Pediatrics
Board Review Online

Subacute sinusitis is defined as symptoms (nasal discharge and/or daytime cough) persisting from 30 to 90 days. The bacteriology is the same as that of acute sinusitis.

Educational Objective:

Recognize the clinical findings associated with glucose-6-phosphate dehydrogenase deficiency.

Key Point:

Children with G6PD deficiency may present with intermittent hemolysis, which is most commonly secondary to certain medication use.

Explanation:

The most likely diagnosis is G6PD deficiency, which is an x-linked enzyme deficiency most common in people whose ancestors are from the Mediterranean countries, China, or Thailand, as well as in African Americans. It can present in 2 ways. One way is in chronic hemolytic anemia (without spherocytes). The patient described here has episodic hemolytic anemia induced by an inciting agent (ie, sulfamethoxazole/trimethoprim). Other triggers for hemolytic episodes in patients with G6PD include diabetic ketoacidosis, hepatitis, and use of sulfonamides, chloroquine, or methylene blue.

Laboratory evidence during an episode will show signs of hemolysis. Te diagnosis is made by measuring the level of the G6PD activity in the red blood cells. Testing should be deferred until the hemolytic episode is over because the G6PD activity levels in immature red cells, also known as reticulocytes, will be higher and may give a falsely normal result. Avoidance of triggers prevents recurrent attacks.

Reference:

Glader B. Hereditary hemolytic anemias due to red blood cell enzyme disorders. In: Greer JP, et al, eds. Wintrobe's Clinical Hematology. 13th ed., 2014:728.

Educational Objective:

Appropriately manage acute episodes of supraventricular tachycardia.

Key Point:

Vagal stimulation may abort attacks of supraventricular tachycardia in asymptomatic patients. If this fails, then medical therapy with adenosine is the treatment of choice.

Explanation:

This girl is in supraventricular tachycardia (SVT). In stable patients, such as this one, vagal stimulation such as putting her face in ice water or performing the Valsalva maneuver (breath holding, straining, or standing on her head) may end the attack. Carotid massage is not usually effective. If vagal stimulation fails, then medical therapy is warranted.

In stable patients, an intravenous push of adenosine is the treatment of choice. Because of the risk of atrial fibrillation, adenosine should only be administered with the means for cardioversion close at hand. Verapamil may be used to treat older children, but it is contraindicated in infants younger than 1 year of age.

In a patient with SVT and signs of heart failure, synchronized direct current cardioversion at 0.5 to 2 J/kg is recommended as the initial management option.

Reference:

Van Hare G. Disturbances of rate and rhythms of the heart. In: Kliegman RM, et al, eds. Nelson Textbook of Pediatrics. 20th ed., 2016:2250-2261.

Educational Objective:

Summarize the clinical presentation of Graves disease in an adolescent.

Key Point:

An adolescent with Graves disease may have tremor, tachycardia, and exophthalmos with lid lag.

Explanation:

The clinical picture and narrative depict a patient with a hyperfunctioning thyroid. Exophthalmos and lid lag are characteristics of Graves disease, along with an enlarged thyroid (goiter). Adults often present with dermatopathy, but this is unusual in children. Children with Graves disease may lose weight despite an increased appetite and may have sleep difficulties. In addition, they may have hyperactivity and problems in school and may have been misdiagnosed with ADHD.

Graves disease is an autoimmune condition that results in the production of thyroid-stimulating immunoglobulin. Addison disease is characterized by primary adrenal insufficiency. Hashimoto and iodine deficiency are associated with decreased thyroid function.

Reference:

LaFranchi S. Clinical manifestations and diagnosis of Graves disease in children and adolescents. Updated July 19, 2018. Accessed September 4, 2018.

Ketamine is unique among the procedural sedation agents in that it is commonly associated with nystagmus. Parents should be warned about this potential effect. Nystagmus following ketamine is benign and self-limited. The other answer choices do not produce nystagmus. Similarly, emesis following administration is most common with ketamine. Propofol has some antiemetic effects; recently, some clinicians have used a mixture of ketamine and propofol in an attempt to achieve the most desired effects of ketamine (analgesia, anesthesia, amnesia) and propofol (amnesia, antiemetic) without some of the adverse effects of either (emesis and respiratory depression). Studies are mixed in terms of whether this regimen is helpful.

References:

 

Burbulys D, et al. Procedural sedation and analgesia. In: Marx JA, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 7th ed., 2010.

 

Caglar, Derya, et al. Pediatric Procedural Sedation and Analgesia in the Emergency Department. Emergency Medicine Reports. August 2011.

 

Vlahos J, et al. Part II. Pediatric Procedural Sedation: Selecting an Agent. Emergency Medicine Reports. June 2007.