Abstract
ABSTRACTS FOR RESEARCH / QI / AUDIT PRESENTATIONS
Audit of antibiotic use and diagnostic utility of FeverPAIN score in the treatment of suspected Group A streptococcal infection in children presenting to a paediatric emergency department
1Paediatric Emergency Department, Royal Hospital for Children, Glasgow
2Department of Medical Paediatrics, Royal Hospital for Children, Glasgow
3Department of Microbiology, Queen Elizabeth University Hospital, Glasgow
4Department of Paediatric Infectious Diseases and Immunology, Royal Hospital for Children, Glasgow
Initial effectiveness and safety data on intravenous ferric derisomaltose for iron deficiency anaemia management in paediatric patients: Real-world data
1Department of Paediatric Gastroenterology, Hepatology and Nutrition, Royal Hospital for Children and Young People, Edinburgh, UK
2Paediatric Pharmacology, Royal Hospital for Children and Young People, Edinburgh, UK
3Child Life and Health, University of Edinburgh, Royal Hospital for Children and Young People, Edinburgh, UK
Use of Kaizer Permanence scoring system compared to West of Scotland early onset sepsis risk factors to determine need for empirical antibiotics in the neonate
1Royal Hospital for Children, Glasgow
2University Hospital Wishaw, Scotland
Group A streptococcal disease in children in hospital in Glasgow – 2012 to 2022
1School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow
2Department of Microbiology, Queen Elizabeth University Hospital, Glasgow
3Department of Paediatric Infectious Diseases and Immunology, Royal Hospital for Children, Glasgow
ABSTRACTS FOR CLINICAL CASE PRESENTATIONS
Intercostal nerve schwannoma as a cause of persistent pleuritic chest pain in a paediatric patient
1Liverpool University Hospital Foundation Trust
2St John's Hospital, NHS Lothian, Scotland
An 11-year-old girl presented with a 1-year history of ongoing left-sided pleuritic chest pain. The pain was exacerbated by increased physical activity and pressure to the left chest wall, and was resistant to trials of medical therapies. She had an extensive work-up including electrocardiogram, chest X-ray, blood tests, chest and abdominal ultrasounds, none of which revealed any abnormalities.
Following persistence of her symptoms she underwent a computed tomography scan which showed a soft tissue density mass immediately inferior to the anterior right 4th rib, measuring 20 × 11 × 17 mm. This was followed by an interval scan 1 month later where its size was unchanged. She underwent a thoracoscopy excision of the lesion, with pathology and immunohistochemistry confirming features of a schwannoma. Following resection her pain resolved completely and she was weaned off all analgesia. She was followed up with a magnetic resonance imaging of the chest which showed no disease recurrence.
Schwannomas are benign peripheral nerve sheath tumours originating from Schwann cells. They are rare in paediatrics and are more likely to be associated with neurocutaneous syndromes. Thoracic wall schwannomas are rare even amongst adults; most are asymptomatic, and their cause is unknown.
Schwannomas are classified on radiological, morphological and immunohistochemical features used to differentiate them from other peripheral nerve tumours. Surgical resection of paediatric peripheral nerve tumours is indicated if pain, function, rapid growth, suspicion of a malignant peripheral nerve tumour, cosmetic disfigurement or mass effect caused by invasion. Schwannomas are extricable as they do not penetrate nerve bundles. Malignant transformation of schwannomas is rare in adults, and to our knowledge has not been reported in children. Therefore unless there is degeneration or recurrence, the prognosis is excellent.
There have been a few case reports of intercostal nerve schwannomas diagnosed in adults following presentation with chest pain. Literature on intercostal schwannomas remains limited and to our knowledge this is the first case published describing a single intercostal nerve schwannoma as a cause of chest pain in children. We highlight this case as an unusual differential of a common paediatric presentation and its consideration in clinical practice.
A case of unexplained hypoxia
1Department of Paediatric Respiratory and Sleep Medicine, Royal Hospital for Children, Glasgow
2Department of Paediatric Surgery, Royal Hospital for Children, Glasgow
3Department of Paediatric Radiology, Royal Hospital for Children, Glasgow
4Department of Maternal and Child Health, University of Glasgow, Glasgow
Pulmonary arteriovenous malformations (PAVMs) are low-resistance, high-flow, structurally abnormal vascular communications between pulmonary arteries and veins. They result in an intrapulmonary left-to-right shunt; the size of which determines the degree of hypoxaemia, exuberant ventilation and high cardiac output. PAVMs of any size allow paradoxical emboli that may cause ischaemic strokes, myocardial infarction and cerebral abscesses.
The majority of PAVMs (80–95%) are inherited in an autosomal dominant manner due to hereditary haemorrhagic telangiectasia (HHT), a multisystemic vascular disorder with a spectrum of clinical manifestations (lesion distribution dependent: epistaxis, mucocutaneous telangiectasia and gastrointestinal bleeding are most common).
A 7-year-old boy was referred to a tertiary centre for further evaluation of hypoxia having been incidentally found to be hypoxic (SpO2 83% in air) during general physician consultation. He was afebrile with a 3-day history of non-productive cough, no other respiratory issues. Previously fit and healthy, he played regular football with no reported exertional dyspnoea. No significant family history.
Weight was 32.75 kg (95th centile). No evidence of cyanosis. Normal heart sounds with no audible murmurs. Chest clear on auscultation. No respiratory distress. Mild finger clubbing evident. No visible muco-cutaneous stigmata. Normal development and neurological examination.
Chest radiography showed focal left upper zone reticulation consistent with either atypical or viral lower respiratory tract infection. Initial treatment included supplemental oxygen, plus a 3-day course of oral azithromycin. Viral throat swab identified seasonal non-SARS-CoV-2 coronavirus. Genetic testing for HHT is awaited.
Persistent oxygen requirement led to further investigations: capillary blood gas was normal (cH 40.5, pCO2 5.8 kPa, BE 0.8, HCO3 26.0). Polycythaemia was noted (Hb 162 g/L, Hct 0.462). C-reactive protein < 1 mg/L. Echocardiogram was normal. Contrast-enhanced computed tomography pulmonary angiogram revealed multiple small vessel PAVMs in the apicoposterior segment of the left lung with evidence of intrapulmonary shunting. Abdominal ultrasound and magnetic resonance imaging of the head scans were normal.
The patient was subsequently discharged once acceptable saturations (≥85%) were maintained in 1L/min continuous nasal cannula oxygen. Following interdisciplinary discussion, PAVM embolisation was deemed too high risk. Additional advice regarding appropriate surgical management was sought from a quaternary hospital. Provisional management, given continual clinical stability, is for surgical lobectomy within the forthcoming months.
This case illustrates the importance of detailed clinical history attainment, alongside detection of pertinent examination findings, in facilitating prompt diagnosis of rarer conditions. Access to radiological and surgical expertise in PAVMs can improve diagnosis and influence treatment decisions.
Now that's what I call a lymphocytosis: A case of haemophagocytic lymphohistiocytosis
1Royal Hospital for Children and Young People, Edinburgh
Haemophagocytic lymphohistiocytosis (HLH) is a rare hyperinflammatory condition that can be primary or secondary. It should be considered as part of the differential diagnosis when presented with an unwell patient with features of a significant inflammatory response.
A previously well 3-year-old boy was transferred from a local DGH for surgical review with a 4 day history of pyrexia associated with vomiting and abdominal pain. On arrival, he was shocked and required multiple fluid boluses to maintain his blood pressure. On examination he had a distended abdomen with right-sided tenderness and hepatosplenomegaly. Initial bloods showed anaemia, lymphocytosis, deranged electrolytes, abnormal liver function tests and raised inflammatory markers. Intra-abdominal sepsis was suspected and an ultrasound and then cumputed tomography scan were performed. These showed abdominal free fluid and inflammatory changes but no specific focus of infection. The patient was transferred to critical care.
Due to the clinical picture and lack of diagnostic certainty from initial results, the scope of investigations was widened to include those looking for a multi-system inflammatory process. Further results showed a marked lymphocytosis (45) with markedly raised D-dimer, ferritin and triglycerides, in keeping with possible HLH.
A multidisciplinary meeting between relevant teams within the hospital was arranged and following this discussion a plan for treatment and further investigation to differentiate between primary and secondary HLH was agreed. Recommended first-line treatment to switch off the severe systemic inflammatory process was anakinra followed by steroids. Due to the need for further invasive investigations such as bone marrow examination and ongoing concerns about potential for further deterioration, the patient was anaesthetised to allow intubation, ventilation and central line insertion.
The patient responded to treatment and gradually improved. He was subsequently found to have Epstein-Barr virus with a polymerase chain reaction titre of over 900,000 which was felt to be the driver of the HLH. He was treated with aciclovir for this. Further genetic tests for familial HLH and primary immunodeficiency were also sent and results are awaited. The patient has since been discharged on aciclovir and a weaning course of prednisolone.
This is an interesting case which highlights a rare pathology presenting initially with non-specific symptoms in keeping with sepsis. It emphasises the importance of keeping a wide scope of differentials and understanding the patterns of laboratory abnormalities in sepsis and other systemic inflammatory syndromes, especially when the clinical picture is not typical.
Forgotten but not gone
A Mallappa
Royal Aberdeen Children's Hospital, Scotland
Lemierre's syndrome (LS) is a potentially fatal complication of acute oropharyngeal infections leading to septic thrombophlebitis of the internal jugular vein (IJV). LS is an uncommon condition that classically starts as with an oropharyngeal infection (like tonsillitis, retropharyngeal abscess or dental infection) which is complicated by suppurative thrombophlebitis of IJV and subsequent emboli to other organs.
The highest incidence is around second decade of age. Due to the modern antibiotics this is now a ‘forgotten disease’.
We want to share a case dealt with to emphasise healthcare providers to be vigilant of this rare disease.
A 15–year-old patient presented to PAU initially with a sore throat was managed conservatively. Representation within a week with worsening symptoms of painful throat, difficulty in swallowing, muffled voice, unable to weight bear, history of collapse at home.
Initial examination unwell, febrile child, tachycardiac, hypotensive, enlarged tonsils and cervical lymphadenopathy. Spoke in a muffled voice, throat enlarged tonsil touching uvula, palatal swelling, tenderness over left clavicle and neck. Tender abdomen, swelling in the right popliteal fossa.
Managed with fluid bolus, broad spectrum antibiotics, imaging and ENT opinion.
Initial working diagnosis was quinsy. Pus aspirated bedside and sent for culture.
The bloods showed thrombocytopenia with raised C-reactive protein.
Worsened over the stay needing optiflow, worsening renal function needed further fluid resuscitation. PICU consulted advice followed.
At this stage some suspicion of PE, CTPA done, thrombophlebitis of left IJV. Magnetic resonancec imaging of the knee fluid collection between gastrocnemius and soleus.
Pus from throat grew Fusobacterium necrophorum, clinched the diagnosis of Lemierre's syndrome. They were treated with 4 weeks of intravenous dual antibiotics and further 2 weeks of oral antibiotics along with 3-month course of rivoraxoban. Review at clinics, back to normal.
Classically, the focus of the infection is oropharynx (pharyngitis or tonsillitis), but it can follow other head and neck infections such as otitis media and mastoiditis. This is followed by thrombophlebitis of the local veins that ultimately ends by thrombosis of the IJV. If not treated promptly, this may lead to high-load bacteraemia and sepsis, with multiple end-organ failure. The diagnosis of classical Lemierre's syndrome is based on fulfilling three criteria, namely, oropharyngeal sepsis, internal jugular vein thrombophlebitis and metastatic infection, as was found in our case. Clinicians should have a high index of suspicion for this condition in a child presenting with sore throat, neck pain, fever and a toxic appearance.