. The use of corticosteroids appears to be preventive against the development of coronary artery aneurysms in these patients. However, the results of this study suggest a lower rate of coronary artery aneurysm regression in patients with incomplete KD. Further studies on a larger scale are needed to assess the risk of non-regression of coronary artery aneurysms in this particular group of patients.

Clinical features and diagnostic value of metagenomic next -generation sequencing in five cases of non-HIV related Pneumocystis jirovecii pneumonia in children.

Pneumocystis jirovecii (PJ) is an opportunistic pathogenic fungus, and PJ pneumonia (PJP) is a commonly problem in HIV-positive patients. While PJP is not caused by HIV, it generally advances rapidly and can quickly lead to severe respiratory failure. To improve pediatricians' understanding of the condition and aid early accurate diagnoses and therapy, we examined the clinical characteristics of five instances of non-HIV related PJP (NH-PJP) in children and the efficacy of metagenomic next-generation sequencing (mNGS) in its diagnosis. From January 2020 to June 2022, five children with NH-PJP were admitted to the PICU of the First Affiliated Hospital of Zhengzhou University. We retrospectively summarize the clinical presentation, previous histories, routine laboratory findings, treatment, outcome of regression, and results of mNGS in these five children. Five male children between the ages of 11 months and 14 years had an acute onset on NH-PJP, three of the children had chest tightness after activity, shortness of breath and paroxysmal dry cough, - and two had high fever and dry cough. All five of the children had several flocculent high-density pictures in both lungs at the beginning of the disease, and lung auscultation revealed coarse breath sounds in both lungs, one of which was accompanied by a modest quantity of dry rales. PJ nuclear sequences were found in one patient and four patients' blood and alveolar lavage fluid. All five children were treated with Trimethoprim-sulfamethoxazole (TMP-SMX) in combination with Caspofungin and corresponding symptomatic treatment. Four patients were cured and one patient died. Children commonly encounter an initial exposure to NH-PJP, which manifests as a high fever, dry cough, chest discomfort, dyspnea that worsens over time, fast disease progression, and a high death rate. The clinical presentation of children with PJ infection should be taken into consideration along with the results for diagnose. mNGS has higher sensitivity and a shorter detection period compared to identification of PJP.

Etiological profile of febrile thrombocytopenia in children aged &lt;12 years in a tertiary care centre

Background: Febrile thrombocytopenia is platelet count &lt;1,50,000/mm3 associated with fever irrespective of age and gender. There is an increasing trend in the incidence of febrile thrombocytopenia with varied etiology. Though infections are the most common cause in tropical countries like India, sometimes non-infectious conditions like primary haematological disorders and malignancies can also present as febrile thrombocytopenia. Hence it is essential for the treating physicians to be fully aware of etiological factors for febrile thrombocytopenia and how to approach to the condition. Methods: A hospital based observational study done at Kamineni Institute of Medical Sciences during the study period October 2020 to December 2021 by collecting and analysing details of 100 patients between 1 month-12 years of age who presented with fever and thrombocytopenia at admission. Patients on drugs causing thrombocytopenia were excluded from the study. Results: Majority of the cases (51%) belonged to the age group of 1-6 years. Out of 100 subjects, 60% of them had dengue fever, 12% of cases had malaria and 10% of cases had enteric fever. Bleeding manifestations were seen in 12% of cases and blood product transfusion was done in 30% of the cases. 98% of cases had recovered and 2 deaths were reported. Conclusions: Febrile thrombocytopenia is a common clinical presentation in children. Majority of the dengue cases responded well to treatment given as per WHO guidelines. In most of the other infections, thrombocytopenia was transient and asymptomatic with lesser severity and resolved with the treatment of underlying condition.

Evaluation of impact of COVID-19 pandemic on the burden and pattern of severe malaria in Nigerian children

Background: Malaria is an infectious disease caused by the protozoan Plasmodium, accounting for 36% of under-five mortality. About 4.5% of all malaria-infected children reported at least one symptom of severe malaria, with worsening outcome. COVID-19 and malaria shared similar clinical presentation in children this similarity may lead to delay in initiation of treatment for malaria, with progression from uncomplicated to severe forms and consequently high mortality. Thus, we set out to study the extent COVID-19 impacted on the burden and pattern of severe malaria. Methods: It was a retrospective study of all the children admitted into the children’s emergency room severe malaria, from March 2018 to February 2022. The data collected included the total number of admissions within the period, the month and year of admission, age, gender, the component of severe malaria that was the final diagnosis and outcome of management. Data were analysed using NCSS 9 statistical software. Results: There were 4761 admissions within the study period: males were 54.7%, subjects 1-&lt;60 months were 60.5% and pre COVID-19 period were 63.7%. The prevalence rates of severe malaria in CHER were 2.6%. Among those with severe malaria, the case fatality rate was 10.7%. Severe malarial anemia was the most common accounting for 49.2% and has predilection for the younger age. Cerebral malaria was predominantly diagnosed during the COVID-19 period. Conclusions: The prevalence of severe malaria was 2.6% and severe malaria anaemia was the most common mode of presentation while cerebral malaria was diagnosed more during the COVID-19 period.

Clinical Presentation of ICU Admitted Dengue Patients During an Outbreak in Bangladesh

Background: Dengue fever is a mosquito born self limiting febrile illness. It may be asymptomatic or can result in a wide spectrum of disease severity ranging from an influenza like illness (Dengue fever) to the life threatening Dengue hemorrhagic fever (DHF)/Dengue shock syndrome (DSS). Dengue fever has currently become a serious public health problem. During 2019‘s Dengue outbreak more than 1 lac Dengue patients were treated in different hospitals of the country which was more than the double of the total number (50,181) in the last 19 years (2000 - 2018). During this outbreak not only the number of the patients increased, the clinical presentation of the patients has also changed. Objectives: This study was designed to document the presenting features of Dengue infection in ICU admitted children during the Dengue outbreak in 2019 in Bangladesh. Materials and Methods: This retrospective observational study was done among the children having Dengue infection and admitted in an ICU of a tertiary care hospital. All patients who were diagnosed as Dengue fever by serological tests (NS1, Dengue IgG and IgM) and admitted to ICU were included in this study. Total 126 (one hundred and twenty-six) patients were enrolled. Data were collected from hospital record files of every patient. Data was analyzed by SPSS version 20. Conclusion: In this study we find out all the clinical features of Dengue patients who were admitted into the ICU. It was observed that Dengue fever had wide spectrum of clinical presentation in children ranging from flue like illness to life threatening hemorrhage and shock. Moreover, the presentation of dengue cases in this year were different from that of the previous ones. Unlike high fever, headache, eye pain or body ache (which were the typical features of Dengue in the previous years), many children had low grade fever associated with loose motion or vomiting and went into shock rapidly. Therefore, for early and proper diagnosis of the spectrum of Dengue fever we should be aware of the newer clinical presentations.

Epidemiology of invasive Haemophilus influenzae serotype a disease in the North American Arctic, 2006–2017

ABSTRACT Invasive Haemophilus influenzae type a (iHia) disease was detected in Alaska and Northern Canada in 2002 and 2000, respectively. From 2006 to 2017, 164 iHia cases (Alaska=53, Northern Canada=111) were reported. Rates of iHia disease per 100,000 persons were higher in Northern Canada compared to Alaska and were significantly higher in Indigenous (Alaska 2.8, Northern Canada 9.5) compared to non-Indigenous populations (Alaska 0.1, Northern Canada=0.4). Disease rates were highest in Indigenous children <2 years of age (Alaska 56.2, Northern Canada=144.1) and significantly higher than in non-Indigenous children <2 (Alaska 0.1, Northern Canada 0.4). The most common clinical presentation in children <5 years was meningitis of age and pneumonia in persons ≥5 years old. Most patients were hospitalised (Alaska=87%, Northern Canada=89%) and fatality was similar (Alaska=11%, Northern Canada=10%). MLST testing showed sequence types ST23 and ST576 in Northern Canada and ST576, ST23 and ST56 in Alaska. Alaska and Northern Canada have high rates of iHia disease. A vaccine is needed in these regions to protect young children.

Sharp-Pointed Foreign Body Ingestion in Pediatric Age.

To assess the clinical complications reported after the ingestion of sharp/pointed foreign bodies (FBs) in pediatric age, their incidence among all FB ingestions, and the features and clinical presentation of children. We have recruited all consecutive patients aged 0-14 years, admitted for sharp/pointed FB ingestion. Clinical data until hospital discharge were accurately recorded, including both children with esophagogastric FB retention who underwent endoscopic removal and children who were radiologically followed-up till spontaneous FB expulsion. Clinical outcomes were recorded for each patient, with special reference to possible prolonged retention and wall perforation during the intestinal passage. We have enrolled 580 children (males/females: 292/288; age range: 11-180 months; mean age ± standard deviation: 50.5 ± 42 months). Sharp/pointed FBs mainly included fragments of metal 270 of 580 (46.55%) and glass 180 of 580 (31%). FBs were endoscopically removed in 79 of 580 (13.6%) children whereas the remaining FBs passed through the gastrointestinal tract over an overall mean time of 29 hours. No cases of intestinal perforation nor prolonged retention were observed. In 3 of 65 (4.6%) procedures the endoscopist faced an uncomfortable endoscopic removal due to the shape and size of the FB which hampered the retrograde passage through the esophageal sphincters. Our original and extensive data emphasize that accidental ingestion of sharp/pointed FB ingestion is a current issue in pediatric age, especially in toddlers. Metal and glass objects are the most involved FBs and their endoscopic retrieval may not be easy in about 5% of cases. Fortunately, in our pediatric sample no surgical intervention was needed.

Murine Typhus: An Overlooked Enemy

Fever due to murine typhus caused by Rickettsia typhi is underdiagnosed in pediatrics due to nonspecific symptoms. We summarize its clinical presentation in children to increase pediatricians' awareness of murine typhus. The classic triad of fever, headache, and rash is encountered in less than half of patients. Other common symptoms in children include nausea, vomiting, and abdominal pain. Frequent laboratory abnormalities in pediatric patients include elevated liver enzymes, lactate dehydrogenase, and erythrocyte sedimentation rate, as well as anemia. There is seasonal and geographic distribution, with most cases reported during warmer months in the Gulf Coast and California in the United States, often associated with flea or animal exposure for children. Pulmonary, neurologic, and renal complications are possible, although mortality is low. Patients of any age respond quickly to the initiation of doxycycline therapy. [ Pediatr Ann . 2022;51(11):e436–e439.]

LBSAT311 Rhabdomyolysis: A Rare Presentation Of Hashimoto Thyroiditis In An Adolescent Boy

Abstract Introduction Hashimoto thyroiditis is the most common cause of hypothyroidism and is associated with a wide range of clinical presentations in children and adolescents. Hypothyroidism-induced rhabdomyolysis without precipitating factors is extremely rare, particularly in pediatric patients. We describe a previously healthy adolescent boy who came to our institution with vague symptoms and was found to have rhabdomyolysis secondary to hypothyroidism due to Hashimoto thyroiditis. Clinical Case A 16 year old boy presented to the emergency department at Riley Hospital for Children due to a two week history of bilateral eye and lip swelling. Additional symptoms included fatigue, sleepiness, slowing of speech, decreased attention span and weight gain. He was not on any medications and had no history of allergies. There was no family history of endocrine or neuromuscular disorders. Physical exam revealed a height of 177 cm (75th tile), weight of 118.4 kg (99th %tile) and BMI at the 99th %tile. Exam was significant for slow generalized movements, facial edema, and delayed deep tendon reflexes in all extremities. The thyroid gland was normal. Laboratory evaluation revealed Creatinine-1.46 mg/dL (0.3-1.2), ALT-88 Units/L (7-52), AST-254 Units/L (13-39), TSH-32.2 mcU/mL (0.4-4.2), fT4 &amp;lt;0.2 ng/dL (0.6-1.5) and CK 20,500 Units/L (30-223). Thyroid peroxidase antibody was elevated at 686.1 IU/mL. A renal and bladder ultrasound showed trace intra-abdominal ascites and decreased echogenicity of the bilateral psoas muscles favoring edema and consistent with rhabdomyolysis. He received IV hydration and was started on levothyroxine 25 mcg daily that was increased over a 10 month period to achieve euthyroidism. Genetic testing for rhabdomyolysis revealed two variants of unknown significance. Acyl carnitine and carnitine profiles were normal ruling out a metabolic myopathy. His symptoms improved significantly after treatment with levothyroxine although his CK levels plateaued around 1,000 Units/L. Liver and kidney function normalized during follow up. Conclusion Rhabdomyolysis is a rare but serious complication of hypothyroidism, the pathogenesis of which is unclear. Proposed hypotheses include impaired mitochondrial oxidative metabolism, decreased muscle carnitine and switching of muscle fibers from fast-twitching type II to slow-twitching type I due to thyroxine deficiency ultimately leading to myolysis and release of intracellular muscle contents into the circulation. It is important for clinicians to have a high index of suspicion for hypothyroidism in children who present with muscle weakness and high creatinine kinase levels. The etiology of the disproportionately mild elevation of TSH in the setting of an unmeasurable free T4 and severe clinical hypothyroidism in our patient remains a mystery. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

A systematic review and meta-analysis of the epidemiological characteristics of COVID-19 in children

BackgroundSeveral individual studies from specific countries have reported rising numbers of pediatric COVID-19 cases with inconsistent reports on the clinical symptoms including respiratory and gastrointestinal symptoms as well as diverse reports on the mean age and household exposure in children. The epidemiological characteristics of COVID-19 in children are not fully understood, hence, comprehensive meta-analyses are needed to provide a better understanding of these characteristics.MethodsThis review was conducted in Medline, Scopus, Cochrane library, Embase, Web of Science, and published reports on COVID-19 in children. Data were extracted by two independent researchers and a third researcher resolved disputes. STATA software and the random-effect model were used in the synthesis of our data. For each model, the heterogeneity between studies was estimated using the Q Cochrane test. Heterogeneity and publication bias were calculated using the I2 statistic and Egger’s/Begg’s tests.ResultsThe qualitative systematic review was performed on 32 articles. Furthermore, the meta-analysis estimated an overall rate of involvement at 12% (95% CI: 9–15%) among children, with an I2 of 98.36%. The proportion of household exposure was calculated to be 50.99% (95% CI: 20.80%–80.80%) and the proportion of admitted cases was calculated to be 45% (95% CI: 24%–67%). Additionally, the prevalence of cough, fatigue, fever and dyspnea was calculated to be 25% (95% CI: 0.16–0.36), 9% (95% CI: 0.03–0.18), 33% (95% CI: 0.21–0.47) and 9% (95% CI: 0.04–0.15), respectively. It is estimated that 4% (95% CI: 1–8%) of cases required intensive care unit admission.ConclusionsThe pediatric clinical picture of COVID-19 is not simply a classic respiratory infection, but unusual presentations have been reported. Given the high incidence of household transmission and atypical clinical presentation in children, we strongly recommend their inclusion in research and population-based preventive measures like vaccination as well as clinical trials to ensure efficacy, safety, and tolerability in this age group.