Section on Pediatrics. (Abstracts of Scientific Posters).

PED 1-B. VITAMIN K-DEFICIENT COAGULOPATHY IN A SEVEN-YEAR-OLD GIRL.

T.K. Gross, R.P. Warrier, and D. Ode. Department of Pediatrics, Louisiana State University Health Sciences Center, New Orleans, LA, and Children's Hospital, New Orleans, LA.

A case of severe coagulopathy involving hemarthrosis of the hip is presented. A seven-year-old Caucasian girl being treated with methylphenidate and clonidine for ADHD, presented to her family physician complaining of hip pain and bruising for several days. Coagulation studies were grossly abnormal, prompting evaluation of all clotting factors. After treatment with vitamin K, coagulation parameters started to return to normal values. Subsequently, blood testing revealed decreased levels of vitamin K-dependent clotting factors. A work-up for vitamin K-losing enteropathy was initiated, and the patient was discharged to home with vitamin K therapy. The patient's caregiver reported on the day after discharge that the patient's clonidine prescription bottle at home was filled with tablets reading "COUMADIN." A discussion of medical errors follows the case report.

PED2-B. CHROMOBACTERIUM VIOLACEUM PNEUMONIA IN A CHILD WITH A NEAR-DROWNING EVENT.

Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Medical College of Virginia of VCU, Richmond, VA.

Human infection caused by Chromobacterium violaceum is rare, but when it occurs may be fatal. It is a common soil saprophyte, and when isolated in blood cultures, it frequently is considered as a contaminant. It is essential to recognize its potential clinical significance so that appropriate therapy may be initiated. A 12 year-old boy presented to the ED after a 4-minute submersion injury. CPR was initiated by the life guard and ventilation assisted. He arrived at the hospital posturing and was immediately intubated. His birth history and medical history were unremarkable. He took no medications. He had a temperature of 39.2[degrees]C; heart rate, 121 beats/mm; respiratory rate, 20 breaths/mm. Physical examination was remarkable for a GCS of 10. His WBC count was 14,000/mm3 with 36 % neutrophils and 7 % bands. His hemoglobin concentration was 12 g/dL and platelet count was 352,000/mm3. Electrolyte values were: sodium, 130 mEq/L; potassium, 4.1 mEq/L; chloride, 101 mEq/L; CO2 17 mEq/L; BUN, 19 mg/dL; and crea tinine, 1.1 mg/dL. Glucose level was 294 mg/dL. His ABG showed a pH of 7.12; PO2, 69 mm Hg, and PCO2,46 mm Hg. The patient was admitted to the PICU. Head CT was normal. His hospital course was complicated by ARDS, bilateral pneumothorax, necrotizing enterocolitis, and steroid- induced hyperglycemia. His blood cultures were positive for Chromobacterium violaceum, which responded to ceftazidime. He was discharged 2 months later to a rehabilitation center. He was able to talk and he moved his extremities well. Chromobacterium violaceum is a facultative anaerobe, gram-negative rod that is confined to tropical and subtropical regions of the world. The organism enters the human body through a minor trauma to the skin or ingestion of contaminated water. The clinical manifestations include sepsis and visceral organ abscesses, such as in the liver, kidneys, and lungs. Other presentations have included cellulitis, lymphadenitis, osteomyelitis, sinusitis, urinary tract infection, and, rarely, pneumonia and meningitis. P rognosis is guarded, with approximately 65% mortality. These infections are very serious, and mandate prompt medical and surgical interventions.

PED3-B. ACUTE HEMORRHAGIC STROKE DUE TO BRAIN METASTASES FROM MAUGNANT FIBROUS HISTIOCYTOMA. Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Medical College of Virginia of VCU, Richmond, VA.

Malignant fibrous histiocytoma (MFH) is a rare tumor in children, but is the most common soft tissue sarcoma. Intracranial metastasis from MFH are also rare, especially with associated hemorrhage. A 16-year-old girl presented to the emergency department with aphasia and weakness in the right arm. She had a history of a Ewing's sarcoma treated with chemotherapy and radiation therapy, and had been in remission for 5 years. She was recently diagnosed with MFH of her right ankle, which was treated with a below-the-knee amputation. A few months previously, a screening chest CT showed small lung nodules. She had a temperature of 37.0[degrees]C; heart rate, 93 beats/min; and respiratory rate, 20 breaths/min. Her physical examination was remarkable for right facial droop, flaccid right upper extremity, and hyperreflexic right lower extremity. Her WBC count was 13,700/mm3 with 89 % neutrophils. Hemoglobin concentration was 14.8 g/dL and platelet count was 279,000/mm3. Electrolyte levels were normal. Her head CT showed 4 enhancing lesions on the left frontal lobe. A head MRI confirmed these lesions as hemorrhagic metastatic tumors. Therapy with phenytoin and decadron was started, and she began undergoing radiation therapy and chemotherapy. She was discharged in stable condition. Malignant fibrous histiocytoma is characterized by a mixture of spindle (fibrous) cells and round (histiocytic) cells arranged in a storiform pattern, with frequent giant cells and areas of pleomorphism. Treatment of MFH includes surgical resection and radiation therapy. Due to longer survival times of children harboring systemic sarcomas, these tumors should be considered in the differential diagnosis of intracranial neoplasms, whether hemorrhagic or not. In particular, history of a soft tissue tumor associated with lung metastasis should evoke the possibility of MFH metastasis.

PED4-B. UNSUSPECTED HEREDITARY MALIGNANT HYPERTHERMIA. Antonio E. Muniz, MD. Department of Emergency Medicine and Pediatrics, Medical College of Virginia of VCU, Richmond, VA

Hereditary malignant hyperthermia is a rare and difficult condition to diagnose, and may have catastrophic consequences if certain precipitants are exposed to the patient. The classic symptom complex includes rapidly rising body temperature, tachycardia, tachypnea, cyanosis, and respiratory and metabolic acidosis. Patients experience rigidity and myoglobinuria. This is a case of a child with hereditary malignant hyperthermia not triggered by anesthetics. A 9-year-old boy presented with 2 days of generalized myalgias, fever, and cough, and was diagnosed with bronchitis by his physician. His medical, social, and family history were unknown, due to adoption. His only medications included ibuprofen. He had a temperature of 38.3[degrees]C; blood pressure, 91/71 mm Hg; heart rate, 140 beats/min; and respiratory rate, 22 breaths/min. Physical examination was remarkable for mild distress, pharyngeal erythema, a systolic ejection murmur, and remarkable muscle tenderness. There was no evidence of edema, erythema, or tr auma to his extremities. His WBC count was 21,200/mm3 with 71% neutrophils and 17% bands. Hemoglobin concentration was 14.4 g/dL and platelet count was 313,000/mm3. His electrolyte levels were normal. His CK value was 15,853 U/L and myoglobin concentration was > 3000 mg/L. Urinalysis revealed large blood without any RBCs on microscopy. He was admitted treatment with dantrolene was started. Sodium bicarbonate was added to his fluids. His CK value peaked at 101,700 U/L; AST, 2,380 U/L; and ALT, 849 U/L. His creatinine level was only elevated to 1.2 mg/dL. Laboratory abnormalities resolved and the patient was discharged in good condition 7 days later. The majority of patients with hereditary malignant hyperthermia have no obvious clinical symptoms of muscle disease. It is inherited in an autosomal dominant pattern. There is a mutation of the ryanodine receptor gene RYR. This condition may not be recognized until the patient is exposed to an anesthetic agent or depolarizing muscle relaxant, and such exposure may be catastrophic. Clinical clues to its diagnosis may be inferred from unexplained fevers, muscle cramps, and elevated CK levels. Treatment is with intra venous dantrolene, which has been shown to decrease resting free calcium in skeletal muscles.

PED5-B. PROGRAM EVALUATION: "EZ BREATHERS: PARTNERSHIP FOR ASTHMA AWARENESS AND PREVENTION IN HEAD START CHILDREN." Nermina Nakas, MD, MPH, and Cynthia Kelly, MD. Center for Pediatric Research, Department of Pediatrics at Children's Hospital of The King's Daughters and Eastern Virginia Medical School.

The Head Start program provides early childhood education to low-income children between 3 and 5 years of age. Asthma morbidity and mortality rates are highest in low-income, minority populations, and Head Start is an excellent setting in which to address asthma awareness, education, and prevention. Children under the age of 5 years frequently require hospitalization for asthma symptoms. Of the 1,237 asthma hospitalizations for all children 0 to 18 years old in the Hampton Roads area in 1994, 623 occurred in children 0 to 5 years of age. According to the Centers for Disease Control and Prevention, black children 0 to 4 years of age were six times more likely to die from asthma than white children of the same age (1992). The majority of children who become asthmatic develop signs and symptoms before 5 years of age, during preschool years, and asthma severity and hospitalization rates are highest in this age group. Objectives: The EZ Breathers program focuses on the health of asthmatic children enrolled in Head Start centers. Specific program goals are to increase access to preventive care, improve asthma awareness and quality of life for Head Start's asthmatic children and their families. This program is located in Hampton Roads Head Start centers. EZ Breathers program is funded through the Maternal and Child Health Bureau and Health Resources and Services Administration, and it is approved by the Eastern Virginia Medical School Institutional Review Board. The EZ Breathers program evaluation addresses what knowledge, attitudes, and behaviors Head Start staff have concerning childhood asthma. As a part of a student's practicum for the Master of Public Health degree (MPH), an asthma-education instrument--tool to help Head Start staff recognize childhood asthma was developed. This tool is planned to he used in practice in the early fall, when the Head Start staff education begins. We will recommend our asthma education tool as a practical and preferred method for education delivery in Head Start centers. Having a goo d educational tool for staff will impact Head Start in a positive way. This impact on Head Start as an agency will strike on improving care for young asthmatic children. A written practicum report includes program history and background, research review of other similar programs, and a summary of findings. Description of the instrument we developed is attached (Appendix 2.). The EZ Breathers evaluable model chart is also attached (Appendix 1.). The evaluation is designed in cooperation with the EZ Breathers program manager, MPH student's mentor. The evaluation seeks to determine whether the asthma education training of Head Start staff is reaching its goals. The program manager is interested in whether the EZ Breathers program is oriented towards Head Start staff knowledge, attitudes, and behavior. Asthma education programs are demonstrated by many studies to improve the health and quality of life for asthmatic children and their families. This evaluation provides program staff, as well as founders, with valu able information concerning the effectiveness of the asthma education training of Head Start staff in the EZ Breathers program in the Hampton Roads region of Virginia.

PED6-B. ECSTASY MAY CAUSE AGONY OR DEATH. Ronald J. Dougherty, MD, FAATP, ASAM. Tully, NY.

There has been a 300% increase in the use of the so-called club drugs. These include GHB, which has contributed to some recent fatalities, and arrest and conviction, usually of young males. In addition, Rophynal, the date-rape drug, appears to be leveling off as far as reported fatalities. In many instances, the alleged date-rape drug overdose which leads to the person going to the ED, turns out not to be Rophynal, but rather other benzodiazepines or other substances. MDMA (methylenedioxymethamphetamine), otherwise known as Ecstasy or XTC, has had explosive use and abuse among teenagers and young adults. MDMA, which is both an hallucinogen and a stimulant, not uncommonly can cause adverse effects upon serotonin levels, causing anxiety, depression, paranoia, confusion, hallucinations, and sleep disturbance. In addition, physical adverse effects can include cardiac arrhythmia, dehydration, hypertension, renal failure, and death. Some MDMA consumers end up dying from malignant hyperthermia when the drugs effects are intensified by dancing in hot, smoky clubs, and the consumers fail to drink enough water to protect their kidneys and brain. Long-term use of MDMA has been reported to cause damage to the hippocampus. There have been many reported side effects from taking what has been marketed as MDMA. These side effects include CI upset, seizures, cardiac arrhythmia, and renal failure. 107 pills that were sold as "Ecstasy" were assayed using gas chromatography-mass spectroscopy. Sixty-three percent of the pills contained some MDMA or an analogue, and 29% contained identifiable drugs, but no MDMA or analogue. The most common drug identified other than MDMA was the cough suppressant dextromethorphan (the DM in many over-the-counter cough mixtures), which was identified in 21% of pills. The amount of dextromethorphan found in the pills was higher than the usual therapeutic dose of 15 to 30 mg, taken up to four times daily (the recommended maximum dose is 90 mg/d in adults). Other drugs found in the pills included caffeine , ephedrine, pseudoephedrine, and salicylates. The conclusion from evaluating these pills is the old adage that, "on the street there is no such thing as truth in packaging."