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Quiz: Can you diagnose these muscle spasms in a 19-year-old-male? | Image Credit: © daqota - © daqota - stock.adobe.com.

Quiz: Can you diagnose these muscle spasms in a 19-year-old-male?

Take this Contemporary Pediatrics quiz, and see if you can correctly diagnose the patient in this case study. Submit your answer to see if you were correct.

William A. Frese, MD, MPH

11-year-old boy with testicular pain and rash

An 11-year-old boy presented to the emergency department complaining of left testicular pain for 2 days, described as intermittent and stabbing, which ranged between 5 and 8 of 10 in intensity. Read the full case to see if you can correctly diagnose the patient.

Newborn with midline neck lesion | Image Credit: Author provided

Newborn with midline neck lesion

A 4-day-old boy with a midline neck lesion was born at term by normal vaginal delivery. After birth, mid line lesion had the configuration of a linear cleft with a cephalocaudal orientation, extending from the level below the hyoid bone to the suprasternal notch with a length of 2.5 cm and a width of 0.5 cm. What's the diagnosis?

A 13-year-old girl with welldemarcated rash on back and chest | Image Credit: © Author provided - © Author provided  - stock.adobe.com.

A 13-year-old girl with well-demarcated rash on back and chest

A healthy 13-year-old girl presented with a 1-month history of an asymptomatic, well-demarcated rash on her back and upper chest. The eruption consisted of discrete, dark brown papules that coalesced into large, flat-topped plaques with mild superficial scale and accentuation of skin markings. What's the diagnosis?

Suspicious facial swelling in a 22-month-old girl | Image Credit: © moonlightfever - © moonlightfever - stock.adobe.com.

Suspicious facial swelling in a 22-month-old girl

A 22-month-old female patient with sickle cell disease on folic acid and penicillin prophylaxis with a 3-day history of nasal congestion, rhinorrhea, fever and decreased oral intake presents to the emergency department (ED) for acute facial swelling noted when she woke up from a nap. What's the diagnosis?

Friction-induced blistering on a child’s feet

Friction-induced blistering on a child’s feet

You are called to the hospital nursery to evaluate a healthy full-term newborn boy who developed painful flaccid blisters and erosions on the tops of his feet and ankles shortly after birth. His mother had a history of similar recurrent skin lesions that healed with scarring. She also had oral and gastrointestinal tract involvement. What's the diagnosis?

Hypothermia and abnormal eye movements in a 5-week-old infant | Image Credit: © Bostan Natalia- © Bostan Natalia - stock.adobe.com.

Hypothermia and abnormal eye movements in a 5-week-old infant

A 5-week-old female infant born at 38 weeks presents to her pediatrician with abnormal eye movements. What’s the diagnosis?

Neonate experiences coffee ground emesis | Image Credit: © Vojtech Vlk - © Vojtech Vlk - stock.adobe.com.

Neonate experiences coffee ground emesis

The infant did not show signs of illness; her mother experienced a routine pregnancy and prenatal lab test results were normal. What is the diagnosis?

Muscle spasms in a 19-year-old male

Muscle spasms in a 19-year-old male

A 19-year-old male presents to the emergency department (ED) with headache and fever of 4 days’ duration. Six days earlier, his left palm had been punctured by a rusty nail. What's the diagnosis?

Treating an 18-month-old who tested positive for cannabis exposure

Treating an 18-month-old who tested positive for cannabis exposure

As more and more states legalize recreational marijuana, caregivers need to be vigilant about keeping products out of reach of children.

Scalp thickening and folding in a pubertal boy

Scalp thickening and folding in a pubertal boy

A 16-year-old boy with developmental delay and intellectual disability developed dramatic chronic wrinkling of his scalp over a year ago. The lesions were persistent but not symptomatic. What's the diagnosis?

Worsening acne after isotretinoin treatment in an adolescent girl

Worsening acne after isotretinoin treatment in an adolescent girl

A healthy 17-year-old girl with inflammatory acne had failed to respond to topical tretinoin, benzoyl peroxide, and oral minocycline. What's the diagnosis?

Psychosis in an 18-year-old male

Psychosis in an 18-year-old male

Alex, an 18-year-old male, presented to the emergency department with a 4-day history of paranoia, agitation, and disorganized behavior. He had no psychiatric history or prior mental health contact and no known medical conditions.

Congenital hypopigmented macules on a healthy child

Congenital hypopigmented macules on a healthy child

You are asked to evaluate an African American boy aged 4 years with a birthmark on his back and right arm. He is healthy with normal growth and development. What's the diagnosis?

Just a little birthmark?

Just a little birthmark?

You are asked to evaluate a healthy 1.5-day-old girl who has a congenital red patch with coarse telangiectasias and a surrounding ring of pallor on the right shoulder. What's your diagnosis?

Can intranasal corticosteroids improve obstructive sleep apnea syndrome in children?

Can intranasal corticosteroids improve obstructive sleep apnea syndrome in children?

A study featured at CHEST 2022 investigated INCS in children with OSAS to determine if the therapy improved their symptoms, polysomnography findings, behavior, and quality of life.

Case of inflammatory acne or something else?

Case of inflammatory acne or something else?

This case study analyzes variants of majocchi granuloma and potential treatment.

A case of late-onset group B Streptococcus infection in fraternal twins

A case of late-onset group B Streptococcus infection in fraternal twins

A 29-year-old White woman presented to the labor and delivery unit due to preterm premature rupture of membranes and delivered twins. The twins were transferred to the neonatal intensive care unit following delivery.

Bilateral blurry vision in a 9-year-old boy

Bilateral blurry vision in a 9-year-old boy

A 9-year-old boy with no significant medical history presented to the emergency department with 2 days of painless blurry vision. What's the diagnosis?

A case of shin guard dermatitis?

A case of shin guard dermatitis?

A healthy 14-year old boy was evaluated for an intensely pruritic shin rash that developed 2 weeks prior and had been treated with oral antibiotics for 10 days.

journal club

A renal anomaly? Look for a Müllerian anomaly as well

A retrospective study found that postmenarchal women with a renal anomaly were also at risk of having a Müllerian anomaly.

A case of progressive joint pain and rash in a 5-year-old

A case of progressive joint pain and rash in a 5-year-old

A 5-year-old nonverbal boy with autism spectrum disorder and global developmental delay presented to the emergency department with bilateral lower-extremity bruising and progressive difficulty ambulating. What's the diagnosis?

Fever and facial swelling in a neonate

Fever and facial swelling in a neonate

An 18-day-old girl whose right cheek had become increasingly red and warm over 24 hours was directly admitted to an inpatient unit. She had firmness and pain to the affected area, fussiness, increased sleeping, and poor feeding, preferring the bottle to breastfeeding. What's the diagnosis?

Altered mental state in a 2-year-old boy

Altered mental state in a 2-year-old boy

A 26-month-old boy presents for mild altered mental status and balance issues following a fall the day before. There was no loss of consciousness or vomiting but he subsequently complained of left-sided head pain. What's the diagnosis?

Painful red lumpy leg

Painful red lumpy leg

A healthy 4-year-old boy presents with painful deep-seated bumps on the front of his right leg. He also complains of a sore throat for the last 4 days. What's the diagnosis?

Severe hemorrhage from infantile hemangioma

Severe hemorrhage from infantile hemangioma

A 5-month-old girl with a large scalp infantile hemangioma (IH), present since 6 weeks of age, is evaluated in the emergency department for lethargy and pallor.

Generalized, eruptive lichen planus in a pediatric patient

Generalized, eruptive lichen planus in a pediatric patient

A healthy 14-year-old boy presented at our dermatology practice with acute onset of an intensely itchy rash that first appeared 2 months prior.

Annular scars with hyperpigmentation

Annular scars with hyperpigmentation

An 18-month-old girl presents with ringed scars with hyperpigmentation on the right side of her buttocks and back. What's the diagnosis?

Lower-extremity nodules in a 2-year-old girl

Lower-extremity nodules in a 2-year-old girl

A 2-year-old girl presents with an itchy, bilateral leg rash. Additionally, the child had several bruises that felt like "hard welts" and were warm to the touch. What's the diagnosis?

Persistent foot and leg swelling in a 17-year-old female

Persistent foot and leg swelling in a 17-year-old female

A 17-year-old girl presents with a 2-year history of unilateral swelling of the left lower extremity as well as a poorly healed ankle sprain of the affected extremity 3 years prior that slowly resolved but left persistent swelling. What's the diagnosis?

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The condition, lessons for the clinician, poster presentations:, section editor’s note, suggested readings, case 5: a 13-year-old boy with abdominal pain and diarrhea.

AUTHOR DISCLOSURE

Drs Sudhanthar, Okeafor, and Garg have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

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Anjali Garg , Sathyan Sudhanthar , Chioma Okeafor; Case 5: A 13-year-old Boy with Abdominal Pain and Diarrhea. Pediatr Rev December 2017; 38 (12): 572. https://doi.org/10.1542/pir.2016-0223

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A 13-year-old boy presents to his primary care provider with a 5-day history of abdominal pain and a 2-day history of diarrhea and vomiting. He describes the quality of the abdominal pain as sharp, originating in the epigastric region and radiating to his back, and exacerbated by movement. Additionally, he has had several episodes of nonbloody, nonbilious vomiting and watery diarrhea. His mother discloses that several family members at the time also have episodes of vomiting and diarrhea.

He admits to decreased oral intake throughout the duration of his symptoms. He denies any episodes of fever, weight loss, fatigue, night sweats, or chills. He also denies any hematochezia or hematemesis. His medical history is significant for a ventricular septal defect that was repaired at a young age, but otherwise no other remarkable history.

During the physical examination, the adolescent is afebrile and assessed to be well hydrated. Examination of the abdomen reveals tenderness in the epigastric region and the right lower quadrant on light to deep palpation, with radiation to his back on palpation. There are no visible marks or lesions on his abdomen. Physical examination is negative for rebound tenderness, rovsing sign, or psoas sign. The remainder of the examination findings are negative.

Complete blood cell count, liver enzyme levels, pancreatic enzyme levels, and urinalysis results are all within normal limits.

Our patient was asked to observe his hydration status and pain at home and to report any changes. However, he arrived at the emergency department the next day due to increased severity of abdominal pain. The pain had localized into the right lower quadrant. Further imaging revealed the diagnosis.

The differential diagnosis for an adolescent who presents with abdominal pain is broad, including gastrointestinal causes such as gastroenteritis, appendicitis, or constipation and renal causes such as nephrolithiasis or urinary tract infections. With our patient, the more plausible answers were ruled out through laboratory studies and physical examination, and he was assumed to have gastroenteritis based on the history of similar symptoms in his family members. However, with the worsening of his abdominal pain, further diagnostic study became imperative and a computed tomographic (CT) scan of the abdomen was obtained to assess for appendicitis or nephrolithiasis.

The CT scan showed a cecum located midline; the large intestine was on the left side of the abdomen, and the small intestine was on the right ( Figs 1 and 2 ). The appendix was buried deep in the right pelvis, and there was no indication of appendicitis. These findings were consistent with intestinal malrotation. Intestinal malrotation is rare beyond the first year of life. Maintaining a higher index of suspicion in any patient with an acute presentation of severe abdominal pain is imperative because of the severity of potential complications such as bowel obstruction, volvulus, and eventual necrosis. Our patient’s pain is assumed to have been due to compressive effects of the peritoneal bands (Ladd bands), which were irritated by an initial gastroenteritis. He did not have the signs or symptoms of a more severe complication, such as bowel obstruction or volvulus.

Figure 1. Computed tomographic scan of the abdomen showing intestinal malrotation, specifically of the subtype nonrotation. The small bowel is present in the right hemi-abdomen and the large bowel in the left hemi-abdomen. The cecum is midline in the pelvis. Haustra are still present, excluding any sign of obstruction.

Computed tomographic scan of the abdomen showing intestinal malrotation, specifically of the subtype nonrotation. The small bowel is present in the right hemi-abdomen and the large bowel in the left hemi-abdomen. The cecum is midline in the pelvis. Haustra are still present, excluding any sign of obstruction.

Figure 2. Swirling appearance of the mesentery is known as the whirl sign, which is also indicative of malrotation. This computed tomographic scan shows the superior mesenteric vein wrapped around the superior mesenteric artery.

Swirling appearance of the mesentery is known as the whirl sign, which is also indicative of malrotation. This computed tomographic scan shows the superior mesenteric vein wrapped around the superior mesenteric artery.

Owing to the severity of the pain, our patient was taken for surgery, specifically, a Ladd procedure and a prophylactic appendectomy. Ladd bands were seen to extend from the cecum to above the duodenum. During the procedure, these bands were lysed, then the mesentery was spread out, and the bowels were rearranged. He tolerated the surgery well and was discharged 3 days after the operation.

His abdominal pain improved after surgery, and he has been doing well at his postoperative checks.

Intestinal malrotation is when the intestines fail to rotate properly in utero. From the fifth to 10th weeks of embryologic development, the small intestine lies in the right aspect of the abdomen, with the ileocecal junction midline, and the large intestine in the left hemi-abdomen. The segments are then pushed out of the abdomen into the umbilical cord. Both segments grow in the first stage of rotation. During the second stage of rotation, the small intestine rotates counterclockwise 270 degrees around the superior mesenteric artery. The remaining intestine is pulled into the abdomen, and the mesentery is fixed to the retroperitoneal space. The large intestine comes in last, with the final segment of the cecum lying anterior to the small intestine in the right lower quadrant.

Nonrotation is the most frequent cause of intestinal malrotation. Nonrotation occurs when the 270-degree rotation does not occur and, thus, the mesentery is not fixed to the retroperitoneal space. Derangements of the second stage of rotation are defined as having the small intestine in the right hemi-abdomen, with the cecum midline in the pelvis, and the large intestine in the left hemi-abdomen.

One percent of the population has intestinal rotation disorders. The incidence decreases with age. Approximately 90% of patients are diagnosed within the first year of their life, with 80% among them within the first month after birth. Due to a delay in diagnosis, the 10% of patients who present beyond that first year after birth can have severe complications.

Symptoms of malrotation are different in infants compared with adolescents. Neonates typically will have bilious emesis. In contrast, children and adults commonly exhibit acute abdominal pain. Some older patients have had chronic abdominal pain that goes unnoticed; others may be asymptomatic before diagnosis. The co-occurrence of intestinal malrotation with congenital cardiac anomalies is a common finding. Twenty-seven percent of intestinal malrotation patients were found to have a concurrent cardiovascular defect such as ventricular septal defect or another minor/major abnormality.

The diagnostic modality of choice is an upper gastrointestinal tract contrast study. This study modality shows any obstruction and depicts the malrotation through contrast media. Sometimes a contrast medium is not needed for diagnosis, as in the case of our patient, where CT scanning was enough to diagnose the malrotation.

Asymptomatic neonates and all symptomatic individuals, regardless of age, go through the Ladd procedure to correct the abnormality. However, the guidelines are not as clear for treatment of children older than 1 year who are asymptomatic. Currently, there is some consensus for performance of the procedure regardless of symptom status because of the severity of the complications or mortality that can occur due to malrotation. The narrow pedicle of the mesentery that forms in malrotation is prone to volvulus and ischemia, leading to complications at any point in an individual’s life. A diagnostic laparoscopy should be performed at the very least and can be therapeutic as well. Removal of the appendix has been suggested to prevent any diagnostic complications on future presentation. Additionally, the Ladd procedure can lyse Ladd bands, which are abnormal fibrous adhesions from the cecum that also arch over the duodenum. Removal of these bands is imperative because they can cause intestinal obstruction and ischemia as well.

Diagnosis of intestinal malrotation should be considered in a patient presenting acutely with severe abdominal pain, especially in a patient with known cardiac anomalies.

Often the symptoms of intestinal malrotation can be vague, and a patient can be asymptomatic for years before presentation.

The diagnostic modality of choice is an upper gastrointestinal tract series, but other imaging, such as computed tomographic scan, can help diagnose the presence of malrotation in emergency situations.

A Ladd procedure should be conducted on a patient even if he/she does not have current symptoms of obstruction due to increased risk of obstruction or complications such as volvulus and gut necrosis with this disease.

This case is based on a presentation by Ms Anjali Garg and Drs Sathyan Sudhanthar and Chioma Okeafor at the 39th Annual Michigan Family Medicine Research Day Conference in Howell, MI, May 26, 2016.

Poster Session: Student and Resident Case Report Poster Presentation

Poster Number: 23

This case is based on a presentation by Ms Anjali Garg and Drs Sathyan Sudhanthar and Chioma Okeafor at the 2016 AAP National Conference and Exhibition in San Francisco, CA, October 22-25, 2016.

Poster Session: Section on Pediatric Trainees Clinical Case Competition

Abdominal Pain in Children: https://www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/Abdominal-Pain-in-Children.aspx

Diarrhea: https://www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/Diarrhea.aspx

For a comprehensive library of AAP parent handouts, please go to the Pediatric Patient Education site at http://patiented.aap.org .

This case was selected for publication from the finalists in the 2016 Clinical Case Presentation program for the Section on Pediatric Trainees of the American Academy of Pediatrics (AAP). Ms Anjali Garg, BS, was a medical student from Michigan State University College of Human Medicine, East Lansing, MI, when she wrote this case report, and she now is a medical resident at Rainbow Babies and Children's Hospital in Cleveland, OH. Choosing which case to publish involved consideration of not only the teaching value and excellence of writing but also the content needs of the journal. Other cases have been chosen from the finalists presented at the 2017 AAP National Conference and Exhibition and will be published in 2018.

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  1. Case Studies

    11-year-old boy with testicular pain and rash. William A. Frese, MD, MPH. January 19th 2024. An 11-year-old boy presented to the emergency department complaining of left testicular pain for 2 days, described as intermittent and stabbing, which ranged between 5 and 8 of 10 in intensity. Read the full case to see if you can correctly diagnose the ...

  2. Case 9-2021: A 16-Year-Old Boy with Headache, Abdominal Pain

    Dr. Neil D. Fernandes (Pediatrics): A 16-year-old boy was admitted to this hospital because of headache, nausea, vomiting, and abdominal pain. The patient had been well until 17 months before this...

  3. Case 5: A 13-year-old Boy with Abdominal Pain and Diarrhea

    A 13-year-old boy presents to his primary care provider with a 5-day history of abdominal pain and a 2-day history of diarrhea and vomiting. He describes the quality of the abdominal pain as sharp, originating in the epigastric region and radiating to his back, and exacerbated by movement.