Patient: Female, 16-year-old
Final Diagnosis: Multiple sclerosis
Symptoms: Blurry vision
Medication: —
Clinical Procedure: Lumbar puncture • magnetic resonance imaging
Specialty: Ophthalmology
Objective:
Rare co-existance of disease or pathology
Background:
Internuclear ophthalmoplegia (INO) presents as a disruption of horizontal conjugate ocular movement and is an uncommon finding in the pediatric population. Its presence warrants a thorough evaluation to search for demyelinating, mass effect, inflammatory, or infectious etiologies.
Case Report:
A 15-year-old African American girl presented to the Emergency Department with acute horizontal binocular diplopia in left gaze. An ophthalmic examination revealed a right INO. She denied any fever, chills, or neck stiffness. Complete blood counts and a metabolic panel were unremarkable. Magnetic resonance imaging (MRI) of the brain and orbits revealed scattered pontine, periventricular, and subcortical white matter signal abnormalities within the left frontal lobe suggestive of active demyelination. MRI of the spinal column also demonstrated multiple areas of increased signal intensity from the C3 to C7–T1 region. Inflammatory and autoimmune studies were negative. However, her serum IgM and IgG studies were positive for
Borrelia burgdorferi
with negative CSF titers. Cerebrospinal fluid (CSF) analysis demonstrated mildly elevated glucose (82 mg/dL) and oligoclonal bands, but was otherwise unremarkable. She was started on intravenous methylprednisolone and ceftriaxone. She was subsequently diagnosed with pediatric-onset multiple sclerosis and started on disease-modifying therapy, with full resolution of diplopia and INO 2 weeks later.
Conclusions:
We present a case of INO presenting as the first manifestation of multiple sclerosis in a pediatric patient with a concurrent infectious etiology. A thorough evaluation can lead to earlier identification and treatment of underlying diseases.
BackgroundConcussion is defined as aberrant brain function consequent to traumatic injury characterized by disorientation or loss of consciousness or memory. If concussions are not recognized and treated appropriately, they can cause significant morbidity. Because ∼20% of sports-related concussions occur in juveniles, pediatricians must be able to treat this injury. Our primary objective was to assess the comfort and competence of pediatric residents in managing patients with concussions. Secondary objective was to assess the change in the In-Training Examination (ITE) scores after instituting a novel multimodal concussion curriculum.MethodFrom February to June 2019, all pediatric residents (N = 24) were required to complete a multimodal concussion curriculum, including board review-style questions, lectures, and rotation in a concussion clinic. Residents voluntarily participated in a pre-and post-curriculum survey. ITE scores from 2018 and 2019 were compared.ResultsTwenty-three of 24 (96%) residents completed both pre- and post-curriculum surveys; of those, 17 (74%) had matched identifiers. Most residents (82%) want more education about concussion management. Residents’ scores on knowledge-based questions increased an average of 0.64 questions, with PGY-1 showing the most improvement. The proportion of residents who correctly answered the ITE head injury/concussion questions increased from 0.33 to 0.88. The concussion clinic was identified as the most helpful tool.ConclusionTo better educate pediatric residents about concussions, we propose a unique multimodal curriculum. We found improved self-assessed comfort and performance on knowledge-based questions and the ITE. We recommend that pediatric and other residency training programs consider implementing this type of curriculum.
PURPOSE OF THE STUDY. With previous observational data, researchers have suggested an association between the frequent use of acetaminophen and possible asthma-related complications in children. The authors of this study specifically address this, evaluating the number of asthma exacerbations in children who received acetaminophen versus ibuprofen for fever or pain alleviation.
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