Background: There are no established guidelines preferring mannitol over hypertonic saline in managing increased intracranial pressure in children.

Objective: This systematic review aimed to assess the available data on the efficacy of 20% mannitol and 3% hypertonic saline in decreasing intracranial hypertension in the pediatric age group.

Method: Search was done through PubMed/MEDLINE, Cochrane Central Registry of Clinical Trials (CENTRAL) and EMBASE. The search of articles yielded 280 studies. After applying the inclusion and exclusion criteria, a total of 7 articles were deemed eligible for assessment.

Results: Seven studies with a total of 1,892 pediatric patients met the eligibility criteria: three RCTs and four retrospective studies. From these studies, two randomized controlled studies showed statistically significant evidence that 3% hypertonic saline was superior to 20% mannitol in reducing increased intracranial pressure (ICP) while two other studies had results that were insufficient to establish statistical significance. A study showed that Glasgow coma scale (GCS) scores were higher and length of stay was shorter in patients given hypertonic saline than in the mannitol group. Relative risk of mortality was comparable in both groups. While more episodes of hypotension and rebound increase in ICP was seen with mannitol, both agents reported occurrences of acute kidney injury, hemolysis and hyperchloremic metabolic acidosis.

Conclusion: This review showed that while both agents effectively decreased intracranial pressure, 3% hypertonic saline showed better results compared with 20% mannitol. Due to the limited number and heterogeneity of studies, a pooled analysis of the effects in ICP could not be done. Recommendations: Larger prospective controlled studies using 20% mannitol and 3% hypertonic saline in the treatment of increased ICP in the pediatric age group are needed to render valid affirmations.

Skeletal tuberculosis accounts for 1-3% of TB cases, and of these only 0.2-1.3% had calvarial involvement. 1 Calvarial TB is most likely secondary to a primary focus.  Diagnosis is confirmed through findings of Mycobacterium tuberculosis via microbiological, histopathological or cytopathological methods. This case report presents
Primary Calvarial Tuberculosis in a five-year old male presenting with multiple cranial masses and initial diagnosis of Langerhans cell histiocytosis (LCH).

Objective: To report a case of multifocal pediatric tuberculosis presenting with mandibular swelling and discuss its etiology, clinical findings, diagnosis, management, and outcome after treatment.

Methods:

Design: Case Report

Setting: Tertiary Government Training Hospital

Patient: One

Results: A 3-year-old boy presented with progressive non-tender, right mandibular swelling for 11 months. Panoramic X-ray exhibited extensive multiple loculations with lytic changes on the mandible. CT Scans revealed a peripherally enhancing hypodense mass with lytic expansion of the right mandibular angle extending across the left mandibular body with an incidental finding of right lung mass. Other extrapulmonary lesions were also detected involving the scapula, pleura with lysis of the adjacent ribs at the level of T7 and T8. Biopsy of the mandibular and lung mass confirmed the presence of caseating and non-caseating granulomas consistent with Koch's infection. The patient showed significant improvement by the 7th month of a 12-month course of anti-tuberculous therapy.

Conclusion: Multifocal TB can present as simple mandibular swelling, and a thorough workup should look for other involved sites. Early diagnosis in children may prevent debilitating sequelae and improve long-term treatment outcomes.

Pyoderma Gangrenosum (PG) was first described in 1916 as “phagedenisme geometrique”, after a French dermatologist observed rapidly progressing, cutaneous necrotic lesions with sharp borders.1 In 1930, Brunsting and his colleagues at the Mayo Clinic coined the term Pyoderma Gangrenosum, because it was initially thought to arise from staphylococcal and streptococcal infections which were observed in 5 of their patients.2 The exact etiology and pathogenesis is still unknown. To date, only a few cases of PG have been shown to affect the ears, all showing no gender or age predilection.3 We report another such case.
Human ; Female ; Child Preschool (a Child Between The Ages Of 2 And 5)

BACKGROUND: Despite extensive studies on dengue fever, there is still limited knowledge about factors associated with poor outcomes in cases of dengue fever. The shock index (SI) is a bedside tool previously used in the adult population, adopted as a marker for poor outcomes in many shock states. There are limited studies applying the SI in children. There are also no known local studies applying an age-adjusted version as a marker or predictor of poor outcomes in severe acute illness, such as dengue.

OBJECTIVES: To determine the diagnostic ability of the age-adjusted pediatric shock index in predicting outcomes in cases of dengue admitted at a tertiary children's hospital.

METHODS: This is a prospective cohort study performed in a pediatric tertiary hospital over a period of 30 days. Admitting heart rate (HR) and systolic blood pressure (SBP) were taken to determine their shock index. This was then grouped according to age groups based on known literature and corresponding acceptable age-adjusted shock indices (ASI), and compared with outcomes such as final dengue classification (non-severe vs severe), use of inotropes, and mortality.

RESULTS: A total of 90 patients were identified for the study. Three were excluded due to exclusion criteria. 87 cases were followed up after admission from the ER. Unadjusted Shock Index (USI) was found not to be associated with both final dengue classification (as severe dengue) and use of inotropic support. In contrast, ASI was associated with both final dengue classification (p < 0.001) and use of inotropes (p < 0.039). The ASI had a fairly accurate capability of predicting poor outcomes for both final dengue classifications, with an area under the ROC curve of 0.7122, and eventual use of inotropes, with an area under the ROC curve of 0.6435.

CONCLUSIONS AND RECOMMENDATIONS: SI was found to be a helpful tool in predicting poor outcomes, but only when the Age-adjusted Shock Index (ASI) was used. A longer data collection period is recommended to be able to include mortality as an outcome. The predictive value of the tool can be tested against various other markers of poor outcome to widen the application of this non-invasive measure of hemodynamic status.

BACKGROUND: Ultrasound?guided quadratus lumborum block (QLB) is a regional anesthetic technique which can provide post-op pain control for pediatric patients undergoing abdominal surgery. We hypothesized that the quadratus lumborum block would be as efficacious as a caudal block in providing pain control.

OBJECTIVE: To compare the postoperative analgesic effect of ultrasound-guided QLB versus ultrasound-guided caudal block among 1-6 years old children undergoing lower abdominal and urological surgeries in Philippine Children's Medical Center.

METHODS: This is a single-blinded randomized control trial. 50 patients enrolled aged between 1 and 6 years. The patients were randomly classified into the caudal block group and quadratus lumborum block group. The primary outcome is the need for analgesia during the first 24 hours.

RESULTS: A significant difference in the proportion of patients who requested for rescue analgesia was observed with caudal block having more patients in need of analgesic (100% CB vs 48% QLB, p<0.001). No postoperative complication was observed.

CONCLUSIONS AND RECOMMENDATIONS: The quadratus lumborum block was more effective in reducing the postoperative pain management during the initial 48 hours. Quadratus lumborum block is recommended for future pediatric procedures requiring postoperative pain control, safety, practicality and economy.

OBJECTIVE: To determine if there is a difference in the duration of mechanical ventilation and hospitalization between patients who underwent early compared to late tracheostomy.

METHODS:

Design:                Causal-Comparative (ex post facto) Chart Review

Setting:                Tertiary National University Hospital

Participants:                   Records of 68 pediatric patients who underwent elective tracheostomy from January 1, 2013 to June 30, 2018 were considered for inclusion. Patients were excluded if invasive mechanical ventilation was not done prior to tracheostomy, if they underwent emergency tracheostomy or had incomplete records. Selected patients were categorized in the early tracheostomy group if the procedure was performed within 14 days of mechanical ventilation and late tracheostomy group if performed beyond 14 days. Early post-tracheostomy weaning from mechanical ventilation was defined as less than 7 days from time of tracheostomy.

RESULTS: A total of 21 patients were included, 6 in the early tracheostomy group and 15 in the late tracheostomy group. Although early tracheostomy did not show significant association with shortened post-tracheostomy duration of mechanical ventilation (O.R. 6; C.I. 0.276 to 130.322; p = .476), two-sample t-tests showed the early tracheostomy group had a significantly shorter mean duration of mechanical ventilation and hospitalization compared to the late tracheostomy group (13.17 vs. 54.13 days, p = .0012; 21.17 vs. 66.67 days, p = .0032).

CONCLUSION: Although early tracheostomy does not shorten post-tracheostomy mechanical ventilation support, there is a significant difference in the duration of mechanical ventilation and hospitalization between early and late tracheostomy groups and this may suggest potential benefits of performing tracheostomy earlier in children.

KEYWORDS: tracheotomy; pediatric; mechanical ventilation; hospitalization

OBJECTIVE: To report a case of a 12-year-old boy with Necrotizing Lymphadenitis (Kikuchi-Fujimoto disease) presenting as lymphadenitis secondary to multiple diagnosis.

METHODS:

Design : Case Report

Setting: Tertiary Private Hospital

Patient: One

RESULTS: A 12-year-old boy consulted for two-month history of cervical lymphadenopathy with the underlying cause remaining unclear despite multiple consults, diagnosis and medical treatment. Lymphoma was considered and excision biopsy with further investigations confirmed a diagnosis of Kikuchi-Fujimoto disease. Supportive management was given with no recurrence of symptoms noted on 18 months of follow up. 

CONCLUSION:  Kikuchi-Fujimoto disease in this case was a diagnosis of exclusion. Even with a proper history and physical examination, experts in otolaryngology can be misled to manage this case as malignant. Awareness of the disease and appropriate examinations including immunohistochemistry are important for a timely diagnosis and proper intervention.

KEYWORDS: lympadenitis; Kikuchi-Fujimoto disease; lymphoma; cervical lymph nodes

The diagnosis of lymphatic malformations can present problems with diagnosis and treatment. Non-response to a chosen procedure can magnify the initial problems or create new ones. We present such a case.

CASE REPORT

            A 9-year-old boy initially presented with a 3-year history of soft upper eyelid mass with red-violet discoloration after hitting his head on a wooden post. About 2 years before this presentation, progressive enlargement in size of the mass with extension to the left maxillary and left scalp region prompted an ophthalmologic consult, and Magnetic Resonance Imaging (MRI) of the orbit and Magnetic Resonance Angiography (MRA) of intracranial vessels revealed a venous-lymphatic malformation. (Figure 1) He was then referred to our institution for further management.

            The patient was noted to have a 4x2 cm reddish vascular mass over the left eyelid with no thrill or bruit and a surrounding 9x9 cm bluish left facial swelling in the periorbital region extending to the maxillary area corresponding to the MRI images. A repeat MRI/MRA showed a prominent branch of the left external carotid artery coursing towards the mass. (Figure 2)

An angiogram of the neck for possible coil insertion into the prominent vessel from the external carotid artery was performed by interventional radiology. However, the left common carotid, left external carotid, and left vertebral arteries showed no evidence of high- or low-flow arteriovenous malformation. (Figure 3) This favored a hypovascular, space-occupying lesion consistent with a cystic lymphatic malformation and the boy was referred back to our service for possible surgery.

Meanwhile, the mass continuously increased in size and by the time he was seen again in our clinic, the mass measured 15x15x20 cm occupying the left hemifacial area from the midportion of the parietal bone superiorly to the body of the mandible inferiorly, with violaceous skin discoloration and verrucous infraorbital lesions. (Figure 4) The patient was not considered a good candidate for surgical excision due to the size of the mass relative to his body, and initial sclerotherapy was planned to possibly decrease the size of the mass enough for excision of any residuals.

Percutaneous Sclerotherapy was performed using a guidewire-catheter replacement technique. An initial drainage of 800mL of non-clotting serosanguinous fluid was followed by infusion of 3% sodium tertradecyl sulfate, followed by 99% ethanol infusion. There was gross decrease in the size of the mass after the procedure. (Figure 5) A pigtail drainage catheter was maintained to continuously drain fluid from the lesion. On the 10th hospital day, the boy had febrile episodes associated with enlargement of the left hemifacial mass. Blood cultures showed no bacterial growth. Culture of the pigtail catheter tip grew Morganella morganii. Amikacin 170mg IV every 8 hours was started but fever was unrelenting. Wound cultures grew Methicillin Resistant Staphylococcus Aureus, and Co-trimoxazole 40mg/200mg per 5ml Pediatric Suspension, 10ml every 12 hours and Metronidazole 200mg/5mL oral suspension, 5mL every 8 hours were initiated.

During this month-long post-operative period, the mass continued to expand to its preoperative size. (Figure 6) Due to lack of funds, the antibiotics were given by mouth and the patient was discharged. On 3-month follow up, the mass had grown to even larger than the pre-embolization stage.

 DISCUSSION

            Lymphatic malformations (LM) are made up of variously dilated lymphatic channels or cysts, lined by endothelial cells with a lymphatic phenotype.1  Histologically, LM is classified into the macrocystic type, consisting of cysts larger than 2 cm with clear boundaries, and the microcystic type consisting of cysts smaller than 2 cm that appear diffuse and sprouted without clear boundaries. The two types coexist in the combined type.2  

            A 5-stage clinicoradiologic staging system has been devised by de Serres et al. based on cervical LM laterality and relationship to the hyoid bone predicting operative risk and surgical outcome.3 The higher the clinicoradiologic stage, the greater the potential risk of intraoperative and postoperative complications.  In general, bilateral microcystic suprahyoid LMs are more difficult to treat than infrahyoid LMs, especially when there are microcystic LMs involving the oral cavity, tongue, and/or pharynx. In this case, confirming whether it was a high-flow or a low-flow disease presented a dilemma early on. We relied on the initial MRI/MRA findings of a possible arterial feeding vessel, considering that MRI/MRI is more than 90% accurate in the diagnosis of high-flow vascular anomalies.4 However, during angiography for coil insertion, there were no feeding vessels found and a low-flow disease was considered. Thus, there were further delays in management associated with these procedures.

            In our case, the patient had a unilateral suprahyoid LM that has a complication rate of 41% with an average of 1.5 procedures to treat and cure the disease.3 The possible complications that were considered included facial nerve palsy, seroma, exsanguination and most importantly, functional compromise due to the projected large post-operative defect and location of the mass which could affect function of the left eye, feeding problems and long term facial disfigurement.5

            Considering these possible complications, we planned to attempt initial sclerotherapy before considering surgery. However, we encountered infection of the pigtail site and wound, and sclerotherapy failed to decrease the size of the mass. At the moment, subjecting the patient to repeat sclerotherapy may have a higher chance of failure.

            Noting that the treatment of lymphatic malformation should be directed towards preservation of functional and aesthetic integrity,5 we present our case for consideration.

Objective: This study determined the demographic data, clinical profile, treatment and outcome of BCN-IE in children at UP-PGH.

Methods: This is a retrospective study of children with BCN-IE admitted at UP-PGH from 2004-2013. Demographic data, clinical presentation, previous antibiotic use, echocardiographic findings, an antibiotic used and outcome of patients were recorded and analyzed. Results in the demographic and clinical profile were expressed as frequencies, percentages and means. To compare the clinical features, echocardiographic findings and antibiotic regimen used as to the outcome, Fischer's exact test was used.

Results: Among 91 patients diagnosed with infective endocarditis, 61.54% had BCN-IE. The age, gender and clinical presentation were similar to other studies. Clinical presentation and echocardiographic findings did not have influence on outcome of children with BCN-IE. The use of penicillin G and amikacin is associated with unfavorable outcome after 4 weeks or less of administration.

Conclusion: The incidence of BCN-IE is high in UP-PGH. The demographic distribution, clinical and echocardiographic features of patients do not have an influence on the outcome. The trend to the unfavorable outcome with the use of penicillin suggests the need to target fastidious organisms in BCN-IE. Further investigation is warranted to establish the etiologic agents of BCN-IE.