Recent Upper Respiratory Tract Infection Research Articles

8062 Uncommon Presentation of Multiple Myeloma as a Rapidly Growing Thyroid Goiter Initially Thought to be Hashimoto's Thyroiditis

Abstract Disclosure: M.S. Shah: None. S. Humayon: None. K.P. Sanu: None. C. Peñaherrera: None. We present a unique case of an 85-year-old female with rapidly growing anterior neck swelling and subclinical hyperthyroidism, initially suggestive of Hashimoto's thyroiditis. The goiter initially responded well to steroids but rebounded back in size despite two courses of prednisone. This prompted further diagnostic workup which revealed unexpected findings, ultimately leading to the diagnosis of multiple myeloma involving the thyroid parenchyma and lymph nodes. The patient had no history of thyroid disorders or recent upper respiratory tract infections. She exhibited sudden neck swelling, mild subclinical hyperthyroidism, and positive TPO antibodies. Initial fine needle aspiration suggested lymphoid tissue with Hurthle cell differentiation, raising suspicion of Hashimoto's thyroiditis. Flow cytometry supported this diagnosis, but the potential for a Hurthle cell neoplasm persisted. Prednisone temporarily reduced thyroid size, but disease recurrence necessitated surgical excisional and incisional biopsies. Subsequent biopsies revealed plasma cell neoplasms consistent with multiple myeloma. The pathologic report confirmed MYC rearrangement, indicative of multiple myeloma involvement in lymph nodes and thyroid tissue. Protein electrophoresis revealed two restricted bands migrating in the gamma globin region. The patient experienced subclinical hyperthyroidism that evolved into euthyroidism over a month. Incidental findings included non-invasive, low grade papillary urothelial carcinoma. Disease progression was evident in a follow-up PET/CT, prompting oncology consultation. The patient initiated Revlimid with chemotherapy. Levothyroxine was prescribed for postoperative hypothyroidism, with adjustments based on thyroid panel results. This case report illustrates the intricate diagnostic challenges posed by multiple myeloma masquerading as a thyroid disorder. The unexpected evolution of the disease, marked by MYC rearrangement and metastatic spread, emphasizes the need for heightened vigilance in managing such cases. Clinicians should consider alternative diagnoses when treatment efforts fail to provide adequate response. This will ensure timely and appropriate management in clinical practice. This report contributes valuable insights into the diagnostic complexities and multidisciplinary considerations for addressing similar presentations in endocrine and oncology settings. Presentation: 6/1/2024

8062 Uncommon Presentation Of Multiple Myeloma As A Rapidly Growing Thyroid Goiter Initially Thought To Be Hashimoto's Thyroiditis

Abstract Disclosure: M.S. Shah: None. S. Humayon: None. K.P. Sanu: None. C. Peñaherrera: None. We present a unique case of an 85-year-old female with rapidly growing anterior neck swelling and subclinical hyperthyroidism, initially suggestive of Hashimoto's thyroiditis. The goiter initially responded well to steroids but rebounded back in size despite two courses of prednisone. This prompted further diagnostic workup which revealed unexpected findings, ultimately leading to the diagnosis of multiple myeloma involving the thyroid parenchyma and lymph nodes. The patient had no history of thyroid disorders or recent upper respiratory tract infections. She exhibited sudden neck swelling, mild subclinical hyperthyroidism, and positive TPO antibodies. Initial fine needle aspiration suggested lymphoid tissue with Hurthle cell differentiation, raising suspicion of Hashimoto's thyroiditis. Flow cytometry supported this diagnosis, but the potential for a Hurthle cell neoplasm persisted. Prednisone temporarily reduced thyroid size, but disease recurrence necessitated surgical excisional and incisional biopsies. Subsequent biopsies revealed plasma cell neoplasms consistent with multiple myeloma. The pathologic report confirmed MYC rearrangement, indicative of multiple myeloma involvement in lymph nodes and thyroid tissue. Protein electrophoresis revealed two restricted bands migrating in the gamma globin region. The patient experienced subclinical hyperthyroidism that evolved into euthyroidism over a month. Incidental findings included non-invasive, low grade papillary urothelial carcinoma. Disease progression was evident in a follow-up PET/CT, prompting oncology consultation. The patient initiated Revlimid with chemotherapy. Levothyroxine was prescribed for postoperative hypothyroidism, with adjustments based on thyroid panel results. This case report illustrates the intricate diagnostic challenges posed by multiple myeloma masquerading as a thyroid disorder. The unexpected evolution of the disease, marked by MYC rearrangement and metastatic spread, emphasizes the need for heightened vigilance in managing such cases. Clinicians should consider alternative diagnoses when treatment efforts fail to provide adequate response. This will ensure timely and appropriate management in clinical practice. This report contributes valuable insights into the diagnostic complexities and multidisciplinary considerations for addressing similar presentations in endocrine and oncology settings. Presentation: 6/1/2024

A Rare Case of Meningitis Caused by Elizabethkingia meningoseptica in a Baby at the Buea Regional Hospital, South West Region, Cameroon

Aim: This report was aimed at determining the possible source, risk factors, antimicrobial susceptibility pattern and clinical management of the first recorded case of meningitis in Cameroon caused by Elizabethkingia meningoseptica. Presentation of case: A 10 months old baby previously diagnosed with otitis media was admitted at the Buea regional hospital on the 21st of October 2023 after a referral following unsuccessful treatment. Upon admission, the baby had persistent fever, catarrh (evidence of an upper respiratory tract infection) and abdominal discomfort. Patient developed decreased body movement, altered consciousness and neck stiffness even after being placed on ampicillin and cefotaxime for two days. Based on cerebrospinal fluid analysis, the patient was considered a probable meningitis case and put on ceftriaxone to no avail. CSF culture later revealed the presence of Elizabethkingia meningoseptica susceptible to ciprofloxacin and resistant to imipenem, amoxicillin-clavulanic acid, cotrimoxazole, ampicillin and ceftriaxone. Marked improvement was noticed and the patient was discharged following full recovery after treatment with ciprofloxacin for 21 days. Epidemiological investigations and active case search did not provide any evidence of the Elizabethkingia being acquired in the hospital. Discussion and conclusion: The Elizabethkingia in this case was most likely community acquired associated with acute otitis media probably linked to a recent upper respiratory tract infection. The isolate was resistant to ceftriaxone and susceptible to ciprofloxacin. In case of meningitis caused by this pathogen, empirical treatment with fluoroquinolones may most likely be an effective option in the absence of antimicrobial susceptibility testing.

Effect of Daily Vitamin D Supplementation on Risk of Upper Respiratory Infection in Older Adults: A Randomized Controlled Trial.

Among individuals with vitamin D deficiency, daily vitamin D supplementation appears to lower risk of acute respiratory infection. However, recent trials, in different populations and using different regimens, have yielded null results. We investigated the effect of daily vitamin D supplementation (vs placebo) on risk of upper respiratory infection (URI) in older adults. The VITamin D and OmegA-3 TriaL (VITAL) is a randomized, double-blind, placebo-controlled trial of supplemental vitamin D and/or omega-3 fatty acids in generally healthy men (age ≥50 years) and women (age ≥55 years). This prespecified analysis focuses on vitamin D3 (2000 IU/day) versus placebo in the 15 804 (61%) participants with baseline serum total 25-hydroxyvitamin D level. The primary outcome was self-report of a recent URI at 1-year follow-up. Participants had a mean age of 68 years and 51% were women; 76% were non-Hispanic White, 16% Black, and 8% other race/ethnicity. The mean 25-hydroxyvitamin D level at baseline was 31 (standard deviation, 10) ng/mL, with <12 ng/mL in 2.4%. The overall effect of vitamin D supplementation on recent URI was nonsignificant (odds ratio [OR], 0.96 [95% confidence interval {CI}, .86-1.06]). In the prespecified subgroup of primary interest (<12 ng/mL and denied taking concurrent vitamin D), which had only 255 participants, vitamin D supplementation was nonsignificant (OR, 0.60 [95% CI, .28-1.30]). Statistical power to assess effect modification in other subgroups was limited. In older adults not selected for vitamin D deficiency, supplemental vitamin D did not lower URI risk overall. Whether effects differ in subgroups requires further study. Clinical Trials Registration. NCT01169259.

GUIDED PUNCTURE AS ANCILLARY TOOL FOR THE DIAGNOSSIS OF MAXILLOFACIAL LYMPHATIC MALFORMATION

Ultrasound-guided puncture is an exam that allows delineation of the lesion margins and extent for better diagnosis and treatment proposal. A 15-year-old boy presented with a painless swelling with 12 months of evolution and progressive enlargement. He reported no history of trauma or recent upper respiratory tract infections, but reported a history of pimple in the region stricken by lesion. On physical examination, a nodular lesion was observed in the right submandibular region, soft in consistency, lobular with ill-defined margins, painless, and freely mobile. An ultrasound-guided aspiration puncture was performed. The punctured material was submitted to the Liquid-based cytology and a diagnosis of lymphatic malformation was made. Ultrasound-guided puncture is an exam that allows delineation of the lesion margins and extent for better diagnosis and treatment proposal. A 15-year-old boy presented with a painless swelling with 12 months of evolution and progressive enlargement. He reported no history of trauma or recent upper respiratory tract infections, but reported a history of pimple in the region stricken by lesion. On physical examination, a nodular lesion was observed in the right submandibular region, soft in consistency, lobular with ill-defined margins, painless, and freely mobile. An ultrasound-guided aspiration puncture was performed. The punctured material was submitted to the Liquid-based cytology and a diagnosis of lymphatic malformation was made.

Effect of Nebulized Salbutamol Premedication on Perioperative Respiratory Adverse Events in Children with Recent Respiratory Tract Infections

BACKGROUND&#x0D; A recent upper respiratory tract infection is linked to the development of peri-operative respiratory complications. In this study we wanted to evaluate the effect of salbutamol premedication on the incidence of peri-operative respiratory adverse events in children with a recent upper respiratory tract infection (PRAE).&#x0D; METHODS&#x0D; A randomized clinical trial study that was conducted at the Children Welfare Teaching Hospital for a period of six months. It included 90 children aged ≤ 16 years who underwent a surgical operation under general anesthesia with a laryngeal mask airway or a tracheal tube and were divided into three groups; (had a recent URTI and received preoperative salbutamol, those who had a recent URTI and didn’t receive preoperative salbutamol, and those with no URTI group). The preferred outcome was the difference in the rate of occurrence of PRAE between children who had received salbutamol and those who hadn’t.&#x0D; RESULTS&#x0D; Four children with no URTI (13.3%) developed peri-operative respiratory adverse events. The incidence of bronchospasm and severe cough was significantly higher in patients with URTI and who didn’t receive preoperative salbutamol than in those with URTI who received preoperative salbutamol.&#x0D; CONCLUSIONS&#x0D; Preoperative salbutamol doses 10 – 30 minutes before surgery have been demonstrated to reduce and treat peri-operative respiratory adverse events.

Do COVID-19 pandemic-related behavior changes affect perioperative respiratory adverse events in children undergoing cardiac interventional catheterization?

BackgroundThe novel coronavirus disease (COVID-19) suddenly broke out in China in December 2019. Pandemic-related behavioral changes can cause perioperative respiratory adverse events in children with congenital heart disease (CHD). Here, we compared the incidence of perioperative respiratory adverse events (PRAEs) in CHD children with and without upper respiratory infection (URI) undergoing the cardiac catheterization before and during the COVID-19 pandemic.MethodsThis prospective observational single-center study was based at a tertiary care center in Shanghai, China. A total of 359 children with CHD with and without recent URI were included between January 2019 and March 2021. The overall incidence of PRAEs (laryngospasm, bronchospasm, coughing, airway secretion, airway obstruction, and oxygen desaturation) in non-URI and URI children undergoing elective cardiac catheterization was compared before and during the COVID-19 pandemic. A logistic regression model was fitted to identify the potential risk factors associated with PRAEs.ResultsOf the 564 children enrolled, 359 completed the study and were finally analyzed. The incidence of URIs decreased substantially during the COVID-19 pandemic (14% vs. 41%, P < 0.001). Meanwhile, the overall PRAEs also significantly declined regardless of whether the child had a recent URI (22.3% vs. 42.3%, P = 0.001 for non-URI and 29.2% vs. 58.7%, P = 0.012 for URI, respectively). Post-operative agitation in children without URI occurred less frequently during the pandemic than before (2.3% vs. 16.2%, P = 0.001). Behaviors before the COVID-19 pandemic (odds ratio = 2.84, 95% confidence interval [CI] 1.76–4.58) and recent URI (odds ratio = 1.79, 95% CI 1.09–2.92) were associated with PRAEs.ConclusionsCOVID-19 pandemic-related behavioral changes were associated with a reduction in PRAEs in non-URI and URI children undergoing elective therapeutic cardiac catheterization.

An evaluation of patients who present to the emergency department with dizziness

This study aimed to analyze the data of patients presenting with dizziness at our hospital’s emergency department (ED) by determining the etiology of dizziness and to contribute to the medical data of our country and the literature. This prospective study was conducted with 116 volunteering patients who presented to the Emergency Department of Afyon Kocatepe University, Faculty of Medicine for one year with dizziness complaints. After the anamnesis, physical examination, diagnostic tests (blood tests, Dix-Hallpike maneuver, audiological-vestibular tests, carotid-vertebral artery color Doppler ultrasonography, and computerized brain tomography), and psychiatric interrogation, the patients were divided into four etiology groups: Peripheral, central, psychogenic, and other causes of dizziness. Clinical features were compared between peripheral and central dizziness groups. A total of 116 (3.4%) of patient admissions to the emergency department complained of dizziness. Forty-nine (42.2%) of these patients were male, 67 (57.8%) were female. In the cohort, 33.9% were under 40, and dizziness increased with older age. Seventy (60.3%) patients had no formal education or were primary school graduates. The initial evaluation at the ED revealed that dizziness mostly shifted with the position (71.6%) and was mainly accompanied by headache (67.2%). Based on their diagnosis, 50 patients (43.1%) were in the peripheral group, 30 patients (25.8%) were in the central group, 22 patients (19%) were in the psychogenic dizziness group, and 14 patients (12%) were in the other causes group. Intergroup analysis between peripheral and central vertigo groups identified that the hearing loss, ear fullness, recent upper respiratory tract infection (URTI), nausea, vomiting, and shifting position was statistically significant (p&lt;0.05). Dizziness is one of the common complaints of admission to the ED and may arise from different etiologies. Our study demonstrated that psychogenic dizziness was common in this patient cohort.

Risk Assessment of Perioperative Respiratory Adverse Events and Validation of the COLDS Score in Children with Upper Respiratory Tract Infection.

Backgroundandobjectives: Children are at greater risk of upper respiratory tract infection (URTI), which can pose a higher risk of perioperative respiratory adverse events (PRAEs), than adults. The purpose of this study was to validate the COLDS score as a pre-anesthetic risk assessment tool for predicting the possibility of PRAEs. Materials and methods: Children aged under 18 years and undergoing elective surgery were retrospectively included. Logistic regression analysis and the area under the receiver-operating characteristic (ROC) curve (AUC) were used to estimate the ability of the COLDS score to predict PRAEs. Propensity-matched comparison was evaluated using the cut-off value from the ROC curve. Results: Among the 6252 children, 158 children had a recent URTI and 34 cases of PRAEs were reported. Age, current symptoms, and COLDS score were found to be significant variables in predicting PRAEs. From the ROC curve, values of 0.652 (p = 0.007) for AUC and 12.5 for the cut-off value of the COLDS score were calculated. Propensity-matched comparison revealed that each and every component of COLDS contributed to the higher COLDS score group. In addition to higher COLDS score, younger age and current URTI symptoms were found to be significant risk factors for PRAEs. Conclusions: This study validated the predictive power of COLDS score as a risk assessment tool for children with URTI undergoing elective surgery under general anesthesia.

Prediction of endotracheal tube size in the pediatric age group by ultrasound: A systematic review and meta-analysis.

Anatomical differences in the airway in pediatric patients, compared to adults pose many challenges during endotracheal intubation, such as selecting the proper sized endotracheal tube (ETT) during intubation. Our primary objective was to assess how accurate is ultrasound (US) co-relation in comparison to standard age-based formulas in pediatric patients. Meta-analysis was registered in PROSPERO 2020, CRD42020220041. Online literature available in PubMed, Cochrane, and Embase, Goggle scholar was searched from year 2000 till November 30, 2020, using relevant Mesh terms, ('airway US' OR (('airway'/exp OR airway) AND ('US'/exp OR US))) AND ('endotracheal intubation'/exp OR 'endotracheal intubation') AND ('pediatric'/exp OR pediatric)" to Predict endotracheal tube size/placement in pediatric age (neonate till 18 years) by the US. Bibliographic cross-references of selected publications were further manually screened. The full texts of each article were studied, once the abstract was found appropriate independently by two reviewers. A total of 48 papers published between 2010 and 2020 were identified as relevant and read in detail. Average numbers of patients were 86 and total numbers of patients were 1978. Most of the studies included pediatric patients posted for elective surgeries under general anesthesia and excluded emergency procedures, known laryngeal or tracheal pathology, high-risk patients, recent upper respiratory tract infections or allergy to ultrasound gel. A total of 18 independent correlations were analyzed. Final combined r value calculated from all the included articles was 0.824 (95% CI 0.677, 0.908) with a P < 0.00001 {strong co-relation (r > 0.80)}. Q statistic of 756.484, and I2 statistics of 97.53% showed a large degree of heterogeneity in the effect size across the studies. Use of US for upper airway in pediatric patients is an effective modality and can effectively predict endotracheal tube size estimations in comparison to standard age-based or height-based formulae in the pediatric age group. US is a non-invasive, cost-effective, portable, and reproducible technique as compared to CT and MRI. It also takes less time with increasing expertise and experience.

Risk factors of postoperative pulmonary complications after primary posterior fusion and hemivertebra resection in congenital scoliosis patients younger than 10 years old: a retrospective study

BackgroundPostoperative pulmonary complications are common and associated with morbidity and mortality. Congenital scoliosis is a failure of vertebral formation and/or segmentation arising from abnormal vertebral development. Posterior fusion and osteotomy are necessary for these patients to prevent deterioration of spine deformity. The incidence of postoperative pulmonary complications in this specific group of patients, especially young children were unknown.MethodsA retrospective study was conducted and electronic medical records of early-onset scoliosis patients who had primary posterior fusion and hemivertebra resection at our institution from January 2014 to September 2019 were reviewed. The demographic characteristics, the intraoperative and postoperative parameters were collected to identify the predictors of postoperative pulmonary complications.ResultsA total of 174 patients (57.5% boys) with a median age of 3 years old were included for analysis. Eighteen patients (10.3%) developed perioperative pulmonary complications and pneumonia (n=13) was the most common. History of recent upper respiratory infection was not related to postoperative pulmonary complications. Multifactorial regression analysis showed thoracoplasty was the only predictive risk factor of postoperative pulmonary complications.ConclusionsFor congenital scoliosis patients younger than 10 years old, thoracoplasty determine the occurrence of postoperative pulmonary complications. Both surgeons and anesthesiologists should pay attention to patients undergoing thoracoplasty and preventive measures are necessary.

Sedation with dexmedetomidine and propofol in children with Fontan circulation undergoing cardiac catheterization: A descriptive study.

Background:A combination of dexmedetomidine and propofol is considered advantageous for maintaining spontaneous breathing with a satisfactory depth of anesthesia. However, the incidence of upper airway obstruction under sedation with dexmedetomidine and propofol in patients with Fontan circulation remains unanswered. This study aimed to evaluate upper airway patency and oxygen desaturation during sedation with dexmedetomidine and propofol for cardiac catheterization in pediatric patients with Fontan circulation.Methods:In this descriptive study, we reviewed medical records of patients with Fontan circulation who underwent cardiac catheterization between December 2018 and August 2020 at a single-center 200-bed academic children's hospital in Japan.Results:A total of 35 patients with Fontan circulation sedated with a departmental protocol of dexmedetomidine and propofol infusion for cardiac catheterization were reviewed. Overall, the incidence of airway interventions and oxygen desaturation were 31.4% and 28.6%, respectively. In children with a history of snoring and additional use of intravenous midazolam, the rates of airway interventions were 50% and 100%, respectively. In patients ≤2 years old with recent upper respiratory infection (URI) symptoms, oxygen desaturation rate was 75%.Conclusions:In children with Fontan circulation, the incidence rate of upper airway obstruction was high under sedation with dexmedetomidine and propofol during cardiac catheterization, which is commonly considered safe in children without Fontan circulation. A history of snoring, an additional bolus of IV midazolam, and the presence of recent URI symptoms in patients ≤2 years old are potential risks for upper airway obstruction.

As-Needed Versus Regular Use of Fluticasone Furoate Nasal Spray in Patients With Moderate to Severe, Persistent, Perennial Allergic Rhinitis: A Randomized Trial

To compare the effectiveness of as-needed fluticasone furoate (FF) nasal spray (27.5 μg; 2 sprays once daily for 1 week, followed by as-needed use for 5 more weeks) with that of regular use of FF once daily for 6 weeks in patients with moderate to severe, persistent allergic rhinitis.Patients were at least 18 years of age living in Thailand with year-round allergic rhinitis characterized by symptoms occurring >4 days per week for at least 4 consecutive weeks that impaired daily activities, school or work, sleep, or quality of life. Patients were excluded if they had rhinosinusitis, nasal polyps, significant deviated nasal septum, asthma or chronic lung disease, recent upper respiratory tract infection, or previous allergen immunotherapy. Patients had a mean age of 30 years (SD: 8.4 years) and an average duration of symptoms of 15 years, and 95% were allergic to dust mites.Outcome assessors were single-blinded in evaluating outcomes of this 2-arm, parallel group randomized controlled trial conducted from October 2017 to June 2019 at a large tertiary care university hospital. The primary outcome evaluated was the total nasal symptom score (TNSS), measured by summing the score of 4 primary symptoms (congestion, rhinorrhea, sneezing, and itching) recorded on a 4-point severity scale from 0 (no symptoms) to 3 (severe symptoms). Secondary outcomes included nasal peak inspiratory flow and rhinoconjunctivitis quality of life-36 questionnaire (RCQ-36). The study was adequately powered (80%) to detect a 0.16 point TNSS treatment difference between groups.Disease burden, as measured by primary and secondary outcomes, improved in both groups. The intention-to-treat analysis evaluated all of 108 patients randomly assigned, revealing a nonsignificant trend in TNSS improvement for patients with regular FF use (difference: 1.21; 95% CI: −.08 to 2.49; P = .066). Although RCQ-36, nasal itching scores, and rhinorrhea scores were not significantly different between groups, the nasal peak inspiratory flow (difference: −19.2; P = .009), nasal congestion scores (difference: 0.42; P = .049), and sneezing scores (difference: 0.51; P = .13) favored regular use of FF. Notably, the cumulative dose of FF was far lower in the as-needed group than in that of daily groups (difference: 1920 μg; P < .001), and as-needed FF use was associated with a lower rate of acne (2.0% vs 7.7%).Patients using as-needed FF reported a 49% reduction in cumulative nasal steroid dose over the study period but experienced similar reductions in TNSS and RSQ-36 score.Previous studies of seasonal allergic rhinitis have revealed improved symptom control with regular, compared with as-needed, use of nasal corticosteroids (NCSs). However, adherence to regular use of NCSs challenges this treatment paradigm in the real-world, where less than one-third of patients regularly use NCS as prescribed. The perfect is not the enemy of the good, and, with this study, the researchers add to a body of literature that as-needed NCS use for allergic rhinitis can be a good option, particularly when considered through a lens of patient-preference–sensitive care and shared decision-making. Although this is not a pediatric study, the issue of adherence and cumulative dose of topical glucocorticoid is highly relevant to children. Considering improvements that are possible with as-needed NCS, this option can be a consideration for children who do not have adequate control with a nonsedating oral or nasal 1H-antihistamine. Still, for patients with inadequate control with an as-needed NCS strategy, regular NCS (with or without a nasal antihistamine) may be even more effective, and additional treatment options, such as specific allergen immunotherapy, remain considerations.

Symptom: Serous Middle Ear Effusion and Hearing Loss

Symptom: Serous Middle Ear Effusion and Hearing Loss

A RARE CASE OF METHICILLIN-RISISTANT STAPHYLOCOCCUS AUREUS EMPYEMA NECESSITANS VISUALIZED ON POINT-OF-CARE ULTRASOUND

TOPIC: Imaging TYPE: Medical Student/Resident Case Reports INTRODUCTION: Empyema necessitans is a rare complication of bacterial pneumonia that occurs when empyema invades the parietal pleura and extends into the surrounding chest wall; if left unchecked it will eventually drain through the skin. Here we present a case of empyema necessitans in a previously healthy 25 year-old man caused by MRSA pneumonia, visualized with bedside ultrasound. CASE PRESENTATION: This gentleman originally presented to an outside hospital with two months of worsening dyspnea, cough, and pleuretic chest pain. He reported night sweats and fever after a recent upper respiratory infection. He denied having any past medical conditions, however his social history endorses intravenous drug use. Prior to his final presentation he presented to an emergency department twice, being diagnosed with costochondritis, and discharged with oral pain medications. He was then treated with two courses of oral antibiotics from an urgent care. During this time he began to develop a fluctuant erythematous anterior chest wall mass. At this point he presented again to an outside hospital, who then obtained a computed tomography (CT) scan of his chest, revealing a large loculated pleural effusion concerning for empyema that may have been communicating with the mass. He was then transferred to our facility to evaluate this complicated pleural effusion. At our facility a point-of-care ultrasound exam was performed, showing a heterogeneous, echogenic pleural effusion that was freely communicating and flowing across a defect in the intercostal muscles directly into the anterior chest wall mass, highly concerning for empyema necessitans. A small chest tube was placed, with purulent fluid that grew MRSA on culture, confirming the diagnosis. Ultimately the patient required surgical intervention for decortication and pleurectomy along with intravenous vancomycin. DISCUSSION: Rapid identification of empyema necessitans is crucial to facilitate the appropriate treatment, which often involves surgical management, in a timely manor to avoid morbidity and mortality. CONCLUSIONS: POCUS in the hands of a trained clinician provides a rapid, accurate, and cost effective diagnostic approach to those with pneumonia and a chest wall mass, to diagnosis empyema necessitans. REFERENCE #1: Elyashiv D, Alpert EA, Granat N. Empyema Necessitans Diagnosed by Point-of-Care Ultrasound. J Emerg Med. 2020 Dec;59(6):e221-e223. doi: 10.1016/j.jemermed.2020.09.020. Epub 2020 Oct 13. PMID: 33059991. DISCLOSURES: Advisory Committee Member relationship with EchoNous Please note: 11/12/2020 Added 04/30/2021 by Keith Barron, source=Web Response, value=Ownership interest Stock ownership relationship with Butterfly IQ Please note: 04/30/2021 Added 04/30/2021 by Keith Barron, source=Web Response, value=Ownership No relevant relationships by Stephanie Scott, source=Web Response

Prevalence of acute otitis media in children younger than four years

Abstract Background Acute otitis media (AOM) is one of the most common diseases in childhood, affecting approximately 50% of all children. The most common age range to develop AOM is 3–24 months, due to a current or recent upper respiratory tract infection, which induces the eustachian tube to develop fluid or secretion from the middle ear inflammation. The acute onset of symptoms in older children is characterized by otalgia and rubbing of the ear, however, AOM in younger children include nonspecific symptoms such as fever, irritability, or poor feeding, being unreliable guides to the diagnosis. Thus, the underdiagnosis of AOM can lead to serious complications include acute mastoiditis or meningitis. Hence, the study aims to investigate the prevalence of AOM in children younger than four years. Methods A cross-sectional study was conducted in a kindergarten, being enrolled children between 1 and 4 years. The protocol included otoscopy and tympanometry. Results A total of 23 children with a mean age of 2-year-old (SD = 0.88) were evaluated, with 17 children (34.8%) diagnosed with AOM, of whom 2 (15.4%) had unilateral alterations and 11 (84.6%) bilateral alterations. Conclusions AOM is one of the main childhood pathologies, affecting approximately 34.8% of younger children. Success in decreasing prevalence of AOM will depend on prevention of nasopharyngeal pathogen colonization, as well as decrease of viral upper respiratory tract infection, which can be reduced with nasal saline irrigation, a clinical and economic therapeutic approach.

Tolosa-Hunt Syndrome: A Rare Cause of Painful Ophthalmoplegia

Tolosa-Hunt syndrome (THS) is a rare inflammatory disorder of unknown etiology with an incidence of one case per million each year. The syndrome is characterized by painful diplopia due to cranial nerve III, IV, or VI palsy. No specific risk factors have been reported, however, in some cases it has been associated with a recent upper respiratory tract infection. THS usually responds well to steroids and they remain the mainstay of treatment. Here, we report a case of a young Hispanic male with no previous health conditions presenting with ophthalmoplegia and retro-orbital pain. After excluding other etiologies of his presentation, a final diagnosis of THS was made. He initially responded well to a course of high-dose steroids, however, he later developed recurrent symptoms and worsening Magnetic resonance imaging (MRI) findings for which he needed an extended course of steroids.

Does Lactoplantibacillus plantarum DR7 Reduce Days of Upper Respiratory Tract Infections and Fever? A Post‐Hoc Analysis of a Randomized, Placebo‐Controlled Trial

Objectives and Hypothesis Upper respiratory tract infections (URTIs) are amongst most common causes of doctor visits, days of work leave and school leave. Lactoplantibacillus plantarum DR7 (KCTC 13909BP) is a probiotic strain previously shown to modulate the tryptophan-serotonin-kynurenine pathway in human hosts. Previous results indicated a positive effect of a 3-month intervention with L. plantarum DR7 (109cfu/day) on individual nasal, pharyngeal and flu-like symptoms in a randomized, double-blinded trial against placebo in 109 adult subjects. We hypothesized that this probiotic could achieve a significant reduction of patient-days of URTI and fever. Also, we wanted to assess whether clinical or demographic traits may influence this effect. Methods Study outcomes were total patient-days of URTI and patient-days of fever during the 3-month intervention. Patient-days of URTI were estimated from symptoms questionnaire using two alternative definitions: i) duration of the longest-lasting symptom, and ii) average duration of symptoms. Patient-days of fever were taken directly from the questionnaire. Pairwise correlations between study outcomes and clinical and demographic parameters (age, sex, body mass index, smoker status, urban vs rural living, income above or below national average, and URTI episodes in the 4 weeks prior to study enrolment) were assessed by Spearman test. Differences in patient-days between groups were assessed by Chi-square (unadjusted) or Mantel-Haenszel tests (adjusted). Significance thresholds were multiplicity-corrected by Bonferroni-Holm method. All procedures on study subjects had been approved by the Internal Review Board of Universiti Sains Malaysia and adhered to the Helsinki Declaration. Summary of Results Of all clinical and demographic parameters analyzed, only recent URTI significantly correlated to study outcomes once corrected for multiplicity (rho=0.27-0.30, all p≤0.005). Compared to subjects without recent URTI (n=71), those with recent URTI (n=38) had increased patient-days of URTI (both definitions) and patient-days of fever (all p<0.001). History of recent URTI was numerically higher in probiotic than placebo group (43% vs 27%, Chi-square p=0.078). Probiotic intervention (n=56) resulted in significantly fewer patient-days of URTI compared to placebo (n=53) according to both definitions, as well as fewer patient-days of fever (all p<0.05 unadjusted, p<0.001 adjusted for recent URTI history; see Table 1). Conclusion Compared to placebo, intervention with L. plantarum DR7 significantly reduced patient-days with URTI by 20%, and patient-days with fever by 27%. Patient history of recent URTI significantly increased the risk of URTI during the intervention, and significance of probiotic efficacy was improved upon accounting for said parameter.

Don't Forget the Flu - Determining the Etiology of Infective Myositis in a Child: A Case Report.

IntroductionInfective myositis is an acute, self-limited condition, rarely occurring in children with recent viral infections. The condition is often overlooked by emergency physicians when endeavoring to exclude other diagnoses included in the differential. Diagnosis of the condition can be difficult when based purely on clinical presentation because it shares symptoms with much more concerning neurological illnesses. A few simple laboratory tests are indicated to reach the correct diagnosis.Case ReportThe following case report describes a three-year-old female diagnosed with a recent upper respiratory tract infection presenting to the emergency department with complaints of fatigue and inability to walk. She was diagnosed with an influenza-like illness three days prior by her pediatrician, the symptoms of which had mostly resolved by the time of presentation.ConclusionMuscle weakness and abnormal, uncoordinated gait with an acute upper respiratory tract infection in a child may be cause for concern, prompting unnecessary work-up. Emergency physicians should be aware of the signs and symptoms of influenza-associated infective myositis in children, especially during influenza season.

Bickerstaff's brainstem encephalitis with monospecific anti-GT1a antibody: A subtype of Guillain–Barre syndrome

Bickerstaff's brainstem encephalitis is an uncommon post-infectious causing autoimmune neurological disease, which is usually associated with the GQ1b antibody. We described a young man with recent upper respiratory tract infection, who presented with sudden onset of left eye ptosis with internuclear ophthalmoplegia, staccato speech with left-sided hemiplegia but with normal deep tendon reflexes. The cerebral imaging was normal and cerebrospinal fluid analysis produced no cyto-albuminologic dissociation, negative result of tuberculosis culture and virus PCR. He was tested positive for serum GT1a IgG antibody. We discussed this case as the neurological presentation was severe, in the presence of GT1a IgG antibody. La encefalitis troncoencefálica de Bickerstaff es una enfermedad neurológica postinfecciosa autoinmune rara, que está normalmente asociada al anticuerpo GQ1b. Describimos el caso de un varón joven con infección reciente del tracto respiratorio superior, que acudió con aparición súbita de ptosis en el ojo izquierdo con oftalmoplejía internuclear, habla entrecortada con hemiplejía izquierda, aunque con reflejos tendinosos profundos normales. La imagen cerebral fue normal, y el análisis del líquido cefalorraquídeo no produjo disociación cito-albuminológica, siendo negativo el resultado del cultivo para la detección de tuberculosis y la PCR para la presencia de virus. El resultado de anticuerpos séricos GT1a IgG fue positivo. Debatimos este caso, dado que la presentación neurológica fue grave, en presencia de anticuerpos GT1a IgG.