Eclampsia in Children

Eclampsia in ChildrenManaging seizures in children is an imperative skill for us all to have. Whether the seizure is Simple Febrile or Complex, we need to be facile in its management and aftercare. Additionally, some of the special circumstances must be considered (ex, Neonatal Seizures, Pyridoxine Deficiency) as well as contemplation of the potential Seizure Mimics.  With this in mind, there is another condition, that is deserves attention. While it may seem like more of an “adult” problem, it actually is critically important we keep this on our radar for pediatric patients also (plus, there are so many “adult” problems that need to be considered in kids – Cholelithiasis, Renal Stones, Pulmonary Embolism). Let’s take a minute to review Eclampsia!

 

Eclampsia: Basics

  • Eclampsia is a leading cause of maternal death worldwide.
  • Pre-eclampsia / eclampsia occurs after the 20th week of gestation.
  • Eclampsia may occur in postpartum period also. [Al-Safi, 2011; Cantey, 2007]
    • Late/Delayed onset postpartum eclampsia = eclampsia >48 hours after delivery
    • Seldom develop the classic pre-eclamptic symptoms. [Cantey, 2007]
    • Can be challenging to diagnose and requires more vigilance.
  • Pre-eclampsia is characterized by:
    • Hypertension
      • SBP >140 and/or DBP >90
      • Unfortunately, these levels may not be seen in younger patients, leading to missed diagnosis. [Olaya-Garay, 2017]
      • Comparison to baseline blood pressures may be more helpful in children. [Olaya-Garay, 2017]
    • Proteinuria
    • Generalized edema
  • Eclampsia can be preceded by: [Scribano, 1996]
    • Neurologic Symptoms: (commonly precede eclampsia [Cooray, 2011])
      • Headaches
      • Visual disturbances (ex, blurred vision, blindness, scotomata)
        • “Eclampsia” is derived from “eklampsis”: Greek, meaning “to shine forth.” [Elliott, 1989]
        • Refers to the flashes of light that patients may describe.
    • Epigastric pain
    • Hyperreflexia
    • Increasing blood pressures
  • Eclampsia is diagnosed when pre-eclampsia is complicated by cerebral dysfunction: [Elliott, 1989]
    • Impaired mental status
    • Focal neurologic signs
    • Seizures
    • Coma
  • Eclampsia complications
    • Pulmonary edema
    • Cerebral hemorrhage
    • Cerebral hypoxia and edema
    • Abruptio placentae
    • Acute renal failure
    • Hepatic rupture
    • Circulatory collapse
    • Fetal and/or maternal death

 

Eclampsia: Risk Factors

  • Maternal age
    • The extremes of the age range are at highest risk.
    • Adolescent age is one of the most important risk factors. [Olaya-Garay, 2017]
  • Chronic hypertension
  • Gestational diabetes
  • Obesity
  • Family history of pre-eclampsia/eclampsia
  • Nulliparity as well as Multiple gestations
  • Urinary tract infection
  • Hydatidiform mole
  • Fetal hydrops

 

Eclampsia: Treatment

  • ABCDs are always first!
  • Check the Sugar! (just in case you forgot to check it during ABCDextrose)
  • Anticonvulsants: [ACOG]
    • Magnesium Sulfate: 46 grams IV bolus over 20 minutes then 1-2 grams/hr infusion
    • Benzodiazepines may also be needed for recurrent seizure activity.
    • Keppra can be used as second line medication.
  • Antihypertensives:[ACOG]
    • Labetalol
    • Hydralazine
  • Delivery of the fetus
    • This is the primary treatment for eclampsia.
    • Delivery should be the next goal once the mother is more stable. [Elliott, 1989]

 

Moral of the Morsel

  • Seizures in children are common, but don’t get complacent. Think about the causes!
  • Few labs are actually useful when managing a seizure. Glucose, Sodium, and Pregnancy Test all potentially change management!
  • Consider pediatric pregnancies as a high risk condition.
  • Be wary of the postpartum patient with a headache! Scrutinize the blood pressure.

 

References

Olaya-Garay SX1, Velásquez-Trujillo PA2, Vigil-De Gracia P3. Blood pressure in adolescent patients with pre-eclampsia and eclampsia. Int J Gynaecol Obstet. 2017 Sep;138(3):335-339. PMID: 28602034. [PubMed] [Read by QxMD]

Ananth CV1, Keyes KM, Wapner RJ. Pre-eclampsia rates in the United States, 1980-2010: age-period-cohort analysis. BMJ. 2013 Nov 7;347:f6564. PMID: 24201165. [PubMed] [Read by QxMD]

Fong A1, Chau CT, Pan D, Ogunyemi DA. Clinical morbidities, trends, and demographics of eclampsia: a population-based study. Am J Obstet Gynecol. 2013 Sep;209(3):229. PMID: 23727516. [PubMed] [Read by QxMD]

Cooray SD1, Edmonds SM, Tong S, Samarasekera SP, Whitehead CL. Characterization of symptoms immediately preceding eclampsia. Obstet Gynecol. 2011 Nov;118(5):995-9. PMID: 22015866. [PubMed] [Read by QxMD]

Al-Safi Z1, Imudia AN, Filetti LC, Hobson DT, Bahado-Singh RO, Awonuga AO. Delayed postpartum preeclampsia and eclampsia: demographics, clinical course, and complications. Obstet Gynecol. 2011 Nov;118(5):1102-7. PMID: 21979459. [PubMed] [Read by QxMD]

Cantey JB1, Tecklenburg FW, Titus MO. Late postpartum eclampsia in adolescents. Pediatr Emerg Care. 2007 Jun;23(6):401-3. PMID: 17572526. [PubMed] [Read by QxMD]

Scribano PV1, Selbst SM. Severe eclampsia in an adolescent: a case report and review of the literature. Pediatr Emerg Care. 1996 Dec;12(6):425-7. PMID: 8989791. [PubMed] [Read by QxMD]

Elliott D1, Haller JS. Eclampsia: a pediatric neurologic problem. J Child Neurol. 1989 Jan;4(1):55-60. PMID: 2918212. [PubMed] [Read by QxMD]

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Flexor Tenosynovitis

Flexor TenosynovitisThe human hand is amazing. Amazing in its power, its structure, … and in its ability to become injured. Children, who are less nimble, get their hands into trouble frequently. Sometimes that injury can be relatively simple (ex, subungal hematoma), while other times it may be a little bit more challenging (ex, metacarpal fractures). Additionally, infectious processes need to be contemplated (ex, Herpetic Whitlow, Blistering Dactylitis). Let’s review another condition that involves both infection and injury – Pyogenic Flexor Tenosynovitis.

 

Flexor Tenosynovitis: Basics

  • Pyogenic flexor tenosynovitis (PFT) = infection of the flexor tendon sheath
    • The flexor tendon sheath provides nutrition, optimal gliding, and restraint for the extrinsic tendons to the digits.
    • The sheath has two layers that form a sealed synovial space.
    • Connections between one synovial space and another can be present, or even develop during an infection. [Hyatt, 2017]
  • PFT can lead to significant sequelae:
    • Finger stiffness
    • Tendon necrosis and rupture
    • Hand dysfunction
    • Amputation
    • Systemic infection
  • ~75% of cases are associated with antecedent injury. [Brusalis, 2017]
    • Penetrating injuries are the most common (ex, cat scratch/bite). [Hyatt, 2017]
    • Patients often present 2-5 days after an injury. [Hyatt, 2017]
  • PFT is a clinical diagnosis!!
    • Kanavel’s Signs:
      1. Tenderness over the tendon sheath
        • Most common finding in kids with PFT. [Brusalis, 2017]
        • The greatest tenderness is generally over the proximal end of the sheath, just over the MCP joint. [Hyatt, 2017]
      2. Pain with passive extension of the digit 
        • 2nd most common finding in kids.
        • These first 2 signs are most useful. [Brusalis, 2017]
      3. Fusiform swelling of the digit 
      4. Flexed position of the digit
    • PFT can be present without Kanavel’s signs. [Hyatt, 2017Brusalis, 2017]
      • These signs are less reliable in the thumb and pinky.
      • They are also less reliable in children.
  • Distinguishing from other clinical entities can be challenging. [Brusalis, 2017]
    • Labs may be requested (like my favorite ESR, CRP, WBC).
    • Labs can be normal in more than 50% of cases. [Brusalis, 2017]
    • Ultrasound has been used to help define PFT. [Cohen, 2015]

 

Flexor Tenosynovitis: DDx

  • Cellulitis – not restricted to one digit, pain with flexion and extension
  • Paronychia – lateral nail fold infection
  • Felon – infection in distal finger pad pulp
  • Deep space infection – diffuse edema, palpable abscess
  • Herpetic Whitlow – vesicles present
  • Septic arthritis – pain with flexion or extension, typically from a dorsal injury

[Hyatt, 2017]

 

Flexor Tenosynovitis: The Bugs

  • Strep and Staph (as expected) are the most common organisms involved.
  • MRSA is often (29-38%) encountered in children. [Brusalis, 2017]
  • ~20% of patients will have multiple organisms involved. [Brusalis, 2017]
  • Anaerobic organisms are also encountered.  [Harness, 2005]

 

Flexor Tenosynovitis: Treatment

  • Orthopaedic/Hand Surgery consultation for irrigation, drainage, and debridement.
    • Multiple approaches have been described. [Hyatt, 2017]
    • Adults may benefit from continuous irrigation, although debated.
    • Children can be adequately managed without irrigation. [Brusalis, 2017]
  • IV antibiotics
    • Use a regimen that covers for MRSA. (ex, vancomycin) [Hyatt, 2017; Brusalis, 2017]
    • Broad spectrum antibiotics are also recommended given potential for polymicrobial infections. (ex, pip/tazo).  [Hyatt, 2017; Brusalis, 2017; Harness, 2005]
    • Discuss timing of antibiotics with surgeon, as she/he may prefer collecting intra-operative cultures prior to antibiotics.
    • Some, very mild cases, may be treated with IV antibiotics alone, but decision should be that of consultant.

 

Moral of the Morsel:

  • Hand infections are bad! They are not all created equal though. Be vigilant for Pyogenic Flexor Tenosynovitis!
  • Know your Kanavel signs, but consider augmenting your exam with U/S!
  • Consult early… and ask whether you can start antibiotics early!

 

References

Hyatt BT1, Bagg MR2. Flexor Tenosynovitis. Orthop Clin North Am. 2017 Apr;48(2):217-227. PMID: 28336044. [PubMed] [Read by QxMD]

Brusalis CM1, Thibaudeau S2, Carrigan RB1, Lin IC2, Chang B2, Shah AS3. Clinical Characteristics of Pyogenic Flexor Tenosynovitis in Pediatric Patients. J Hand Surg Am. 2017 May;42(5):388. PMID: 28341068. [PubMed] [Read by QxMD]

Cohen SG1, Beck SC. Point-of-Care Ultrasound in the Evaluation of Pyogenic Flexor Tenosynovitis. Pediatr Emerg Care. 2015 Nov;31(11):805-7. PMID: 26535504. [PubMed] [Read by QxMD]

Harness N1, Blazar PE. Causative microorganisms in surgically treated pediatric hand infections. J Hand Surg Am. 2005 Nov;30(6):1294-7. PMID: 16344191. [PubMed] [Read by QxMD]

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Uveitis

Uveitis in ChildrenThe “Pediatric Red Eye” is a commonly encountered presentation that we are all accustomed to evaluating.  The vast majority of the time, the eye redness and irritation is related to a standard conjunctivitis; however, as with many presentations, we need to still be vigilant for other entities. Certainly, conditions like Kawasaki Disease should be thought of, but there are other entities that sound like more of “adult” problems that shouldn’t be overlooked, like glaucoma. Let’s take a minute to review another potential cause of the Pediatric Red Eye – Uveitis:

 

Uveitis: Basics

  • Uveitis is a rare, but significant disorder.
    • 3rd leading cause of blindness in developed countries.
  • Complications are frequent. [Sardar, 2017]
    • Retinopathy
    • Cataract
    • Blindness (accounts for ~20% of pediatric blindness)
  • Uveitis more commonly affects adults, but:
    • The posterior chamber of the eye is more likely to be involved in kids and,
    • Children are more likely to develop blindness from it.
  • Causes of uveitis include:
    • Idiopathic – occurs without associated systemic illness in 30-50% of cases
    • Juvenile Idiopathic Arthritis (JIA) is the leading defined cause
      • Uveitis is the most common extra-articular manifestation of JIA.
      • 10-20% of patients with JIA are at risk for uveitis.
      • Young age at onset of arthritis (< 7 years), +ANA, +antihistone antibodies, and oligoarticular JIA were risk factors for development of uveitis. [Nordal, 2017]
      • Majority of uveitis cases develop within first 4 years of JIA diagnosis.
    • Behcet Disease
    • Sarcoidosis
    • Lupus
    • Inflammatory Bowel Disease
    • Infections
      • Syphilis
      • Chlamydia
      • HIV/AIDS
      • Tuberculosis

 

Uveitis: Presentation

  • Presentations is varied.
    • Can present with acute symptoms, but
    • Can also be insidious and be asymptomatic.
  • Symptoms related to compartment involved:
    • Anterior
      • Eye Pain and Photophobia
      • Red Eye
    • Posterior
      • Blurred vision and floaters
      • Can by asymptomatic
  • Can also find:
    • Increased Intraocular Pressure [Kothari, 2015]
    • Vision Loss – ~25% will be legally blind
  • Risk factors for severe uveitis (sight-threatening): [Angeles-Han, 2016]
    • Short duration between development of arthritis and uveitis
    • Young age at uveitis onset
    • Uveitis diagnosed before arthritis
    • Male gender

 

Uveitis: Therapy

  • Corticosteroids 
    • Typically used as first line.
    • Topical or systemic therapies have been used.
  • Immunomodulator Drugs
    • Methotrexate and azathioprine are second-line therapies.
    • Mycophenolate mofetil as also been used.
    • Anti-TNF-alpha monoclonal antibodies are effective. [Sardar, 2017]
  • Even with appropriate therapy, cases are often recurrent.
  • Conventional therapies are often insufficient. [Sardar, 2017]
  • Chronic, remittent course is common and many will require long-term therapy. [Angeles-Han, 2016]

 

Moral of the Morsel

  • Be vigilant! Not all red eyes are due to viruses.
  • Ask the right questions. History of rheumatologic problems in patient or strong family history of them… consider uveitis.

 

References

Nordal E1, Rypdal V2, Christoffersen T3, Aalto K4, Berntson L5, Fasth A6, Herlin T7, Nielsen S8, Peltoniemi S4, Straume B9, Zak M8, Rygg M10; Nordic Study Group of Pediatric Rheumatology (NoSPeR). Incidence and predictors of Uveitis in juvenile idiopathic arthritis in a Nordic long-term cohort study. Pediatr Rheumatol Online J. 2017 Aug 18;15(1):66. PMID: 28821293. [PubMed] [Read by QxMD]

Sardar E1, Dusser P2, Rousseau A3, Bodaghi B4, Labetoulle M3, Koné-Paut I2. Retrospective Study Evaluating Treatment Decisions and Outcomes of Childhood Uveitis Not Associated with Juvenile Idiopathic Arthritis. J Pediatr. 2017 Jul;186:131-137. PMID: 28457525. [PubMed] [Read by QxMD]

Angeles-Han ST1, Rabinovich CE. Uveitis in children. Curr Opin Rheumatol. 2016 Sep;28(5):544-9. PMID: 27328333. [PubMed] [Read by QxMD]

Hettinga YM1, de Groot-Mijnes JD2, Rothova A3, de Boer JH1. Infectious involvement in a tertiary center pediatric uveitis cohort. Br J Ophthalmol. 2015 Jan;99(1):103-7. PMID: 25138763. [PubMed] [Read by QxMD]

Kothari S1, Foster CS2, Pistilli M3, Liesegang TL4, Daniel E5, Sen HN6, Suhler EB7, Thorne JE8, Jabs DA9, Levy-Clarke GA10, Nussenblatt RB6, Rosenbaum JT11, Lawrence SD12, Kempen JH13; Systemic Immunosuppressive Therapy for Eye Diseases Research Group. The Risk of Intraocular Pressure Elevation in Pediatric Noninfectious Uveitis. Ophthalmology. 2015 Oct;122(10):1987-2001. PMID: 26233626. [PubMed] [Read by QxMD]

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