Streptococcus intermedius is a member of the Streptococcus anginosus group of bacteria. This group is part of the normal flora of the oropharynx, genitourinary, and gastrointestinal tracts; however, they have been known to cause a variety of purulent infections including meningitis, endocarditis, and abscesses, even in immunocompetent hosts. In particular, S. intermedius has been associated with the development of liver and brain abscesses. There have been several case reports of S. intermedius liver abscesses with active periodontal infection. To our knowledge, however, there has not been a case following a routine dental procedure. In fact, the development of liver abscesses secondary to dental procedures is very rare in general, and there are only a few case reports in the literature describing this in relation to any pathogen. We present a rare case of S. intermedius bacteremia and liver abscess following a dental cleaning. This case serves to further emphasize that even routine dental procedures can place a patient at risk of the development of bacteremia and liver abscesses. For this reason, the clinician must be sure to perform a detailed history and careful examination. Timely diagnosis of pyogenic liver abscesses is vital, as they are typically fatal if left untreated.
Mesalamine-containing products are often a first-line treatment for ulcerative colitis. Severe adverse reactions to these products, including cardiovascular toxicity, are rarely seen in pediatric patients. We present a case of a 16-year-old boy with ulcerative colitis treated with Asacol, a mesalamine-containing product, who developed sudden onset chest pain after four weeks on therapy. Serial electrocardiograms showed nonspecific ST segment changes, an echocardiogram showed mildly decreased left ventricular systolic function with mild to moderate left ventricular dilation and coronary ectasia, and his troponins were elevated. Following Asacol discontinuation, his chest pain resolved, troponins were trending towards normal, left ventricular systolic function normalized, and coronary ectasia improved within 24 hours suggesting an Asacol-associated severe drug reaction. Mesalamine-induced cardiovascular toxicity, although rare, may represent a life-threatening disorder. Therefore, every patient presenting with acute chest pain should receive a workup to rule out this rare drug-induced disorder.
Improved survival in children with hypoplastic left heart syndrome has created a sub-population of children and young adults who are living with functionally univentricular physiology. Routine surveillance with comprehensive screening for structural cardiac disease, functional cardiac disease, arrhythmias, thromboembolic disease, and associated dysfunction of end organs is important. Future directives will better define the plans of care for routine surveillance in patients with hypoplastic left heart syndrome.
BACKGROUND: Inflammatory Bowel Diseases (IBD) are rising in incidence in the pediatric population. While most present classically, some have limited findings. We present a case of pediatric Crohn's Disease (CD) diagnosed during a fever of unknown origin (FUO) evaluation. We aim to stress the importance of uncommon presentations of a diagnosis with significant implications and requiring prompt intervention. CASE: A 6-year-old male presented with 2 weeks of evening 104–106 F fevers, weakness, decreased intake, and weight loss. He also had one loose, non-mucous, non-bloody stool daily. Fevers failed to resolve with outpatient courses of antibiotics and CRP continued to rise. History revealed camping in North Carolina 2 weeks preceding symptom onset. Family history was unremarkable. No further symptoms, including abdominal pain, were elicited. Exam exhibited fever, tachycardia, tachypnea, uvular and palatal ulcers, dry mucous membranes, cervical, submandibular and inguinal lymphadenopathy. No skin, eye, joint, perianal or abdominal findings observed. Preliminary labs showed hypoalbuminemia (2.6), elevated CRP (7.4) and ESR (55), mild leukocytosis (14.9), and microcytic anemia (Hgb 10.1, MCV 71.8). An extensive FUO evaluation failed to identify a source and thus imaging was pursued. CT abdomen/pelvis showed terminal ileitis and free fluid along the right paracolic gutter and right hepatic margin. Endoscopic evaluation for IBD discovered esophagitis along with ulcerations, edema and friable mucosa in the terminal ileum. Pathology was significant for active chronic lymphoplasmacytic gastritis with eosinophils and subtle early granulomatous inflammation with multinucleated giant cells. Distal esophagus showed chronically active inflammation and lymphocytic esophagitis without granulomas. Terminal ileum biopsy revealed active, chronic granulomatous ileitis with ulceration and granulation. No organisms noted throughout. He was diagnosed with CD and initiated on steroids along with Mesalamine. DISCUSSION: One quarter of IBD is diagnosed by the age of 20, with 4% presenting before 5 and 18% before 10 years of age. Recent incidence reports show combined U.S. and Canadian data of 10 per 100,000. Prevalence in the U.S. alone is 100–200 per 100,000. Furthermore, IBD in those less than ten is becoming more common. With recent therapeutic advances, significant morbidity and mortality is preventable. However, treatment delays occur from a diagnostic lag in 20% when symptoms are ambiguous. This case highlights early onset IBD and brings attention to non-classic presentations. Our patient was diagnosed 1.5 months after initial symptoms. An average diagnosis lag time of about 3.4 months in pediatric CD has been documented, with further delay if pre-existing gastrointestinal symptoms exist (26 months). Whereas CD is considered when abdominal pain, diarrhea, and weight loss are identified, our patient presented with daily fever along with oral lesions, lymphadenopathy and weight loss. A few case reports cite FUO, another difficult and often unclear diagnosis, as the presentation for IBD. Fever as the sole initial symptom for IBD occurs in 10-15% of cases. IBD is a complicated illness, especially in the pediatric population. When considering effects on growth, psychosocial development and the long-term complications, we must consider IBD in the differential of pediatric patients with vague and persistent symptoms including FUO.
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