Rare case of central congenital hypothyroidism due to a TSHβ mutation presenting with macro-orchidism

A male infant was brought to our paediatric endocrine unit with typical clinical features of congenital hypothyroidism (CH) and striking macro-orchidism. On evaluation, free T3, free T4 and thyroid stimulating hormone (TSH) were found to be low, suggestive of congenital CH. Cortisol was within reference range and prolactin was mildly elevated. No suspicious lesions were encountered on neurosonography. On commencing treatment with thyroxine, clinical features of hypothyroidism showed dramatic improvement with regression of testicular enlargement. Genetic analysis revealed deletion of the TSHβ gene.Our case highlights a rare presentation of central CH with macro-orchidism in a genetically proven deletion of TSHβ gene. Macro-orchidism has been widely reported in IGSF-1 mutations leading to central CH; however, central CH and macro-orchidism have not been reported in association with TSHβ deletions.

Rare but life-threatening cause of massive haemoptysis in an adolscent with tuberculosis: Rasmussen's aneurysm

Rasmussen's aneurysm is a rare yet fatal cause of massive haemoptysis in pulmonary tuberculosis. Early identification and timely intervention are of utmost importance to reduce the associated mortality. A girl in early adolescence presented with persistent fever and massive haemoptysis who required intubation and was subsequently confirmed to have tuberculosis. CT pulmonary angiogram showed the presence of pseudoaneurysms in the left upper and lower lobes. The haemoptysis resolved following the embolisation of the culprit's vessel. Residual lung destruction was evident on CT after a 12-month course of antituberculosis therapy. Rasmussen's aneurysm is a significant vascular complication of cavitary tuberculosis and needs to be considered in patients presenting with massive haemoptysis.

Cow's milk protein allergy in a neonate presenting with methaemoglobinaemia

Cow's milk protein allergy (CMPA) is the most common food allergy in infants. A previously healthy neonate fed with infant formula presented diarrhoea, vomiting and respiratory distress with cyanosis. Investigations showed thrombocytosis and leucocytosis with lymphocyte predominance. To our surprise blood gas analysis showed metabolic acidosis and a high methaemoglobin level of 33% (normal range <3%). Clinical status, metabolic acidosis and methaemoglobin level returned to normal following fluid resuscitation and methylene blue administration. The neonate was later managed with breast feeding and elemental formula. CMPA was diagnosed based on history and clinical improvement after elemental formula. Although not common in CMPA, methaemoglobinaemia should be recognised as a differential diagnosis in a hypoxic infant with metabolic acidosis and diarrhoea as early recognition and treatment with methylene blue can save a child's life.

Neonatal rhabdomyoma with cardiac dysfunction: favourable response to sirolimus

Cardiac rhabdomyoma is the most common cardiac tumour in childhood, with a strong genetic association to tuberous sclerosis complex. Although most of the patients remain asymptomatic, a small proportion present with cardiac complications in the early neonatal period. Timely initiation of treatment can potentially reduce disease morbidity, and mammalian target of rapamycin (M-TOR) inhibitors play an effective role in promoting regression of these tumours. A healthy term newborn was diagnosed with a giant congenital cardiac rhabdomyoma at birth. He developed clinical signs of compromised cardiac function and progressive myocardial ischaemia, with echocardiography showing significant dyskinesia. He was treated with M-TOR inhibitors and clinical response was monitored via serial echocardiography. Remarkable regression of the tumour was visibly demonstrated within 4 months of sirolimus treatment. The infant continues to be reviewed by a multidisciplinary team of physicians and monitored for features of tuberous sclerosis complex.

Guillain-Barre syndrome (GBS) associated with COVID-19 infection that resolved without treatment in a child

A 9-year-old boy presented with unbalanced gait, back pain and lower limb weakness. His physical examination revealed almost absent lower limbs reflexes and cerebro-spinal fluid (CSF) showed albuminocytologic dissociation. The brain and spine MRI with contrast illustrated abnormal enhancement—suggestive of Guillain-Barré syndrome.

The case had limited distribution and it did not progress beyond the presenting clinical involvements. They did not need immunotherapy, self-recovered, managed conservatively using painkillers and gabapentin along with physiotherapy—with a wait and see approach. The child is now almost back to normal after 8–12 weeks.

Congenital long QT syndrome presenting as unexplained bradycardia

Congenital long QT syndrome (LQTS) is a genetically autosomal heterogeneous disorder of the ion channels and causes about 10% of sudden death infant syndrome in newborns. Its estimated prevalence is approximately 1 in 2500, probably underestimated because of its clinical heterogenicity. Few cases of neonatal LQTS have been reported. In 4% of them, life-threatening arrhythmic events can be the first manifestation of LQTS. The authors report two cases of neonatal LQTS with heterogeneous genetic mutations. Both manifested by bradycardia, one since fetal life. One case had serious arrhythmias during beta blocker therapeutic establishment needing a pacemaker implantation. Genetic mutations found were not the most frequently described in association with neonatal bradycardia, thus the importance of this report. Presentation with bradycardia is relatively frequent in neonatal period, thus LQTS should be actively investigated in neonates with unexplained bradycardia. Beta blocker therapy reduces QTc and avoids arrhythmic events and sudden death.

Methylene blue for the treatment of refractory septic shock secondary to listeriosis in a paediatric patient

Current therapies frequently used for refractory septic shock include hydrocortisone, vasopressin, extracorporeal membrane oxygenation (ECMO) support, inodilators, levosimendan and methylene blue. The evidence for these treatments is very limited. We present a case of a 5-year-old patient with refractory septic shock, secondary to Listeria monocytogenes meningitis. She presented with status epilepticus and developed septic shock. Shock persisted despite multiple high-dose vasoactive medications. ECMO support was not available. The medical team decided to use methylene blue to revert the vasoplegia, with excellent results. Shortly after the administration, vasopressors were weaned off and the high lactate cleared. She developed severe neurological sequelae due to brain haemorrhage secondary to the Listeria meningitis. The evidence supporting methylene blue for refractory septic shock in paediatric patients is limited. This case represents the effectiveness of this therapy without secondary effects.

Benzocaine-induced methaemoglobinaemia in an adolescent with sepsis

Methaemoglobinaemia is a potentially life-threatening condition characterised by hypoxaemia, cyanosis, pallor, fatigue, metabolic acidosis, headache and in severe cases, coma or death. Topical anaesthetics have been reported to cause methaemoglobinaemia. Topical benzocaine was specifically implicated in roughly 66% of anesthetic-induced methaemoglobinaemia cases in a large systematic review in adults. This complication has occurred often in adult patients with pre-existing comorbidities resulting in diminished use in children overall with only few paediatric cases reported worldwide. Additionally, there is growing evidence of a link between sepsis and methaemoglobinaemia due to increased circulating nitrous oxide from infectious pathogen metabolism. In this report, we discuss a case of a 16-year-old young boy, being evaluated for suspected endocarditis, presenting with acute methaemoglobinaemia after use of topical benzocaine spray for transesophageal echocardiogram. This case exemplifies the importance of blood gas with co-oximetry testing in all cases of refractory hypoxemia who have had procedures requiring topical anaesthetics.

Suboccipital extracranial and intracranial abscess of a neonate: an exceedingly rare occurrence

Intracranial abscess is a life-threatening disease that is uncommon in paediatric populations. Although there have been few reports in the literature, some aetiologies, such as mastoiditis and sinusitis, have been proposed. The pathophysiology is not completely known, and there are no data regarding the long-term follow-up of these patients. Herein, we present a case of a newborn affected with a mass in the suboccipital region due to an extracranial and intracranial abscess that had no clear association with infections except for a transient fever episode 1 month earlier. Isolation of Staphylococcus aureus from an open-surgery sample identified the cause of the mass. The patient achieved excellent recovery with no recurrence even after 8 years of follow-up. To our knowledge, this rare pattern of infection highlights the importance of early diagnosis in combination with a surgical approach as an effective diagnosis and treatment approach that provided a good outcome.

Diagnosis of a floppy neonate with misleading clues: unraveled as congenital hypomyelinating neuropathy

Contactin-associated protein 1 (CNTNAP1)-related congenital hypomyelinating neuropathy (CHN) is a rare type of peripheral neuropathy and has a clinically heterogeneous presentation. We report a neonate with an atypical presentation in the form of global hypotonia, facial diparesis and partial response to neostigmine challenge test. There was no clinical improvement on initiation of anticholinesterase drug for suspected congenital myasthenia and hence stopped. Detection of a pathogenic variant in CNTNAP1 gene by clinical exome sequencing and subsequent reverse phenotyping confirmed CHN as the aetiology for this floppy neonate, which is known to have high mortality. The baby was given supportive care and she succumbed secondary to complications of prolonged ventilation.

Dental manifestations of pseudo-vitamin-D deficiency rickets in a paediatric patient

Vitamin D-resistant rickets shows the resistance to vitamin D (Vit-D) therapy, which traditionally works well in cases with deficiency rickets. The signs start appearing as early as in the first month of life and are characterised by the defective mineralisation at the ends of cartilage and bones despite having normal Vit-D levels in the serum. This case report highlights the dental and maxillofacial manifestations in a 3-year-old girl diagnosed with pseudo-Vit-D deficiency rickets. The report also highlights the variations in the dental manifestations of the condition reported in the literature.

Recurrent painful ophthalmoplegic neuropathy: a cause for recurrent third nerve palsy in a child

Recurrent painful ophthalmoplegic neuropathy (RPON), previously called ophthalmoplegic migraine, is a rare condition characterised by recurrent episodes of headache and ophthalmoplegia. We report a case of 11-year-old girl with recurrent painful ophthalmoplegia due to isolated right oculomotor nerve involvement. MR brain imaging showed enhancing lesion of cisternal segment of right oculomotor nerve. A possibility of Tolosa Hunt syndrome was considered and she was treated with glucocorticoids, followed by azathioprine due to recurrence. In the fourth episode, she developed migraine headache followed by right third nerve palsy, after which the diagnosis was revised to RPON. She was started on flunarizine along with short-term glucocorticoids. At 1-year follow-up, she remained asymptomatic. RPON should be considered in patients with recurrent third nerve palsy to avoid inadvertent long-term exposure to immunosuppressive agents.

Acquired growth hormone deficiency in Fanconi-Bickel syndrome

Fanconi-Bickel syndrome (FBS) is a rare autosomal recessive disease, resulting from mutations in the SLC2A2 gene, causing impaired glucose transporter 2 protein transporter protein function, impaired glucose and galactose utilisation, hepatorenal glycogen accumulation and organ dysfunction. Clinical features include failure to thrive, hepatomegaly, rickets, short stature and delayed puberty. Therapy includes electrolyte supplementation and uncooked cornstarch. We present a 15-year-old boy diagnosed with FBS in infancy. Growth velocity was normal on standard treatment until age 8.5 years, at which time growth failure led to a diagnosis of acquired growth hormone (GH) deficiency. Initiation of recombinant human GH (rhGH) replacement of 0.25 μg/kg/week resulted in marked improvement in growth velocity and height. While short stature is expected in FBS, growth velocity that falls below the normal range despite adequate therapy should prompt further evaluation. Our case suggests that acquired GH deficiency can arise in FBS and benefits from rhGH therapy.

Pharmacokinetics and Drug-Drug Interactions of Abacavir and Lamuvudine Co-administered With Antituberculosis Drugs in HIV-Positive Children Treated for Multidrug-Resistant Tuberculosis

Given the high prevalence of multidrug-resistant (MDR)-TB in high HIV burden settings, it is important to identify potential drug-drug interactions between MDR-TB treatment and widely used nucleoside reverse transcriptase inhibitors (NRTIs) in HIV-positive children. Population pharmacokinetic models were developed for lamivudine (n = 54) and abacavir (n = 50) in 54 HIV-positive children established on NRTIs; 27 with MDR-TB (combinations of high-dose isoniazid, pyrazinamide, ethambutol, ethionamide, terizidone, fluoroquinolones, and amikacin), and 27 controls without TB. Two-compartment models with first-order elimination and transit compartment absorption described both lamivudine and abacavir pharmacokinetics, respectively. Allometric scaling with body weight adjusted for the effect of body size. Clearance was predicted to reach half its mature value ∼ 2 (lamivudine) and ∼ 3 (abacavir) months after birth, with completion of maturation for both drugs at ∼ 2 years. No significant difference was found in key pharmacokinetic parameters of lamivudine and abacavir when co-administered with routine drugs used for MDR-TB in HIV-positive children.

Placental chorioangioma: an unusual cause of neonatal cardiomyopathy

A late preterm baby presented with clinical and echocardiographic features of cardiomyopathy and cardiac failure soon after birth. After extensive metabolic, infective and genetic investigations, the likely cause was established to be due to multiple small placental chorioangiomas. While large placental chorioangiomas are associated with maternal, fetal and neonatal complications, small chorioangiomas are usually asymptomatic and diagnosed incidentally on placental histology. Our case demonstrates that multiple small chorioangiomas might behave like a giant chorioangioma, causing significant neonatal morbidity. This report also highlights the importance of assessing the placental histology where no identifiable cause for neonatal cardiomyopathy can be found.

Acquired cryptorchidism: an unexpected consequence of inguinoscrotal lymphatic malformation treated with Eppikajutsuto

Lymphatic malformation (LM) that causes inguinoscrotal swelling is extremely rare. Surgery, sclerotherapy and pharmacotherapy have been reported as possible treatment options for LM. Recently, Eppikajutsuto (TJ-28), a traditional Japanese herbal medicine has emerged as therapeutic option for LM. We report the case of a 2-year-old boy who presented with a left inguinoscrotal swelling, which was diagnosed as retroperitoneal LM extending into the left scrotum. The surgical approach was less favourable, given the risk of damaging the testicular vasculature or the spermatic cord. Therefore, the patient received medical treatment with TJ-28. As a result, a volume reduction of 83% was obtained, as well as the unexpected consequence of the left testicle retracting into the inguinal area. Laparoscopic exploration was performed and a small bulge on the internal inguinal ring was detected. The patient's acquired cryptorchidism was subsequently treated by orchidopexy.

Spontaneous bladder rupture secondary to posterior urethral valves in a boy with Down syndrome

We describe a case of a 3-year-old boy with Down syndrome who developed a bladder rupture as a consequence of an undiagnosed posterior urethral valve (PUV). He had a history of urinary tract infections and constipation and was acutely admitted in poor condition and underwent laparotomy that revealed peritoneal sepsis secondary to bladder perforation. Bladder was drained using a suprapubic catheter and the condition of the boy gradually improved. Once stable, a cystourethroscopy confirmed the presence of PUV. Video-urodynamic studies performed at the check cystoscopy showed the bladder to be of reduced compliance (end fill pressure at 100 mL fill 30 cmH2O) with raised voiding pressures (76-100 cmH2O) and significant incomplete bladder emptying. Currently, the patient is doing very well, serum creatinine has normalised, he is infection-free and thriving; his bladder is managed with a vesicostomy.

Delayed presentation of a baby with an oesophageal atresia on day 14 of life

Delayed presentation of oesophageal atresia (OA) with a tracheo-oesophageal fistula (TOF) is rare. Only a few case reports and two larger case series have been published. We present a neonate who was referred to our unit on day 14 of life with a missed OA and a TOF, having survived without any feeds or total parenteral nutrition up until referral.We concluded that although such a delayed presentation is rare and avoidable, it does occur. This case highlights the necessity of good feedback to the referral hospitals with education on how to prevent this from recurring again. It also emphasises the necessity of a comprehensive clinical examination of all newborn babies. A high index of suspicion for OA with or without a TOF is essential in all babies with clinical drooling, feeding problems (from the first feed) and/or respiratory symptoms especially if combined with antenatal polyhydramnios.

Meropenem-induced thrombocytopenia: a paediatric case

Meropenem is a broad-spectrum carbapenem widely used to treat both Gram-positive and negative bacterial infections, including extended-spectrum beta-lactamase-producing microbes. We describe the occurrence of thrombocytopenia and hypersensitivity in a boy receiving intravenous meropenem for intra-abdominal sepsis secondary to perforated appendicitis. The patient developed a pruritic maculopapular rash with occasional petechiae, associated with severe thrombocytopenia, after 7 days of meropenem administration. Investigations for other causes of thrombocytopenia, including possible line sepsis, were unfruitful, and the thrombocytopenia did not resolve until cessation of meropenem. Drug-induced reactions should be considered in children receiving meropenem who present with a rash and thrombocytopenia.

Spontaneous pyohaemothorax in a teenager with von Willebrand disease: a case report and review of literature

An 18-year-old man with a history of type 3 von Willebrand disease (VWD) presented with a spontaneous pyohaemothorax. Type 3 VWD may present with both mucocutaneous and deep-seated bleeds, such as visceral haemorrhages, intracranial bleeds and haemarthrosis. There have been very few cases described in children of spontaneous pyohaemothorax. Management of this patient was challenging due to risks of bleeding following surgical drainage, requiring constant replacement with von Willebrand factor concentrate, while monitoring factor VIII levels to balance the risks of thrombosis.

Bleeding duodenal ulcer with ovarian torsion-a rare presentation in neonates

Massive upper gastrointestinal bleed is an emergency in newborns. Common causes are coagulopathy and thrombocytopenia. Stress-induced duodenal ulcer has also been reported as an unusual cause for massive upper gastrointestinal bleed. Managing such cases requires correct diagnosis and prompt treatment to prevent catastrophic complications. We report a case of bleeding duodenal ulcer probably secondary to ovarian torsion.

Transient acetylcholine receptor-related myasthenia gravis, post multisystem inflammatory syndrome in children (MIS-C) temporally associated with COVID-19 infection

We report on a unique case of a 7-year-old girl with new onset ocular myasthenia gravis shortly after recovery from multisystem inflammatory syndrome in children (MIS-C) temporally associated with SARS-CoV-2 infection. The diagnosis of myasthenia gravis was based on suggestive symptoms of fatigable bilateral orbital ptosis, diplopia, positive ocular cold compression test and serum acetylcholine receptor antibody positivity, as well as a favourable treatment response to pyridostigmine. The addition of corticosteroids and methotrexate resulted in complete resolution of the ocular signs.

Severe acute inflammatory myositis and rhabdomyolysis in paediatric SARS-CoV-2-associated MIS-C (multisystem inflammatory syndrome in children)

We present the case of a 12-year-old African girl infected with SARS-CoV-2 who was admitted to a tertiary academic hospital in Johannesburg with severe acute inflammatory myositis complicated by rhabdomyolysis and acute kidney injury requiring renal replacement therapy and intensive care. She also fulfilled the diagnostic criteria for multisystem inflammatory syndrome in children.

Isolated right subclavian artery with interrupted aortic arch, ventricular septal defect and bilateral patent ductus arteriosus: a rare congenital anomaly

Isolation of the left subclavian artery or its anomalous origin from the pulmonary artery has been documented in several cases, especially in association with a right-sided aortic arch. However, similar anomaly involving the right subclavian artery has been less frequently reported. Isolated right subclavian artery in association with interrupted aortic arch (IAA) is extremely rare, and only three cases have been reported so far. Here, we have presented yet another case of isolated right subclavian artery associated with ventricular septal defect, type B IAA and bilateral patent ductus arteriosus.

Management of severe hyponatremia with low-dose continuous kidney replacement therapy and peripheral D5W in an infant with acute kidney injury

We report a 7-month-old female infant who presented with anuric acute kidney injury and severe hyponatremia (serum sodium 110 mEq/L). The patient was treated with low-dose continuous kidney replacement therapy (CKRT), that is, 85% of total clearance dose divided equally between normonatric (Na 140 mEq/L) replacement and dialysate fluids. The remaining 15% of the clearance was provided by peripheral infusion of dextrose 5% (D5W). The patient's sodium was maintained between 119 mEq/L and 121 mEq/L for the first 24 hours of CKRT. Over the next 2 days, the rate of D5W infusion was slowly decreased while replacement and dialysis flow rates were proportionately increased. Serum sodium was normalised by day 2 of the therapy. The patient had no neurologic sequelae associated with this therapy.

Recurrent cavernous sinus thrombosis: a rare complication of Cushing disease

A 14-year-old girl who presented in 2017 with headache, unilateral right eye ptosis and secondary amenorrhoea had an initial workup consistent with non-functioning pituitary macroadenoma. She underwent debulking of pituitary tumour in October 2017. Postoperatively, she developed recurrent cavernous sinus thrombosis. In view of recurrent thrombosis, she was reinvestigated and was found to have adrenocorticotropic hormone-dependent Cushing. Follow-up MRI 1 year after initial presentation showed that there was structural recurrence of pituitary macroadenoma. She subsequently underwent a petrosal craniotomy for debulking of tumour. Postsurgery she remained biochemically Cushingnoid. MRI 5 months after second surgery showed an enlarging pituitary mass which was deemed inoperable. A multidisciplinary meeting discussion consensus for treatment included radiotherapy and somatostatin analogue, pasireotide. She completed 30 cycles of radiotherapy and MRI post radiotherapy showed reduction in the size of the macroadenoma. Currently, she is waiting for pasereotide initiation.

Acquired unilateral upper limb hypertrophy as a late complication of tuberculous meningitis complicated by Chiari 1 malformation and syringomyelia

Syringomyelia associated with tuberculous meningitis (TBM) is an extremely rare condition. Only a few adult cases have been reported. A 12-year-old woman, who previously suffered TBM at the age of 6 months, presented with a long-standing history of right upper limb panhypertrophy, dissociate anaesthesia, frequent headaches, scoliosis and acquired macrocephaly. MRI demonstrated hydrocephalus, descent of the cerebral tonsils and an intramedullary syrinx extending from C2 to L1. Endoscopic third ventriculostomy (ETV) leads to reduction in the size of the syringomyelia and resolution of the thermoanaesthesia. This case highlights a very rare long-term complication associated with childhood TBM and the potential benefit offered by ETV.

Orofacial characteristics and dental management in a child with moyamoya disease

Moyamoya disease is a chronic, progressive intracranial arteriopathy. It is characterised by progressive stenosis/occlusion of distal intracranial carotid and cerebral arteries. It is associated with a high risk of ischaemic and haemorrhagic stroke. Hereditary, infectious and inflammatory factors have been found to be associated with this condition; however, its aetiology is still unclear. The estimation of disease prevalence is approximately 1.6 to 16.1 in 100 000 live births. This article presents the case of a 5-year-old girl child diagnosed with moyamoya disease, placing emphasis on the clinical and radiographic orofacial characteristics of the case and its dental management.

Complications associated with intrathecal drug delivery in a paediatric patient with Niemann-Pick type C

We report on a male subject with a diagnosis of Niemann-Pick type C (NPC). He received an experimental medicinal product intrathecally initially via lumbar puncture (LP) and eventually via intrathecal drug delivery device. Shortly after implantation, the device catheter migrated outside of the intrathecal space and coiled subcutaneously. The treatment continued via LP after removal of the device. A subdural haematoma developed after repeated LPs. It was surgically evacuated and the patient recovered with sequelae. Surgically implanted drug delivery devices are designed to bypass the blood-brain barrier and deliver a medicinal product directly into the cerebrospinal fluid circulation. Their use has extended into the field of neurodegenerative disorders. Significant adverse events can occur at any given time after implantation including neurological injury, dislodgement or displacement of any of its components, infection and drug-related complications; all can significantly affect the quality of life of patients. Repeated LPs also carry significant risk.

Haematuria without diagnosis? Think about the rare causes…

We describe a case of a 17-year-old man admitted in the emergency room with a 2-month history of intermittent macroscopic haematuria and left lumbar pain. Physical examination and vital signs were normal. Investigation indicated a recurrent non-glomerular haematuria. The Doppler ultrasound revealed a compression of the left renal vein with upstream dilatation which was subsequently confirmed by CT angiography. These findings are in keeping with a case of nutcracker syndrome (NutS). Although asymptomatic in most cases, it can be a rare cause of haematuria. The teenager was referred to paediatric nephrology and was treated conservatively with spontaneous resolution of macroscopic haematuria. With this case, we would like to highlight that in children or adolescents with haematuria without an apparent cause, a high level of suspicion and appropriate imaging are necessary for the diagnosis of NutS.

Abnormal movements and diaphragmatic flutter in a case of suspected induced illness

A 6-month-old girl presented to hospital via ambulance with a decreased conscious level (initial Glasgow Coma Scale of 3) and an abnormal breathing pattern described as diaphragmatic flutter. She then developed abnormal movements and continued to have episodes of fluctuating conscious levels so was transferred to a tertiary hospital paediatric intensive care unit for further investigation. During her 16-day stay in hospital, she continued to experience discrete episodes of drowsiness, bradycardia, unusual breathing patterns and abnormal movements which were associated with agitation, tachycardia, hypertension and insomnia. The patient underwent extensive investigation for her symptoms and, after some delay in waiting for initial results before considering a urine drug screen, she was ultimately found to have lisdexamfetamine and clonidine in her urine drug screen. Her symptoms subsequently resolved after her mother's visits were restricted.

Leucocytoclastic vasculitis secondary to COVID-19 infection in a young child

The current case report describes a 13-year-old young boy who presented with purpuric rashes following a completely asymptomatic COVID-19 infection and biopsy-confirmed leucocytoclastic vasculitis, mild haematuria and mild elevation of serum IgA. This case highlights one of the dermatological manifestations of COVID-19 infection which has not been reported so far. Paediatricians should explore the history of this infection when evaluating any child presenting with a vasculitic rash.

Unintentional ingestion of a high dose of acenocoumarol in a young child

Acute intoxication with a vitamin K antagonist may cause serious coagulopathy. We report the accidental ingestion of a high dose of acenocoumarol in a young child. Two intravenous administrations of 5 mg of vitamin K, in combination with fast and repeated administration of activated charcoal and sodium sulfate, were sufficient to prevent coagulopathy and related symptoms, despite a confirmed elevated blood acenocoumarol concentration (260 µg/L).

Gianotti-Crosti syndrome: a challenging exanthema

Gianotti-Crosti syndrome (GCS) is a self-limited condition, mainly affecting children younger than 6 years, less common in adolescents and adults. It consists of a viral exanthema with papular lesions with a flat top and symmetrical distribution, affecting predominantly extremities, gluteal region and extensor surfaces. It is often associated with viral infections but can also be related to bacterial infections, vaccination or be idiopathic. In this report, we present a case of GCS in a 13-year-old healthy female adolescent who presented with fever, odynophagia, prostration and diffuse maculopapular rash. The diagnosis of infectious mononucleosis due to infection by the Epstein-Barr virus was established. On the second week of the disease, a clinical recrudescence occurred, with worsening of the fever and modification of the exanthema characteristics. GCS is often an underdiagnosed entity. The differential diagnosis of viral exanthema can prove to be challenging and clinical suspicion is essential to achieve the diagnosis.

Complicated EBV infection in a healthy child

The Epstein-Barr virus (EBV) is highly prevalent throughout the population. Although in most cases, the infection has a good prognosis, it can cause severe complications. We report a case of a healthy child with a primary EBV infection that evolved with two rare complications. She first presented in the emergency room with fever and sore throat, and was diagnosed with tonsillitis and medicated with antibiotic. She returned 7 days later for fatigue, vomiting and abdominal pain. The examination revealed tonsillitis, swollen cervical lymph nodes and pain in the right hypochondrium. An abdominal ultrasound was performed, compatible with acute acalculous cholecystitis. She was admitted in the paediatric nursery and medicated with intravenous antibiotics. The EBV serology revealed primary infection. Two days later, she developed cardiogenic shock and had to be transferred to an intensive care unit under mechanical ventilation and inotropics. She was discharged 12 days later, keeping a moderate left ventricular dysfunction.

Hypertrophic cardiomyopathy in an extremely preterm infant

We present a case of an extreme preterm infant (Baby X) born at 24-week gestation. The echocardiogram showed evidence of hypertrophic cardiomyopathy (HCM) and a patent ductus arteriosus (PDA). There are a number of well-known causes of neonatal HCM including genetic, metabolic and endocrine. PDA is commonly present in preterm infants, and this can contribute to cardiac remodelling and result in cardiac changes mimicking HCM. Furthermore, medications such as steroids can also cause HCM through various mechanisms. A careful consideration of all the different aetiologies for HCM is important for appropriate management of such cases. This report examines the evidence in the literature for the above differential diagnoses and highlights the challenges in diagnosing the underlying cause of HCM in a preterm infant.

Miliary tuberculosis in a paediatric patient with psoriasis

We present a 16-year-old girl with a history of well-controlled psoriasis, on immunosuppression, who sought evaluation in the emergency department for 4 months of fever, cough and unintentional weight loss. The patient had seen multiple providers who had diagnosed her with community-acquired pneumonia, but she was unimproved after oral antibiotic therapy. On presentation, she was noted to be febrile, tachycardic and chronically ill-appearing. Her chest X-ray showed diffuse opacities and a right upper lobe cavitary lesion concerning for tuberculosis. A subsequent chest CT revealed miliary pulmonary nodules in addition to the cavitary lesion. The patient underwent subsequent brain MRI, which revealed multifocal ring-enhancing nodules consistent with parenchymal involvement. The patient was diagnosed with miliary tuberculosis and improved on quadruple therapy. Though rates of tuberculosis are increasing, rates remain low in children, though special consideration should be given to children who are immunosuppressed.

Unusual cause of severe iron deficiency anaemia in a child: paraoesophageal hernia

Iron deficiency anaemia is a known complication of a large hiatal hernia in adults. It occurs as a result of erosions on the gastric mucosa secondary to traction at the hiatus during respiration and/or gastric acid-related injuries to the mucosa. Even though anaemia occurs as a result of chronic gastrointestinal blood loss, testing for faecal occult blood is often negative and upper gastrointestinal endoscopy normal as the bleeding is intermittent. In children, a hiatus hernia as a rare cause of iron deficiency anaemia and has been described only in case reports. Here, we describe a 5-year-old boy who presented with severe transfusion-dependent iron deficiency anaemia caused by a paraoesophageal hernia. Surgical repair of the hiatus hernia led to complete resolution of anaemia. One should consider a hiatus hernia as a diagnostic possibility when evaluating a child with refractory iron deficiency anaemia.

Concomitant nephrotic syndrome and tubulointerstitial nephritis in a child with Epstein-Barr virus mononucleosis

Acute kidney injury (AKI) and nephrotic syndrome (NS) are uncommon manifestations of Epstein-Barr virus (EBV) mononucleosis. We report a 4-year-old boy with Infectious mononucleosis (IM) who presented with dialysis-requiring AKI and NS. Renal biopsy showed severe acute tubular necrosis, mild chronic interstitial nephritis and focal podocyte foot processes effacement. EBV early RNA was not detected in the renal tissue. However, immunophenotyping of peripheral lymphocytes showed increased cytotoxic T cell activity and increased memory B cells. Treatment with steroid led to rapid resolution of NS within 3 weeks. Renal function stabilised. EBV viral capsid antigen (VCA) IgM remained elevated until 4 months before starting to decline when VCA IgG and nuclear antigen started appearing. B lymphocytes are the predominant target cells in EBV infection and additionally may also act as antigen presenting cells to T lymphocytes, thereby eliciting the strong immune response and leading to podocyte and tubulointerstitial injury.

Novel compound heterozygous variants in the NBAS gene in a child with osteogenesis imperfecta and recurrent acute liver failure

Osteogenesis imperfecta (OI) consists of a group of genetically and phenotypically heterogeneous diseases characterised by bone fragility. Recent improvement in gene sequencing methods has helped us identify rare forms of OI that are inherited in an autosomal recessive manner. Paediatric endocrinology was consulted on a newborn girl with multiple fractures and wavy thin ribs noted on X-rays. In addition to the bone phenotype, she also has short stature and recurrent acute liver failure (ALF) episodes triggered by intercurrent illness. Whole exome sequencing revealed two novel compound heterozygous variants in neuroblastoma amplified sequence (NBAS) gene. NBAS gene codes for a protein that is involved in nonsense-mediated decay pathway and retrograde transport of proteins from Golgi to endoplasmic reticulum. Recognition of pathogenic variants in this gene as a rare cause of autosomal recessive OI and recurrent ALF has important therapeutic implications.

Hyperthermic intraperitoneal chemotherapy (HIPEC) as another treatment modality for desmoplastic round cell tumour patients: first paediatric experience from UK

We present the first young paediatric patient with desmoplastic small round cell tumour (DSRCT) treated in UK with hyperthermic intraperitoneal chemotherapy (HIPEC). A 7-year-old girl was diagnosed with abdominal DSRCT with peritoneal and liver metastases. After six cycles of chemotherapy she obtained a partial response, including almost complete resolution of the two liver metastases. It was decided to pursue cytoreductive surgery (CRS) combined with HIPEC, a procedure commonly performed in adults, but seldom in a child. The surgery was macroscopically complete and the HIPEC uncomplicated. She continued treatment without delays, including whole abdomino-pelvic radiotherapy and maintenance chemotherapy (cyclophosphamide/vinorelbine for 12 months). She is currently in complete remission 4 months after end of treatment and 26 months after diagnosis. HIPEC was made possible by successful collaboration between multiple teams. CRS-HIPEC proved to be safe and feasible and could be offered to other children with diagnoses of peritoneal malignancies across the UK.

Difficulties in diagnosing vertebral osteomyelitis in a child

Vertebral osteomyelitis is a rare diagnosis and often delayed diagnosis in children. This is a case of a child presenting with fever, back pain and raised C reactive protein who was found to have a Staphylococcus aureus (S.aureus) bacteraemia. Initial imaging with CT, MRI of the spine and abdominal ultrasound failed to demonstrate a vertebral osteomyelitis or identify another source of the bacteraemia. Due to the high clinical suspicion of a spinal source of the infection, second-line investigations were arranged. A bone scan identified an area of increase metabolic activity in the 12th thoracic vertebrae (T12) and subsequently a diagnosis was confirmed with a focused MRI of T12. This serves as an opportunity to discuss the diagnostic difficulty presented by paediatric vertebral osteomyelitis and more generally the need for clinicians to pursue their clinical suspicion in the face of false negative results to make an accurate and timely diagnosis.

Cutaneous larva migrans in a young child following circumrotation as a cultural ritual

Cutaneous larva migrans is an acquired, self-limited infestation caused by cat hookworm, Ancylostoma braziliense, and dog hookworm, A. caninum The disease is acquired by direct contact with contaminated soil. Circumrotation is a religious ritual practised by devotees of Hinduism as a fulfilment of vows taken at the shrine and involves rolling over with uncovered upper body on the sand over a distance of up to 600 m. It is a reported mode of acquisition of cutaneous larva migrans infestation. The authors report a 10-year-old boy who acquired cutaneous larva migrans on his right forearm after circumrotation. The forearm is an unusual site for this infestation, and most reported cases had lesions on the feet, thighs and buttocks following either sitting or playing on contaminated soil. The child made complete recovery following treatment with albendazole for 1 week.