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Two boys with the clinical and radiographic picture of acute tropical pyomyositis of the short external rotators of the hip were treated surgically followed by parenteral antibiotics (Figure 1). Intraoperatively, no pus was found. Histopathology specimens from 1 patient demonstrated small foci of degenerative changes and necrosis without evidence of infection (Figure 2). Prior to decompressing the muscle in the second patient, intramuscular pressure was measured and found to be significantly elevated. Surgical decompression was performed and both patients fully recovered after a course of intravenous antibiotics. Tropical pyomyositis' clinical presentation is often insidious with a variable course accounting for its frequent missed or late diagnosis. Often the illness progresses through three stages - invasive, suppurative, and late. Patients progress from a diffuse muscle inflammation to abscess formation and sepsis. Staphylococcus aureus is responsible for the infection in >75% of the cases. The quadriceps, iliopsoas, and gluteal muscles are most commonly affected. Multiple reports addressed the optimal treatment of tropical pyomyositis. Traditionally, surgical treatment was advocated. However, there are reports of successful nonsurgical or minimally invasive treatment. Based on our experience, it is suggested that the sequence of events in the development of tropical pyomyositis is an initial insult such as vigorous exercise, leading to elevated compartment pressure, resulting in a compartment syndrome. If simultaneous bactermia occurs, the vulnerable muscle is seeded with the infectious organism and abscess formation follows. That may explain other authors' findings that early aspiration, combined with antibiotic treatment, may be sufficient to decompress the muscle, prevent abscess formation and result in full recovery. [ABSTRACT FROM AUTHOR]

Two siblings aged 5 and 15 years from Connecticut were hospitalized with petechial rash, oral mucositis, and severe thrombocytopenia approximately 10 days after they played with a jar of elemental mercury they found in their home. Before the mercury exposure was disclosed, the siblings were treated with platelet transfusions, intravenous immune globulin (IVIG) for possible immune thrombocytopenic purpura, and antibiotics for possible infectious causes. When their conditions did not improve after 6 days, poison control facilitated further questioning about toxic exposures including mercury, testing for mercury, and chelation with dimercaptosuccinic acid. The older sibling soon recovered, but the younger child required a prolonged hospitalization for severe thrombocytopenia, ultimately receiving repeated doses of IVIG, steroids, and romiplostim, a thrombopoietin receptor agonist. Close collaboration among multiple agencies was required to identify the extent of mercury contamination, evaluate and treat the other family members, and decontaminate the home. These cases demonstrate the importance of ongoing public health outreach to promote early detection of elemental mercury toxicity, and the need to evaluate for environmental exposures when multiple close contacts experience similar signs and symptoms., Competing Interests: All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.

Competing Interests: Declaration of interests We declare no competing interests.

Dermatologists reported an outbreak of pernio (red to purple swollen painful toes) during the COVID-19 pandemic. Most subjects lacked positive CoV-19 polymerase chain reaction (PCR) or antibodies or a preceding illness. The dermatologists termed the illness "COVID toes." Pernio usually affects adults versus "COVID toes" usually children. Pernio is preceded by a clear history of exposure to wet and cold. Patients with "COVID toes" lack this history. Also, it is not unusual for multiple family members to have "COVID toes." Our case report describes "COVID toes" in an 18-year-old with no preceding illness, a negative SARS-CoV-19 PCR, and an initially negative SARS-CoV-19 antibody, and also his 2 siblings also developed "COVID toes." In our index case, repeat SARS-CoV-19 antibodies were positive. Seroconversion has rarely been reported in patients with "COVID toes." Why most "COVID toes" patients lack a clinical history of COVID-19 and are SARS-CoV-19 PCR and antibody negative is a mystery., Competing Interests: The author has no funding or conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome is the most common periodic fever syndrome in children. The disease appears to cluster in families, but the pathogenesis is unknown. We queried two European-American cohorts and one Turkish cohort (total n = 231) of individuals with PFAPA for common variants previously associated with two other oropharyngeal ulcerative disorders, Behçet's disease and recurrent aphthous stomatitis. In a metaanalysis, we found that a variant upstream of IL12A (rs17753641) is strongly associated with PFAPA (OR 2.13, P = 6 × 10 -9 ). We demonstrated that monocytes from individuals who are heterozygous or homozygous for this risk allele produce significantly higher levels of IL-12p70 upon IFN-γ and LPS stimulation than those from individuals without the risk allele. We also found that variants near STAT4 , IL10 , and CCR1-CCR3 were significant susceptibility loci for PFAPA, suggesting that the pathogenesis of PFAPA involves abnormal antigen-presenting cell function and T cell activity and polarization, thereby implicating both innate and adaptive immune responses at the oropharyngeal mucosa. Our results illustrate genetic similarities among recurrent aphthous stomatitis, PFAPA, and Behçet's disease, placing these disorders on a common spectrum, with recurrent aphthous stomatitis on the mild end, Behçet's disease on the severe end, and PFAPA intermediate. We propose naming these disorders Behçet's spectrum disorders to highlight their relationship. HLA alleles may be factors that influence phenotypes along this spectrum as we found new class I and II HLA associations for PFAPA distinct from Behçet's disease and recurrent aphthous stomatitis., Competing Interests: Competing interest statement: F.D. is a consultant to Novartis and receives royalties from UpToDate. K.M.E. is on the Data Safety and Monitoring Board for Seqirus, Pfizer, Sanofi, Moderna, and X4 Pharma, and serves as an advisor to Bio-Net and Merck. P.F.W. is on the scientific advisory boards for GlaxoSmithKline, Sanofi-Pasteur, and Meissa Vaccines., (Copyright © 2020 the Author(s). Published by PNAS.)

Human granulocytic anaplasmosis (HGA) is a tick-borne infection, characterized as an acute and sometimes severe febrile illness which may be associated with leukopenia and thrombocytopenia. Most case reports of HGA have been in adults, with only 8 case reports of HGA in children. We add a ninth case of HGA, which occurred in a 5-year-old. The paucity of pediatric HGA case reports maybe because publication bias, or HGA in children is a mild illness and children with HGA are less likely than adults to seek medical care, or the diagnosis of HGA requires a blood draw and adults (versus children) are more likely to get diagnostic testing. The 9 case reports in children suggest that pediatric HGA is usually a mild infection and that doxycycline and rifampin are effective therapies. Like adults, children with HGA frequently present with fever, headache, and malaise; however, children are more likely than adults to have abdominal pain as a prominent complaint., (Copyright © 2017 Elsevier Inc. All rights reserved.)

A previously well infant aged 9 months presented with an acute, self-limiting illness characterised by high fever and a papular eruption that started on the face. Although fever subsided within 3 days, the rash worsened and extended over the whole body, with some papules evolving into vesiculobullous lesions. The infant had been exposed to children with a similar illness 1 week before onset. PCR of vesicular swabs and stool samples taken on day 6 of illness showed Coxsackie virus A6. The illness resolved within 10 days of onset, although onychomadesis was seen on both big toes at follow-up 5 weeks later. Our case exemplifies the severe, atypical cases of hand, foot, and mouth disease that have been reported worldwide since 2008, and in the USA since the 2011. Atypical hand, foot, and mouth disease is caused by a new lineage of Coxsackie virus A6 and is characterised by high fever and vesiculobullous eruptions on the calves and backs of the hands. Infants with eczema might be predisposed to severe disease., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Kikuchi disease is a self-limited disorder of unknown etiology characterized by focal painful lymphadenitis, fever, and weight loss that can be mistaken for malignancy. Diagnosis is established by node biopsy. Kikuchi disease is endemic in Asia; 10 cases have been reported in the US to date. We report 3 cases and review other US cases., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Overall, 3% to 19% of travelers to the developing world will return to the United States with fever or will develop fever within weeks of their return. When evaluating the returning traveler with fever, it is important to know which pretravel immunizations the patient received; which medications he or she took during travel; the likely pathogen exposures during travel; and the incubation interval between travel and onset of fever. A physical examination that includes a search for focal findings may narrow the list of possible infections. Fever compatible with a common illness that occurs in the United States (e.g., mononucleosis) should always be considered. If the patient has fever without a focus and a tropical infection is suspected, malaria, dengue fever, and typhoid fever are common causes. These infections may appear clinically similar, with symptoms of fever, headache, muscle pain, joint pain, and malaise, and decreased white blood cell and platelet counts. Malaria can usually be diagnosed with a thin blood smear. Dengue fever is a clinical diagnosis. Serologic testing for dengue virus immunoglobulin M and G and virus detection tests can be performed to confirm the diagnosis, but are not immediately available. Typhoid fever can usually be diagnosed with a blood, urine, or stool culture.

Rabies has the highest case fatality of any infectious disease. Pathobiological and clinical insights have questioned the assertion that death is inevitable after onset of acute encephalomyelitis. Relying upon national laboratory-based surveillance, we reviewed records of human rabies acquired in the United States during 1960-2009. Changes in the epidemiology of human rabies were notable, due to improved animal management, safer and more efficacious biologics, and revisions in prevention guidelines. Historically, domestic animals were the most important source of infection. Since the 1990s, more human cases were associated with rabid bats. Prior to 1980, postexposure prophylaxis failures were reported. After development of modern rabies immune globulin and vaccines, none occurred. Of 75 human cases identified, only four patients survived. Rabies remains an extremely high consequence zoonosis, but the disease is not uniformly fatal, per se. Rabies is essentially preventable when primary exposures are averted, or appropriate prophylaxis occurs before illness.

The most common clinical manifestation of Lyme disease is the characteristic rash, erythema migrans (EM). In the 1980s EM-like eruptions were reported in Missouri and other southeastern states. The EM-like eruptions, which were of unknown etiology, often followed the bite of the Lone Star tick (Amblyomma americanum) and the rash is called STARI (southern tick-associated rash illness). Although the Lone Star tick is found in the Lyme disease-endemic areas of New England and Mid-Atlantic regions of the United States, STARI has been reported only once from the Northeast and Mid-Atlantic regions. We report a child from Connecticut who visited Long Island, New York, and developed a rash that was thought to be EM. Because the patient failed to respond to antibiotics used to treat Lyme disease, an investigation ensued, and the diagnosis of STARI was established.

Objective: To determine how frequently Connecticut primary care physicians are diagnosing and treating patients with chronic Lyme disease., Study Design: A survey was mailed to a random 33% sample of primary care physicians in Connecticut, which asked how many cases of Lyme disease and chronic Lyme disease they diagnosed and treated in the last 3 years., Results: The survey had a response rate of 39.1%. Physician respondents (n = 285) fit in one of 3 groups. Group 1 included 6 of 285 (2.1%) physicians who diagnose and treat patients with chronic Lyme disease. Group 2 included 137 of 285 (48.1%) physicians who are undecided on the existence of chronic Lyme disease, but did not diagnose or treat any patients with chronic Lyme disease. Group 3 included 142 of 285 (49.8%) physicians who do not believe in the existence of chronic Lyme disease., Conclusion: A small percentage (2.1%) of primary care physicians diagnose and treat patients for presumed chronic Lyme disease., (Copyright © 2010 Mosby, Inc. All rights reserved.)

We describe a case of polyoma virus hemorrhagic cystitis in a nonimmunosuppressed child. Polyoma virus infection was suspected because of abnormal urine cytology. Polyoma virus cystitis in nonimmunosuppressed children is self-limited, resolving spontaneously within 2 weeks.

This article reviews pediatric Lyme disease in the United States. The agent of Lyme disease includes three pathogenic species (Borrelia burgdorferi, B afzelii, and B garinii), but only B. burgdorferi strains are found in the United States. The article's discussion is limited to the single species B burgdorferi.

Methicillin-resistant Staphylococcus aureus (MRSA) infections have become more common over the last decade. Recently, severe MRSA infections including necrotizing pneumonia, purpura fulminans, and rapidly progressive skin abscesses have been reported. These severe infections frequently have been associated with the virulence factor Panton-Valentine leukocidin (PVL). Two unusual cases of occult deep tissue abscesses in children who had family members with a history of severe MRSA skin abscesses are presented in this article. Both children initially presented with fever without a focus. Deep tissue MRSA (PVL positive) abscesses evolved. Empiric antibiotic therapy for MRSA should be considered for infants and children who are hospitalized with occult fever and who have a family member with a history of MRSA infection.

Most patients with erythema migrans, the pathognomonic rash of Lyme disease, do not recall a deer tick bite. The rash is classically 5 to 68 cm of annular homogenous erythema (59%), central erythema (30%), central clearing (9%), or central purpura (2%). Serologic testing is not indicated for patients with erythema migrans, because initially, the result is usually negative. Successful treatment of a patient with erythema migrans can be accomplished with 20 days of oral doxycycline, amoxicillin, or cefuroxime axetil. Patients with Lyme arthritis usually present with a mildly painful swollen knee. Patients with Lyme arthritis have markedly positive serology and can usually be successfully treated with 28 days of oral doxycycline or amoxicillin. Some patients may have persistent effusion despite 4 to 8 weeks of antibiotics and may need synovectomy. Persistent effusion is not due to persistent infection. Antibiotic therapy for more than 8 weeks for patients with Lyme disease is not indicated. Chronic Lyme disease due to antibiotic resistant infection has not been demonstrated.

Objective: Patients and families searching the Internet about Lyme disease may find conflicting information. Our purpose was to review the accuracy of information on Lyme disease easily available on the Internet., Methods: We used 15 search engines to find general information about Lyme disease. We found 251 Lyme disease websites, which we reviewed. Of these 251 websites, 19 gave general Lyme disease information and were analyzed. We evaluated the accuracy of information concerning 8 Lyme disease topics., Results: Ten of the 19 websites gave accurate information and 9 of the 19 websites provided inaccurate information. There were 8 websites with the word "Lyme" in the domain name, and 7 of the 8 sites gave inaccurate information. There were 2 ".gov" websites, and both gave accurate information., Conclusions: Patients and families searching the Internet for medical information about Lyme disease may encounter inaccurate information.

In normal infants and children, zoster can occur at any time after varicella or varicella vaccination. It is usually diagnosed clinically: a unilateral vesicular eruption following a dermatome or dermatomes. The incidence of zoster increases with age, although children who have had varicella during the first year of life (or in utero) are at increased risk of developing zoster. The incidence of zoster is less after varicella vaccination than after natural infection. Zoster in children is frequently mild, postzoster neuralgia rarely if ever occurs, and antiviral therapy is usually not needed. In a previously normal child with zoster, if the history and physical examination are normal, a laboratory search for occult immunodeficiency or malignancy is not needed. We present five cases of zoster in healthy children and review zoster in the pediatric age group.

We used multiparameter flow cytometry to characterize leukocyte immunophenotypes and cytokines in skin and peripheral blood of patients with erythema migrans (EM). Dermal leukocytes and cytokines were assessed in fluids aspirated from epidermal suction blisters raised over EM lesions and skin of uninfected controls. Compared with corresponding peripheral blood, EM infiltrates were enriched for T cells, monocytes/macrophages, and dendritic cells (DCs), contained lower proportions of neutrophils, and were virtually devoid of B cells. Enhanced expression of CD14 and HLA-DR by lesional neutrophils and macrophages indicated that these innate effector cells were highly activated. Staining for CD45RO and CD27 revealed that lesional T lymphocytes were predominantly Ag-experienced cells; furthermore, a subset of circulating T cells also appeared to be neosensitized. Lesional DC subsets, CD11c(+) (monocytoid) and CD11c(-) (plasmacytoid), expressed activation/maturation surface markers. Patients with multiple EM lesions had greater symptom scores and higher serum levels of IFN-alpha, TNF-alpha, and IL-2 than patients with solitary EM. IL-6 and IFN-gamma were the predominant cytokines in EM lesions; however, greater levels of both mediators were detected in blister fluids from patients with isolated EM. Circulating monocytes displayed significant increases in surface expression of Toll-like receptor (TLR)1 and TLR2, while CD11c(+) DCs showed increased expression of TLR2 and TLR4; lesional macrophages and CD11c(+) and CD11c(-) DCs exhibited increases in expression of all three TLRs. These results demonstrate that Borrelia burgdorferi triggers innate and adaptive responses during early Lyme disease and emphasize the interdependence of these two arms of the immune response in the efforts of the host to contain spirochetal infection.

We report 2 cases of Haemophilus parainfluenzae endocarditis and review 34 cases of HACEK endocarditis from the literature. HACEK organisms are the most common cause of Gram-negative endocarditis in children. They have a propensity to form friable vegetations (especially H. parainfluenzae) that break off and cause symptomatic emboli. HACEK endocarditis (from a review of the 36 published cases) may involve previously normal hearts (33%), may be complicated by embolization (31%) and may require vegetectomy or other surgery (31%). Mortality with HACEK endocarditis was 14%. HACEK organisms may be resistant to penicillins but are susceptible to third generation cephalosporins.

Practice guidelines have been published for the treatment of Lyme disease (LD). These guidelines have been challenged as inadequate. Two common LD management problems are antibiotic prophylaxis of deer tick bites (deer ticks may carry Borrelia burgdorferi, the spirochete that causes LD) and antibiotic treatment of erythema migrans, the pathognomonic rash of LD. A 1-page questionnaire was sent to a 13% (573/4300) sample of Connecticut physicians to define how they treat deer tick bites and erythema migrans. Questionnaires were returned by 320 (56%) of 573 physicians. Questionnaires were analyzed for the 267 physicians who saw patients with LD. Seventy (26%) of the 267 surveyed physicians prescribed antibiotic prophylaxis for patients with tick bites. B burgdorferi serology was ordered by 31% of physicians for patients with tick bites. Most surveyed physicians treated erythema migrans with doxycycline or amoxicillin for a mean of 21 days. Serology was ordered by 49% of physicians for patients with erythema migrans. Most physicians did not use prophylaxis for patients with deer tick bites. In addition, most of the physicians surveyed followed established guidelines for treating patients with erythema migrans. However, many of the physicians surveyed do serologic testing for patients with tick bites and/or erythema migrans. Serologic testing for these patients is usually not necessary.

Methicillin-resistant Staphylococcus aureus (MRSA) infections are an emerging problem in children. The following are 2 case reports of unsuspected MRSA infections: the first is an infant with cervical adenitis and the second is a child with a deep infection of the toe. Both patients failed outpatient therapy with oral cephalosporins and required hospitalization for surgical drainage. Both patients had cultures positive for MRSA at surgery. Neither patient had any risk factors for acquiring MRSA. Thus, outpatients with presumed staphylococcal infections who fail oral therapy with cephalosporins may be infected with MRSA.

Periodic fevers (fevers that occur predictably at fixed intervals) are unusual in infants and children. The classic periodic fever syndrome is cyclic neutropenia (neutropenia followed by infections and fever that recur every 21 days). A new periodic fever syndrome PFAPA (periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis) has been characterized over the past decade. PFAPA is defined clinically, because specific laboratory abnormalities have not been found. The clinical characteristic of PFAPA is high fevers (usually 40.0 degrees C to 40.6 degrees C) recurring at fixed intervals every 2 to 8 weeks. The fevers last for about 4 days, then resolve spontaneously. Associated with the fevers are aphthous stomatitis in 70% of patients, pharyngitis in 72% of patients, and cervical adenitis in 88% of patients. PFAPA is not familial and begins before the age of 5 years. An episode of PFAPA can be aborted with one or two small doses of prednisone. The episodes of PFAPA may last for years and the patient is well between episodes. The cause of PFAPA is unknown and there are no reported sequelae.

Background and Objective: A recombinant lipoprotein vaccine against Lyme disease, containing 30 microg of Borrelia burgdorferi outer surface protein A (OspA) with aluminum adjuvant, has been shown in a large US field trial of subjects >/=15 years of age to offer 76% efficacy against clinical Lyme disease after 3 injections given at 0, 1, and 12 months. Lyme disease is also an important problem in children; thus, OspA vaccine trials in children are needed. The purpose of this study was to investigate the safety and immunogenicity of 2 different doses of lipoprotein OspA with aluminum adjuvant vaccine in healthy children 5 to 15 years of age in a double-blind, randomized study., Study Design: In a double-blind study, 250 children from the Czech Republic were randomly assigned to receive 15 microg or 30 microg of OspA vaccine at 0, 1, and 2 months. Serum samples, obtained before vaccination and 1 month after the second and third doses, were analyzed for antiOspA antibody. Solicited and unsolicited symptoms were collected from diary cards., Results: Local pain at the injection site was reported by approximately 76% of the 250 children. Headaches (after 5% to 18% of the injections) and malaise (after 2% to 16% of the injections) were the most frequently reported general symptoms. Local and generalized symptoms were not different between the 15 microg and 30 microg groups, and all symptoms resolved within 4 days. Both doses were highly immunogenic, with the 30 microg dose eliciting higher antibody levels. Seroconversion occurred in 99% of the 250 children., Conclusions: The OspA vaccine against Lyme disease was well tolerated and highly immunogenic in children.

Objectives: To describe the presentation, clinical course, therapeutic response, and long-term follow-up of patients with a syndrome of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA)., Study Design: Patients with PFAPA (n = 94) referred over a 10-year period completed a registry form and provided medical records. Follow-up telephone calls were made in late 1997 to determine the persistence of episodes and sequelae., Results: PFAPA episodes lasted 4.8 days (95% confidence interval 4.5 to 5.1) and recurred every 28 days (confidence interval 26 to 30), with a maximal temperature of 40.5 degrees C (confidence interval 40. 4 degrees to 40.6 degrees ). Of the 83 children available for follow-up, 34 no longer had episodes. In the remainder the episodes did not differ in character but recurred less frequently over time. The affected children had no long-term sequelae. Glucocorticoids were highly effective in controlling symptoms. Tonsillectomy and cimetidine treatment were associated with remission in a small number of patients., Conclusions: PFAPA is a not uncommon cause of periodic fever in children. In some children the syndrome resolves, whereas symptoms in others persist. Long-term sequelae do not develop. The syndrome is easily diagnosed when regularly recurring episodes of fever are associated with aphthous stomatitis, pharyngitis, or cervical adenitis.

Objective: An orally administered antimicrobial regimen for the treatment of group A beta-hemolytic streptococcal (GABHS) pharyngitis given once rather than multiple times each day would be more convenient and might result in improved patient compliance. The purpose of this study was to evaluate the effectiveness of once-daily amoxicillin in the treatment of GABHS pharyngitis., Patients: Children presenting to a private pediatric office with GABHS pharyngitis., Design: Patients were randomly assigned to receive orally either amoxicillin (750 mg once daily) or penicillin V (250 mg three times a day) for 10 days. Compliance was monitored by urine antimicrobial activity., Outcomes: Outcomes were measured by impact on the clinical course, eradication of GABHS within 18 to 24 hours, and bacteriologic treatment failure rate as determined by follow-up throat cultures 4 to 6 and 14 to 21 days after completing therapy. GABHS isolates were serotyped to distinguish bacteriologic treatment failures (same serotype as initial throat culture) from new acquisitions (different serotypes)., Results: During the 16 months of this study, 152 children between 4 and 18 years of age (mean, 9.9 years) were enrolled; 79 children were randomly assigned to receive once-daily amoxicillin and 73 were assigned to receive penicillin V three times a day. The children in the two treatment groups were comparable with respect to age, duration of illness before initiation of therapy, compliance, and signs and symptoms at presentation. There was no significant difference in the clinical or bacteriologic responses of the patients in the two treatment groups at the 18- to 24-hour follow-up visit. Bacteriologic treatment failures occurred in 4 (5%) of the 79 patients in the amoxicillin group and in 8 (11%) of the 73 patients in the penicillin V group., Conclusions: These data demonstrate that once-daily amoxicillin therapy is as effective as penicillin V therapy given three times a day for the treatment of GABHS pharyngitis, and if confirmed by additional investigations, once-daily amoxicillin therapy could become an alternative regimen for the treatment of this disease.