Online Exclusives
Pulmonary artery pseudoaneurysm after MRSA septicemia in a pediatric patient
We document a previously unreported case of a pulmonary artery pseudoaneurysm (PAP) that developed in a pediatric patient initially presenting with Methicillin-resistant Staphylococcus aureus hip joint sepsis. This is the first reported case of PAP of infectious origin in a pediatric patient, and this case is unique as the evolution of the PAP was documented by computed tomography.Clostridium septicum gas gangrene in a previously healthy 8-year-old female with survival
We present the only reported case of an immunocompetent pediatric patient in the literature to have fulminate gas gangrene of the lower extremity and concomitant gastrointestinal tract infection due to Clostridium septicum coinfected with Clostridium difficile colitis respectively. The patient survived with aggressive medical and surgical treatment.Traumatic disruption of the abdominal wall: Lap-belt injuries in children
Traumatic abdominal wall hernia (TAWH) from high speed mechanism is a unique finding in adult trauma, and exceedingly rare in pediatrics. The majority of reports are of low-speed “handlebar” hernias associated with direct injury by bicycle handlebars. We report a series of three pediatric patients in motor vehicle collisions (MVC) who experienced TAWH by lap-belt and associated intra-abdominal injuries necessitating immediate operative intervention. Different operative approaches were used in each case to manage the varying types of disruptions.Infected urachal cyst secondary to a Crohn's enterourachal fistula
Enterourachal fistulas are exceedingly rare in Crohn's patients. We report a case of a presumed enterourachal fistula that led to an infected urachal cyst. Preoperative medical treatment obliterated the fistula and avoided the need to resect bowel at the time of operation. We recommend consideration of this diagnosis in a Crohn's patient with a midline abdominal mass.Angiodysplasia (vascular malformations) of the colon presenting as an acute abdomen
Angiodysplasia (vascular malformations) of the colon is extremely rare in children, and, as in adults, present with lower gastrointestinal hemorrhage. Here we report an unusual pediatric case of angiodysplasia of the terminal ileum and cecum presenting as an acute abdomen with radiological features suggestive of lymphoma.Retroperitoneal lipoblastoma: A discussion of current management
Retroperitoneal lipoblastomas are rare tumors found in young pediatric patients. Despite their large size at presentation, complete resection is usually achieved with minimal complications. Diagnosis is typically made after pathologic examination of the operative specimen, and cytogenetic analysis may be a key component in differentiating lipoblastoma from other lipomatous tumors. We present one such case of a large, retroperitoneal lipoblastoma and discuss the management of this uncommon entity.An unusual case of small bowel obstruction in a child caused by ingestion of water-storing gel beads
Foreign body ingestion occurs most commonly in the pediatric population. Small bowel obstruction is a rare complication that can occur, and surgical intervention is required. We present the first report of a case of an 18-month-old child with a jejunal obstruction caused by ingestion of water-storing gel beads used for botanical arrangements. The child presented with obstipation and nonbloody, nonbilious emesis. Symptoms resolved after a large bead 3 cm in diameter was retrieved via laparoscopic-assisted excision.Successful use of extracorporeal membrane oxygenation for acute respiratory failure in a patient with chronic granulomatous disease
A 9-year-old boy presented with pneumonia, bilateral pulmonary lesions, and fulminant respiratory failure requiring support with extracorporeal membrane oxygenation (ECMO). Open lung biopsy and subsequent bronchoscopy identified Nocardia cyriacigeorgica and Burkholderia cepacia pneumonia. Chronic granulomatous disease (CGD) was diagnosed by an abnormal neutrophil oxidative burst assay. An aggressive diagnostic and therapeutic strategy, which included ECMO, allowed for patient survival and return to baseline function.Schwannoma of the diaphragm—a pediatric case report and review of the literature
Diaphragmatic tumors are uncommon and difficult to diagnose in the pediatric population. Schwannoma is a benign, slow-growing peripheral nerve sheath tumor that is most commonly associated with the extremities in childhood. We herein report a schwannoma of the diaphragm in a pediatric patient and review the pediatric literature.Pediatric synchronous bilateral ovarian torsion: a case report and review of the literature
Ovarian torsion is a surgical emergency that can present with a variety of symptoms and hence is difficult to diagnose. We present the first case of a pediatric synchronous bilateral ovarian torsion in ovaries without pathology and review its presentation, diagnosis, treatment, outcome, and the associated literature.Papillary carcinoma with extensive squamous metaplasia arising from thyroglossal duct cyst in an 11-year-old girl: significance of differentiation from squamous cell carcinoma: a case report
We report a case of papillary carcinoma (PC) with extensive squamous metaplasia arising from a thyroglossal duct cyst (TDC) that required differential diagnosis from squamous cell carcinoma (SCC). An 11-year-old Japanese girl presented with a 9-month history of an anterior-midline neck mass that was clinically diagnosed as TDC. Open neck biopsy revealed nested proliferation of atypical squamous cells within the cystic structures, and SCC arising from TDC was initially suspected. Further examination, however, including immunohistochemistry, revealed the tumor to be of thyroid cell origin.Dangerous deliveries: lessons learned during retroperitoneal specimen retrieval
Laparoscopy is now a standard technique in pediatric surgery and urology. Unique complications have been reported during port/instrument insertion and dissection, often relating to issues of visibility or working space. Complications during specimen retrieval are currently unreported. We describe our experience of 2 serious complications occurring during attempted retrieval of a specimen through a port site at the end of the laparoscopic procedure.Unresectable multifocal omental and peritoneal inflammatory myofibroblastic tumor in a child: revisiting the role of adjuvant therapy
Inflammatory myofibroblastic tumor is an uncommon lesion, also called pseudotumor, with a variable natural course from benign with spontaneous regression to mimicking malignant tumors. We report a case of diffuse peritoneal and omental pseudotumor in a 10-year-old boy characterized by aggressive behavior at the onset followed by stability after subtotal resection and chemotherapy. Total excision was not possible because of the tumor dissemination over the whole peritoneal surface. Adjuvant antiinflammatory drug (ketorolac tromethamine) and chemotherapy (methotrexate-vinblastine followed by ifosfamide-adriamycin and ifosfamide alone) were helpful to obtain rapidly complete resolution of clinical symptoms and anatomic stability of the residual lesions.Minimally invasive colopexy for pediatric Chilaiditi syndrome
Chilaiditi syndrome is a rare disorder characterized by abdominal pain, respiratory distress, constipation, and vomiting in association with Chilaiditi's sign. Chilaiditi's sign is the finding on plain roentgenogram of colonic interposition between the liver and diaphragm and is usually asymptomatic. Surgery is typically reserved for cases of catastrophic colonic volvulus or perforation because of the syndrome. We present a case of a 6-year-old boy who presented with Chilaiditi syndrome and resulting failure to thrive because of severe abdominal pain and vomiting, which did not improve with laxatives and dietary changes.Diagnosis and laparoscopic treatment of ileoileal intussusception secondary to heterotopic pancreas in an infant: case report and review of the literature
Small bowel intussusception in infancy owing to a pathologic lead point is a rare event requiring immediate surgical attention. We report a case of a 7-month-old patient presenting with ileoileal intussusception with isolated heterotopic pancreas as the lead point. We review the literature of small bowel intussusception focusing on diagnosis and treatment. In contrast to comparable previous reports of infants with heterotopic pancreas and intussusception, the diagnosis was based solely on ultrasound findings followed by operative management using a laparoscopically assisted surgical approach.Excision of extensive metastatic dysgerminoma to control refractory hypercalcaemia in a child at high risk for tumour-lysis syndrome
Hypercalcaemia is a rare life-threatening complication of paediatric cancer that is commoner in haematological than solid malignancies and associated rarely with acute renal failure. Often refractory to medical therapy, control of hypercalcaemia in children with solid tumours may necessitate excision of localised tumours or urgent chemotherapy for metastatic ones. We present a child with refractory hypercalcaemia, bulky chemosensitive metastatic tumours and acute renal failure in whom chemotherapy posed high-risk of tumour lysis syndrome (TLS).Cervical esophageal duplication cyst: case report and review of the literature
Cervical esophageal duplication cysts are rare congenital anomalies that can be successfully managed surgically. These anomalies are rare causes of upper airway obstruction. We present here a case of a cervical esophageal duplication cyst in an infant, along with a review of the literature concerning this anomaly.Giant ossifying malignant thymoma in a child
We present the first reported case of an ossifying pediatric thymoma. Our patient was diagnosed with a massive thymoma replacing the whole of the left thoracic cavity. Percutaneous biopsy was attempted 3 times followed by an open incisional biopsy and adjuvant chemotherapy. Complete resection required a median sternotomy and a “trap door” thoracotomy after the tumor failed to respond to chemotherapy. Histology confirmed World Health Organization type B1 lymphocyte-rich thymoma, Masaoka stage I, with extensive osseous metaplasia.Use of gauze-based negative pressure wound therapy in a pediatric burn patient
Negative pressure wound therapy (NPWT) is described as it is used in the treatment of an infant burn victim. This case highlights the ability and techniques used to maintain an airtight dressing seal in the perirectal region. Use of this dressing type post–skin grafting allowed for 100% graft adhesion and no bacterial contamination despite close proximity to the rectum. Favorable experience and outcome with this patient are strong indicators that NPWT should be considered as a viable treatment in pediatric populations and that situations where body contour or fluids may make NPWT difficult to administer should not be a deterrent to therapy.Galactocele: an unusual cause of breast enlargement in children
Galactoceles in children, either cystic or pseudotumors, are described in the literature as a rare cause of increasing breast size and can appear in males. We report a case of galactocele in a 15-month-old male, treated at our institution. The patient presented with a tumor in the right breast that had appeared 6 months earlier with no pain, signs of inflammation, or nipple secretion. Twelve cases found in the literature emphasize the importance of including galactocele in the differential diagnosis of benign breast masses in infancy.Successful embolization of a delayed splenic rupture following trauma in a child
Delayed rupture of the spleen following trauma is an exceedingly rare phenomenon in children. In the case we have experienced, arterial embolization was successfully performed, surgery was avoided, and functional splenic tissue was preserved. Embolization is of value in the management of blunt splenic injuries in hemodynamically stable children, even after delayed rupture. The exact criteria for its use remain to be established.Mesenteric lipoblastoma presenting as a segmental volvulus
Mesenteric lipoblastoma is a rare tumor and, its presentation as a bowel obstruction with possible midgut volvulus has only been reported once before. A 7-year-old girl presented with nausea and vomiting but a benign abdominal examination. Upper gastrointestinal contrast study demonstrated possible malrotation with midgut volvulus. During emergency laparotomy, segmental small bowel volvulus secondary to a large mesenteric lipoblastoma was found. The lipoblastoma was resected with a segment of small bowel.Mesenteric lipoblastoma: a rare location in children
Lipoblastoma is a rare childhood tumor composed of embryonic fat. It is benign and most often presents in children younger than 3 years. These tumors primarily present as a rapidly enlarging mass in the extremities or trunk with abdominal lipoblastomas comprising less than 10% of all reported cases. Abdominal lipoblastomas are most commonly found in the retroperitoneum with less than 15 reported cases arising in the mesentery. We report the unusual presentation of a lipoblastoma arising in the mesentery of a 3-year-old boy.Asymmetric development of tumor-like cysts in a child with autosomal dominant polycystic kidney disease
We report a case of asymmetric development of tumor-like cysts in a child with autosomal dominant polycystic kidney disease (ADPKD). The preliminary considerations were renal cell carcinoma and Wilms' tumor. After open biopsy, the patient was diagnosed with ADPKD with atypical renal cyst development. The development pattern of renal cysts in children with ADPKD is varied, and open biopsy is sometimes needed.Primary hepatic carcinoid tumor in children
Primary carcinoid tumors of the liver are rare, with fewer than 60 cases currently reported in the English literature. We present the evaluation and management of a solid hepatic tumor in a 14-year-old boy. Intraoperative biopsy was indeterminant for malignant potential, and the patient underwent complete resection by left hepatic lobectomy. Final histopathologic evaluation of the mass revealed a carcinoid tumor. Extensive endoscopic and radiologic workup revealed no other primary source. The patient recovered well from surgery and is currently free of disease 32 months after initial resection.Wilms' tumor, pancreatic islet cell carcinoma, and pheochromocytoma in a child
We present the first case of Wilms' tumor, pancreatic islet cell carcinoma, and pheochromocytoma affecting the same individual. This case underscores the importance of repeat biopsies in patients with multiple neoplasms to confirm the diagnosis and guide management.Combined living-related segmental liver and bowel transplantation for megacystis-microcolon-intestinal hypoperistalsis syndrome
Megacystis-microcolon-intestinal hypoperistalsis syndrome (MMIHS) is the most severe form of functional intestinal obstruction in the newborn. To date, multivisceral transplantation has been the only accepted treatment modality for these patients, and the results have met with marginal success. We report the first case of a patient affected by MMIHS and cholestatic liver failure treated by a combined living-related liver and intestinal transplant (CLRLITx).Pacifier-induced bowel obstruction—not so soothing
Pacifiers are nearly ubiquitous among children in the United States, and although safety regulations exist, the responsibility to choose and maintain a safe pacifier generally falls on the parents, many of whom are unaware of potential hazards. We report a case of a complete bowel obstruction because of an ingested pacifier nipple and recommend increased awareness among practitioners as well as education of parents.An unusual case of neuroblastoma with angiomatoid features
Neuroblastoma is the most commonly occurring solid tumor in children. Most of these neoplasms are diagnosed within the first few years of life. The diagnosis of neuroblastoma may be difficult because of its ability to arise in different locations, its propensity to metastasize, and variable clinical signs and symptoms. Therefore, accurate and timely pathologic diagnosis is imperative. Herein, we present the rare description of an angiomatoid neuroblastoma. Only 1 other case has been previously reported.Continuous hyperthermic peritoneal perfusion for desmoplastic small round cell tumor
Desmoplastic small round cell tumor (DSRCT) is a rare disease of children, adolescents, and young adults that begins and spreads on the peritoneal surfaces. Desmoplastic small round cell tumor usually presents with diffuse abdominal metastatic disease similar in gross appearance to carcinomatosis. To date, very aggressive treatment programs have yielded dismal outcomes. Here we present 2 cases of DSRCT that were treated with aggressive surgical excision followed by intraoperative continuous hyperthermic peritoneal perfusion using cisplatin.Thoracoscopic aortopexy for primary tracheomalacia in a 12-year-old
Aortopexy is the therapeutic modality of choice for severe primary tracheomalacia. The thoracoscopic approach has been used with good results in infants and toddlers, but little information exists on the use of aortopexy in older children. We present the case of a boy with a lifelong history of refractory, a steroid-dependent reactive airway disease, and who was found to have severe primary tracheomalacia. He subsequently underwent thoracoscopic aortopexy with immediate resolution of the tracheomalacia as demonstrated by serial bronchoscopy and long-term resolution of his clinical respiratory symptoms at 1 year.Tracheal diaphragm: a very unusual form of congenital tracheal stenosis
A 3.2-kg newborn was intubated for neonatal respiratory distress owing to a congenital tracheal stenosis. The preoperative assessment showed a sphincter-like stenosis located 1 cm above the carina. The child was cured by resection-anastomosis through sternotomy under cardiopulmonary bypass. The pathological examination showed hypoplastic cartilage islets embedded in a fibroelastic conjunctive tissue. The posterior membranous region was preserved with the existence of smooth muscle cells. This curious malformation resembled a diaphragm at the junction between trachea and carina.Treatment of toxic epidermal necrolysis in a pediatric patient with a nanocrystalline silver dressing
To report a case of toxic epidermal necrolysis (TEN) involving 90% body surface area, successfully treated with a nanocrystalline silver dressing (Acticoat, Smith & Nephew, Largo, FL).Traumatic duodenal necrosis with avulsion of Vater's papilla in a child
Blunt duodenal trauma with avulsion of the papilla of Vater is an extremely uncommon injury in children. The usual management of these injuries relies on complex reconstructive procedures and bypasses. We report the case of a 6-year-old girl with near total traumatic duodenal necrosis and avulsion of Vater's papilla managed by a simple physiological montage avoiding pancreatic resections and gastrointestinal bypasses.Multiple injuries diagnosed using full-body digital x-ray
Missed injuries in patients with multiple trauma are primarily attributable to inadequate radiography. A case is presented that demonstrates the value of a full-body digital radiography system in diagnosing pathology in pediatric multiple trauma patients. Full-body imaging allowed the identification of a ruptured diaphragm, a pelvic fracture, and a femoral fracture on a single radiographic projection in the resuscitation room, facilitating immediate intervention.Total laparoscopic left lateral sectionectomy performed in a child with benign liver mass
Despite the increasing number of recent reports on laparoscopic liver resection in adults, there are only rare reports on such a procedure being performed in children. The authors report here on a total laparoscopic left lateral sectionectomy that was performed in a 5-year-old girl who had a cystic tumor of the liver. The operative time was 150 minutes, the estimated blood loss was about 100 mL, and no intraoperative transfusion was required. The patient was discharged on postoperative day 11 without any significant complications.Horner syndrome due to first rib fracture after major thoracic trauma
A case of Horner syndrome diagnosed during the follow-up after major thoracic trauma is presented in this report. A 10-year-old boy was admitted to the emergency service with severe thoracic trauma with left clavicular and first rib fracture after a traffic accident. During the follow-up, myosis and ptosis were recognized in his left eye. Cranial tomography and neurological examination were all normal. The symptoms were thought to be caused by compression of the local hematoma to the cervical ganglia.Elevated plasma vascular endothelial growth factor levels in 2 patients with hemangioendothelioma
Two patients with hemangioendothelioma and elevated plasma vascular endothelial growth factor (VEGF) levels are presented. A reduction in the plasma VEGF level after therapeutic intervention correlated with a successful clinical response. Conversely, a stable plasma VEGF level correlated with therapeutic failure.Exhaust system burn injuries in children
The authors had noted a number of children who had sustained burn injuries from the exhaust systems of recreational vehicles and wished to document the incidence of pediatric burn injury sustained from the exhaust systems of a wide scope of motorized vehicles.Obstruction of the proximal jejunum by an anomalous congenital band—a case report
A case of proximal jejunal obstruction by a congenital band is reported. The band ran from the antimesenteric wall of the proximal jejunum just distal of the Treitz's ligament to the root of the mesentery. Lysis of the band and enterotomy were performed to make sure no intrinsic obstruction cured the patient. No recurrence was found after 3 months of follow-up. To the best of the authors' knowledge, this is the second case with an anomalous congenital band causing proximal jejunal obstruction reported in the English-language literature.
