LEARN Paediatrics EASY

Torticollis (Wry Neck) :

Torticollis is an abnormal head posture caused by contraction or shortening of neck muscles, most commonly the sternocleidomastoid (SCM) muscle. The head tilts toward the affected side while the chin rotates toward the opposite side.

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Types

1. Congenital Muscular Torticollis

Present at birth or noticed during the first few months of life.

Causes

* Intrauterine malposition
* Birth trauma
* Fibrosis/shortening of the SCM muscle

Clinical Features

* Head tilted to one side
* Chin rotated to opposite side
* Limited neck movement
* Palpable SCM mass (“sternomastoid tumor”) in some infants
* Associated plagiocephaly (flattening of the skull)

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2. Acquired Torticollis

Develops after birth.

Causes

Muscular

* Sleeping in an awkward position
* Neck muscle strain
* Trauma

Infectious

* Retropharyngeal abscess
* Tonsillitis
* Cervical lymphadenitis
* Upper respiratory infections

Neurological

* Cervical Dystonia
* Brain tumors
* Posterior fossa lesions

Ocular

* Strabismus
* Extraocular muscle palsies

Skeletal

* Congenital cervical vertebral anomalies
* Atlantoaxial rotatory subluxation (Grisel syndrome)

Drug-induced

* Metoclopramide
* Haloperidol
* Prochlorperazine
* Other dopamine-blocking medications

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Clinical Features

Symptoms

* Neck pain
* Stiff neck
* Restricted neck movement
* Head tilt
* Muscle spasms
* Shoulder asymmetry

Signs

* Head tilted toward affected side
* Chin rotated away
* Tight SCM muscle
* Reduced range of motion

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Diagnosis

History

* Age of onset
* Recent trauma
* Infection symptoms
* Drug exposure
* Neurological symptoms

Physical Examination

* Head posture
* Neck range of motion
* Palpation of SCM muscle
* Neurological examination
* Eye examination

Investigations

Not always required.

May include:

* Neck X-ray
* CT scan
* MRI brain/cervical spine
* Ultrasound of SCM (infants)
* CBC and inflammatory markers if infection suspected

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Differential Diagnosis

* Meningitis
* Retropharyngeal abscess
* Cervical spine injury
* Posterior fossa tumor
* Sandifer syndrome
* Dystonic reactions to medications

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Treatment

Congenital Muscular Torticollis

* Early physiotherapy (most important)
* Passive stretching exercises
* Positioning therapy
* Surgical release if severe and persistent after 1 year

Acute Muscular Torticollis

* Heat application
* Gentle stretching
* Analgesics (paracetamol, ibuprofen)
* Muscle relaxants in selected cases

Drug-Induced Dystonic Torticollis

* Stop offending drug
* Anticholinergics (e.g., Benztropine)
* Antihistamines (e.g., Diphenhydramine)

Infectious Causes

* Appropriate antibiotics
* Drainage of abscess if present

Cervical Dystonia

* Botulinum toxin injections
* Physiotherapy
* Oral medications

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Complications

* Facial asymmetry
* Plagiocephaly
* Limited neck movement
* Chronic pain
* Cosmetic deformity

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Red Flags 🚩

Urgent evaluation is needed if torticollis is associated with:

* Fever
* Severe headache
* Altered mental status
* Neurological deficits
* Recent significant trauma
* Persistent vomiting
* Difficulty swallowing or breathing

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Pediatric Pearls

* Most congenital cases improve with physiotherapy started before 6 months of age.
* Always consider retropharyngeal abscess in a child with fever, neck pain, and torticollis.
* Sudden torticollis after metoclopramide or prochlorperazine is often an acute dystonic reaction.

Quick Mnemonic: “TORTI”

T – Trauma
O – Ocular causes
R – Retropharyngeal abscess
T – Tumor (posterior fossa)
I – Idiopathic/Inflammatory causes

ANAPHYLAXIS :

Anaphylaxis is a severe, rapid-onset, systemic hypersensitivity reaction that can cause airway obstruction, respiratory failure, shock, and death if not treated promptly.

It is most commonly mediated by IgE antibodies, leading to mast cell and basophil degranulation with release of:

* Histamine
* Tryptase
* Leukotrienes
* Prostaglandins
* Cytokines

These mediators cause:

* Vasodilation → hypotension/shock
* Increased capillary permeability → edema
* Bronchoconstriction → wheezing
* Mucosal swelling → airway obstruction

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Common Causes

Foods

* Peanuts
* Tree nuts
* Milk
* Eggs
* Fish
* Shellfish
* Sesame

Drugs

* Penicillins
* Cephalosporins
* NSAIDs
* Some biologic agents
* Contrast media

Insect Venom

* Bee stings
* Wasp stings
* Hornets

Other

* Latex
* Exercise-induced anaphylaxis
* Idiopathic anaphylaxis

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Clinical Features

Symptoms usually occur within minutes to hours after exposure.

Skin (80–90%)

* Urticaria (hives)
* Pruritus
* Flushing
* Angioedema

Respiratory

* Throat tightness
* Hoarseness
* Stridor
* Wheezing
* Shortness of breath
* Hypoxia

Cardiovascular

* Hypotension
* Tachycardia
* Dizziness
* Syncope
* Shock

Gastrointestinal

* Nausea
* Vomiting
* Abdominal cramps
* Diarrhea

Neurologic

* Anxiety
* Sense of impending doom
* Confusion
* Loss of consciousness

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Diagnostic Criteria

Anaphylaxis is highly likely when one of the following occurs:

1. Acute illness with skin/mucosal involvement plus either:

* Respiratory compromise OR
* Hypotension

2. Rapid onset of two or more:

* Skin involvement
* Respiratory symptoms
* Hypotension
* GI symptoms

3. Hypotension after exposure to a known allergen

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ECG Findings

ECG is usually nonspecific:

* Sinus tachycardia (most common)
* ST-segment changes
* Arrhythmias (rare)
* Signs of myocardial ischemia

Possible complication:

* Kounis Syndrome (allergic myocardial infarction)

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Laboratory Tests

Diagnosis is primarily clinical.

Serum Tryptase

* Elevated 1–3 hours after onset
* Peaks around 1–2 hours
* Returns to normal within 6–24 hours

Other Tests

* CBC (may show eosinophilia later)
* Allergy testing after recovery

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Management

Immediate Treatment: ABCDE Approach

A – Airway

* Assess for tongue/laryngeal edema
* Early intubation if airway compromise is developing

B – Breathing

* High-flow oxygen
* Nebulized bronchodilator if wheezing

C – Circulation

* Establish IV access
* Aggressive IV fluids

Adults:

* 1–2 L normal saline rapidly

Children:

* 20 mL/kg normal saline bolus

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First-Line Drug: Epinephrine (Adrenaline)

IM Epinephrine

Adults

* 0.5 mg IM (1:1000 solution)
* Into the anterolateral thigh

Children

* 0.01 mg/kg IM
* Maximum 0.5 mg

Can repeat every 5–15 minutes if needed.

Auto-injectors

* 0.15 mg for smaller children
* 0.3 mg for older children/adults

Epinephrine is the most important treatment and should never be delayed.

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Adjunctive Treatments

Antihistamines

* Diphenhydramine
* Chlorpheniramine

Help itching and hives but do not treat airway edema or shock.

Corticosteroids

* Hydrocortisone
* Methylprednisolone

May help reduce prolonged symptoms but work slowly.

Bronchodilators

* Salbutamol (albuterol)
* For persistent bronchospasm

Vasopressors

If shock persists despite:

* IM epinephrine
* IV fluids

Then:

* Epinephrine infusion
* Norepinephrine infusion

in ICU settings.

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Biphasic Anaphylaxis

Recurrence of symptoms after apparent recovery.

Usually occurs:

* Within 4–12 hours
* Occasionally up to 72 hours

Risk factors:

* Severe initial reaction
* Delayed epinephrine
* Need for multiple epinephrine doses

Observation:

* Mild cases: 4–6 hours
* Severe cases: 12–24 hours

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Differential Diagnosis

* Acute severe asthma
* Vasovagal syncope
* Panic attack
* Septic shock
* Foreign body aspiration
* Hereditary angioedema

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Prevention

* Identify and avoid triggers
* Allergy specialist referral
* Carry epinephrine auto-injector
* Wear medical alert identification
* Education on trigger avoidance

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Pediatric Dosing Summary

Weight Epinephrine IM
30 kg 0.3 mg
Adult 0.5 mg

Key Exam Points

* Most common cause of death: airway obstruction and cardiovascular collapse.
* First-line treatment: IM epinephrine in the thigh.
* Do not delay epinephrine while giving antihistamines or steroids.
* Serum tryptase can support the
diagnosis but should not delay treatment.
* Observe for biphasic reactions after stabilization.

PANCREATITIS:

The pancreas is a gland located behind the stomach. It produces:

* Digestive enzymes (amylase, lipase, proteases) to digest food.
* Hormones such as insulin and glucagon to regulate blood sugar.

Pancreatitis occurs when digestive enzymes become activated inside the pancreas, causing inflammation and damage to pancreatic tissue.

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Types of Pancreatitis

1. Acute Pancreatitis

* Sudden inflammation lasting days to weeks.
* Usually reversible with treatment.
* Can range from mild to life-threatening.

2. Chronic Pancreatitis

* Persistent inflammation causing irreversible damage.
* Leads to fibrosis (scarring), pancreatic insufficiency, and diabetes.

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Causes

Acute Pancreatitis

Most common causes:

1. Gallstones (35–50%)
2. Alcohol use (25–35%)

Other causes:

* Hypertriglyceridemia (>500–1000 mg/dL)
* Hypercalcemia
* Trauma
* Viral infections (mumps, coxsackievirus)
* ERCP procedure
* Medications:
* Valproate
* Azathioprine
* 6-Mercaptopurine
* Didanosine
* Thiazides
* Furosemide
* Autoimmune pancreatitis
* Scorpion sting (rare)

Chronic Pancreatitis

* Chronic alcohol use
* Genetic disorders (CFTR, PRSS1 mutations)
* Recurrent acute pancreatitis
* Autoimmune pancreatitis
* Idiopathic

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Symptoms

Acute Pancreatitis

* Sudden severe epigastric pain
* Pain radiating to the back
* Nausea and vomiting
* Fever
* Abdominal tenderness
* Pain often improves when leaning forward

Chronic Pancreatitis

* Recurrent abdominal pain
* Weight loss
* Fatty stools (steatorrhea)
* Malnutrition
* Diabetes mellitus

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Physical Signs

Severe Disease

* Tachycardia
* Hypotension
* Fever
* Jaundice (if gallstones are present)

Rare Signs of Hemorrhagic Pancreatitis

* Cullen sign: bluish discoloration around the umbilicus
* Grey Turner sign: flank bruising

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Diagnosis

Diagnosis requires 2 of the following 3 criteria:

1. Typical abdominal pain
2. Serum lipase or amylase ≥3 times normal
3. Imaging consistent with pancreatitis

Laboratory Findings

* Elevated lipase (most specific)
* Elevated amylase
* Elevated CRP
* Leukocytosis
* Elevated ALT (>150 U/L suggests gallstone pancreatitis)
* Hyperglycemia
* Hypocalcemia (severe disease)

Imaging

Ultrasound

* First-line for gallstones

CT Scan

* Evaluates severity and complications
* Usually performed after 48–72 hours if diagnosis is uncertain or severe disease suspected

MRI/MRCP

* Useful for biliary and pancreatic duct abnormalities

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Severity Classification

Mild

* No organ failure
* No complications

Moderately Severe

* Transient organ failure (48 hours)
* High mortality risk

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Complications

Local Complications

* Pancreatic necrosis
* Pancreatic pseudocyst
* Abscess
* Hemorrhage
* Pancreatic duct disruption

Systemic Complications

* Shock
* Acute respiratory distress syndrome (ARDS)
* Acute kidney injury
* Sepsis
* Multi-organ failure

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Treatment

Initial Management

1. Aggressive IV fluids (especially in first 24 hours)
2. Pain control
3. Oxygen if needed
4. Monitoring of vital signs and urine output

Nutrition

* Early oral feeding when tolerated
* Enteral feeding preferred if severe disease
* Avoid prolonged fasting

Antibiotics

* Not routinely recommended
* Only for proven infected necrosis or another infection

Gallstone Pancreatitis

* Cholecystectomy after recovery
* ERCP if cholangitis or persistent bile duct obstruction

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Chronic Pancreatitis Treatment

Lifestyle

* Stop alcohol
* Stop smoking

Nutrition

* Low-fat diet
* Small frequent meals
* Fat-soluble vitamin supplementation

Medications

* Pancreatic enzyme replacement
* Pain management
* Insulin if diabetes develops

Surgery/Endoscopy

* For duct obstruction, stones, strictures, or uncontrolled pain

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Prognosis

Acute Pancreatitis

* Mild disease: mortality

Idiopathic Intracranial Hypertension (IIH) / Pseudotumor Cerebri :

Idiopathic Intracranial Hypertension (IIH) is a condition in which intracranial pressure (ICP) is elevated without a brain tumor, infection, hydrocephalus, or other identifiable cause. It is also called pseudotumor cerebri (“false brain tumor”) because symptoms can mimic those of a brain tumor.

Who gets it?

* Most common in obese women of childbearing age
* Can occur in children, men, and non-obese individuals
* Risk factors:
* Obesity
* Recent weight gain
* Female s*x
* Certain medications:
* Vitamin A derivatives (e.g., isotretinoin)
* Tetracyclines (e.g., doxycycline, minocycline)
* Growth hormone
* Withdrawal of corticosteroids

Symptoms

Headache (most common)

* Daily or near-daily
* Often worse in the morning
* May worsen with coughing or straining

Visual symptoms

* Transient visual obscurations (brief episodes of blurred or dark vision)
* Blurred vision
* Double vision (diplopia)
* Peripheral visual field loss
* Permanent vision loss if untreated

Other symptoms

* Pulsatile tinnitus (“whooshing” sound in the ears)
* Nausea and vomiting
* Neck or shoulder pain

Signs

Papilledema

Swelling of the optic discs due to raised intracranial pressure.

Cranial nerve VI palsy

* Horizontal diplopia
* Limited lateral eye movement

Diagnosis

Brain Imaging

* MRI brain with MR venography (MRV)
* Used to exclude:
* Brain tumors
* Cerebral venous sinus thrombosis

Lumbar Puncture

Shows:

* Elevated opening pressure
* Adults: usually >25 cm H₂O
* Children: often >28 cm H₂O
* Normal CSF composition

Modified Diagnostic Criteria

1. Papilledema present
2. Normal neurological examination except possible VI nerve palsy
3. Normal neuroimaging
4. Normal CSF analysis
5. Elevated CSF opening pressure

Investigations

* MRI/MRV
* Lumbar puncture
* Visual field testing
* Optical coherence tomography (OCT)
* Regular ophthalmology follow-up

Treatment

Weight Loss

* Most effective long-term treatment
* Even 5–10% weight reduction can improve symptoms

Medication

Acetazolamide

* First-line treatment
* Reduces CSF production

Topiramate

* May help headaches
* Promotes weight loss
* Reduces CSF production

Surgical Treatment

For threatened vision or severe disease:

* Optic nerve sheath fenestration
* CSF shunting (VP shunt or LP shunt)
* Venous sinus stenting (selected patients)

Complications

* Permanent visual field defects
* Optic atrophy
* Blindness (if untreated)

Prognosis

* Many patients improve with treatment and weight reduction.
* Vision must be monitored closely because visual loss can become irreversible.

Common Examination Findings

Finding Frequency
Headache Very common
Papilledema Nearly universal
Pulsatile tinnitus Common
Diplopia (VI palsy) Common
Visual field defects Common

Red flags requiring urgent evaluation:

* Rapidly worsening vision
* Severe papilledema
* Progressive visual field loss
* New focal neurological deficits beyond isolated VI nerve palsy.