Abstract Proceedings EROC 2011 - New York Osteopathic Medical ...

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EROC 2011 Abstract Proceedings – March 4, 2011 Dept. of Emergency Medicine, Good Samaritan Hospital Medical Center, West Islip, NY Title: PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Strep) Authors: Andrew Mapley DO, Jonathan Golden MD, Steven Sattler DO, Mikhail Mirer MD Emergency Medicine Residency Program, Good Samaritan Hospital Medical Center, West Islip, NY Introduction: Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS) can present as a variety of neuropsychiatric complaints such as obsessivecompulsive behavior or involuntary muscle movements. First described in 1998 by Swedo et. al, PANDAS is becoming an increasingly recognized diagnosis and should be understood by physicians caring for pediatric patients. Case description: This case is that of a 3 year old male brought to the emergency department by his parents with a primary complaint of “twitching and jerking” of hands and neck. The parents do not recall any febrile illness, sore throat, skin rash or joint pain. No other significant symptoms or past medical history reported. On exam, the patient is generally well appearing and has involuntary movements of head, neck and choreiform movements of his extremities. The remainder of the physical exam was unremarkable. Laboratory and radiographic testing was unremarkable with the exception of a grossly elevated ASO titer. Discussion: PANDAS, first described in 1998, has been well studied over the past ten years without significant elucidation in the understanding of the mechanism behind the disorder. Researchers believe that the process is an autoimmune condition triggered by Group A Beta Hemolytic Streptococcal (GABHS) infections, such as Strep throat or Impetigo, similar to the mechanism of rheumatic fever. Considered a clinical diagnosis, the diagnosis of PANDAS can be made by ruling out other etiologies of a patient’s symptoms or by confirming exposure to recent streptococcal infection. In order to make the clinical diagnosis, the following criteria should be met: presence of OCD or tic disorder onset of symptoms between 3 years of age and puberty episodic course of the symptom severity association with strep infection association with neurological abnormalities Treatment of children with PANDAS is still controversial and should be managed by a pediatric neurologist. 38
EROC 2011 Abstract Proceedings – March 4, 2011 Dept. of Emergency Medicine, Good Samaritan Hospital Medical Center, West Islip, NY Title: GBS: Making the Connection Author: Chantel O’Shea DO, David Levy DO, Sara Arzt DO, Sandra Deniz MD Emergency Medicine Residency Program, Good Samaritan Hospital Medical Center, West Islip, NY Introduction: We present a case report of a patient who developed Group A streptococcus (GAS) peritonitis from as ascending infection of her genitourinary tract. Case description: A 34 year old female presented to the emergency department with fever, dizziness, and lower abdominal pain. She had foul smelling urine and a slight vaginal discharge. Her only sick contact was her husband who had a pharyngitis diagnosed several weeks prior. Her vital signs were T: 102.2°F, P: 115, BP: 96/65. She appeared comfortable and had an exam significant for lower abdominal tenderness and mild cervical motion tenderness. The patient received a fluid bolus and acetaminophen with improvement of her fever and tachycardia. She had a WBC count of 11.2 with 39 bands. Other labs and transvaginal sonogram were normal. CT of the abdomen and pelvis showed a bowel ileus without obstruction and a small amount of pre-sacral fluid. She was given antibiotics and was taken to the OR for an exploratory laparoscopy where a large amount of intra-abdominal purulent material was found; without obvious source of infection. Blood cultures, intra-abdominal cultures and vaginal cultures were all positive for Group A Streptococcus. The patient denied any recent infections, but stated her husband had a confirmed Group A Streptococcal pharyngitis. The patient later admitted that they had engaged in oral sex while he was ill. Discussion: GAS is well known to be associated with a variety of human illnesses, including invasive disease associated with high morbidity and mortality. The organism is not, however, considered part of the normal vaginal flora. Therefore, genitourinary tract colonization serving as a reservoir for GAS as a sole causative organism leading to ascending infection, bacteremia, and invasive disease is distinctly unusual. We speculate that her husband was the initial reservoir and transmitted the organism to the patient through genital contact with oral secretions. 39
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