The use of child restraints such as car seats or booster seats inevitability increases with the implementation of laws mandating its use in the general public. This is of great importance to child health and injury prevention as child restraint use has been shown to reduce the risk of serious injury by 71% to 82% for children less than 1-year-old, and 45% for children aged 4 to 8 years old.2,3 In terms of averting death, child restraints were associated with 28% reduction in risk for death.4 It has been found that using ageand size-appropriate child restraints is the best way to save lives and reduce injuries in a crash.5 It is reasonable, therefore, that one study that investigated the association between child restraint law implementation and traffic injury rate among 4 to 6 years old children in New York State found that these children experienced an 18% reduction in traffic injury rate. (See full-text for continuation).
Human ; Child Preschool (a Child Between The Ages Of 2 And 5) ; Pediatrics

Oblique facial clefts (Tessier Clefts) are severe orofacial clefts beyond the lip and palate that count among the rare congenital malformations "with an incidence of 1.43 to 4.85 per 100,000 births."1,2 The Tessier Classification System devised by Paul Tessier in 1976 assigned specific caudo-cranial numbers to clefts involving the "soft tissue and underlying bones of the mouth, maxilla, nose, eyes, and forehead" in relation to the sagittal midline of the face.1,3,4 The midline is designated 0 - 14, and adjacent clefts are numbered 1-13, 2-12 and so on, depending on the location and axis of the malformation. We present a patient with a bilateral Tessier 5 cleft.

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)

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.

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 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.

BACKGROUND: Childhood tuberculosis (TB) remains a significant health problem worldwide despite the increase in its emphasis on national health programs.

OBJECTIVE: This study aimed to describe how TB in children is identified and managed in a routine TB program in a rural setting in a high-burden country.

METHODS: This is a prospective, community-based surveillance study in public rural clinics in the Philippines. Observations on case finding and management of TB in children as well as contact tracing in an existing TB program are described.

RESULTS: Out of 266 children with presumptive TB, 41 (15.4%) were cases of TB, 15 (5.6%) had latent TB infection (LTBI), 81 (30.5%) had TB exposure, and 129 (48.5%) had no TB. There were 37 (90%) TB cases who were clinically diagnosed. Ninety-three percent (93%) of children with TB disease were cured or completed treatment. Among 25 children targeted for isoniazid preventive therapy (IPT) for LTBI and TB exposure, only 12 (52%) completed the recommended 6 months of IPT. Only 40 (43%) children aged 0 to 4 years exposed to smear-positive TB cases were screened.

CONCLUSION: Barriers in the diagnosis, low IPT completion, and problems in contact tracing may hinder the successful implementation of TB programs for children.

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 AND OBJECTIVE: Kawasaki Disease (KD) is the leading cause of acquired heart disease in children in developed countries. We aimed to determine the predictors of intravenous immunoglobulin (IVIG) resistance based on clinical manifestations and laboratory parameters.

METHODOLOGY: This was a retrospective cohort study of classic KD patients.    

RESULTS: Two hundred and ten patients were included in the study. The mean age was 2.0 ±1.8 years old with slight female predominance at 51.4%. Seven (3.3%) cases were found to be IVIG resistant. There was no significant difference in age, clinical manifestations or fever duration.  Univariate analysis revealed that IVIG resistant group had a heavier weight with mean of 16.4 kg ± 12.2 compared to the IVIG responder group 12.2kg ± 4.8. The IVIG resistant group had a higher white blood cell count of 23.9 ± 7.8 compared to the responder group of 17.9 ± 6.5.                           

CONCLUSION AND RECOMMENDATIONS: There is an IVIG resistance rate of 3.3% among classic KD patients. A high white blood cell count and weight are probable predictors for IVIG resistant KD. We recommend a larger sample size of resistant cases and a case-control multicenter study.