Teaching file for students.6,

First case 

Previously health 12 year old boy, noticed swelling above his left ankle. Initially he was not disturbed with this as it was not painful and did nt limit his play and activities.
Later he had minimal pain on brisk walking  and he observed swelling was gradually  increasing in size.
He came to us three months after the onset.
He did nt have  fever.
No similar swelling anywhere else.
He did nt have other symptoms like fatigue ,syncope bleeding manifestations.
No family history of similar swelling on the body.

On examination 

Diffuse swelling on the medial aspect of lower limb, 4 X 4 cms. Surface normal ,there was no discoloration.
No other swelling anywhere.
No pallor 
No lymph nodes.



As the swelling was growing over the last three months we considered the possibility of malignancy. 
We did a Plain X-Ray lower leg and foot AP and Lateral






Differential diagnosis of lytic lesions of bone considered. 



Within next three days pain increased and the swelling changed its consistency.
It was soft and fluctuant.
He was afebrile.
His blood counts and ESR, Hemoglobin were normal.

Two possibilities were considered at this point

1.Chronic non bacterial osteomyelitis

2.Brodies abscess.
  he was put on antibiotics and taken for surgery .Antibiotics with staphylococal coverage given till we got the biopsy results



So it was non ossifying fibroma 

2.Two cases of Staphylococal scalded skin syndrome

Nothing special about these cases. Just to share the nature of the lesion on the back.

Second case is a baby 45 days, with SSSS.

This baby came with excessive cry pain on picking up .Low grade fever. All causes of excessive cry at this age thought of .Features of SSSS evolved by next day.

Both of them improving.This picture taken during recovery.sorry for poor picture.Just to highlight the case occurring in that young baby.

Third case 

Six year old girl previously normal,bought with complaints of episodes of vertigo.As per her description feeling of rotation was there.Each episode lasted for few seconds.There was no loss of consciousness,she was fully aware of episodes.No pallor ,sweating noticed by parents.Episodes lasts for less than a minute.

No palpitation,chest pain associated. 

These episodes were happening at least once a day,or more. Most of the episodes occurred during day time.No aggravation during play and activities. She is not on any drugs.

No family history of sudden death,or major cardioascular diseases ,seizure disorder or other major neurological problems.

Examination 

Under nourished,No pallor, lymph nodes.No neuro cutaneous markers.

Blood pressure normal for age 

Ear assessed by experts, normal

Cardiovascular and neurological examination within normal limits

No nystagmus,hallpike maneuver negative.

Lab Investigations

Her hemoglobin,peripheral smear,Blood sugar,calcium electrolytes system functions all came normal

ECG rhythm strip normal.ECHO done normal 

EEG done normal.

Provisional diagnosis and management 

Provisional diagnosis of episodic vertigo 

Initially she was put on Betahistine for one week followed by dimenhydrinate.(dramamine)

No response, she was having these episodes with same frequency.

Holter monitoring 

The above record at 2 AM
PR intervals prolonged,type I AV block,but it is unlikely to explain the above events
Sudden slowing of rates . Is it slipping to higher grades of AV block episodically?
But  waves missing.So some problem at SA node.
Here question to be answered is
1.Is nt this just a normal phenomenon at night.High vagal tone can suppress the node for short while 
2.Can this explain the episodes or this is an unrelated benign phenomenon?
May be, but as she is symptomatic we cant leave alone taking this lightly.
we have sent her for electro-physiological studies to chithra

In this context, see this  ECG of a similar case 

12 year old boy presented with frequent episodes of loss of consciousness. These episodes were taken initially as syncopes and later finding loss of consciousness he was on anti epileptics