Chronic diarrhea is a common chief complaint in the pediatric population with a wide range of diagnostic differentials; as such, whilst suspecting common causes, less prevalent conditions tend to be overlooked, such as neuroendocrine tumor pathologies. VIPomas are characterized by hypersecretion of the vasoactive intestinal peptide (VIP), causing watery diarrhea, hypokalemia, and achlorhydria. Nonetheless, its low incidence rate in children makes it an easily unnoticed pathology. Herein, we report a case of a 14-year-old female patient and a review of relevant literature. The patient complained of 7-month history of watery diarrhea, multiple emetic episodes, and relevant past medical history of multiple hospitalizations. Chronic diarrheal disease work-up studies, including a high VIP scintigram, showed a lesion suggestive of a VIPoma-type neuroendocrine pancreatic tumor. A distal pancreatectomy was performed with a complete resolution of the symptoms. When faced with a pediatric patient presenting with chronic secretory diarrhea and whose work-up studies rule out the most common pathologies, the possible presence of a neuroendocrine tumor as VIPoma should be considered.

Background Guillain-Barré syndrome is the most common cause of flaccid paralysis, with multiple known clinical variants. Autonomic dysfunction, although frequently reported in the clinical course, is often overlooked in the pediatric population and is usually not the initial presenting symptom in this age group Case presentation We present the case of a previously healthy 17-year-old who arrived at the Emergency Department complaining of gastrointestinal symptoms associated with lipothymia. An initial electrocardiogram (ECG) showed sustained sinus bradycardia subsequently associated with arterial hypertension. Structural and inflammatory cardiac pathology were ruled out, as well as auriculoventricular conduction block and posterior reversible encephalopathy syndrome. On the ninth day after initial symptoms, the patient presented sensory and motor nerve disturbances with the cerebrospinal fluid analysis showing a clear albumin-cytologic dissociation, consistent with an atypical presentation of GBS with autonomic dysfunction. Immunoglobulin therapy was administered, developing subsequent aseptic meningitis, that required discontinuation of previous therapy and treatment with plasmapheresis. Clinical improvement was achieved with full motor function recovery. Conclusion This case illustrates a Guillain-Barré syndrome variant in which autonomic dysfunction preceded neurologic deficit, a finding uncommon in children, emphasizing this as an important differential diagnosis for severe bradycardia in pediatric patients.

BackgroundHypercalcemia is a rare metabolic disorder in the pediatric population, with several differential diagnoses that resemble hematologic malignancies. In cases of severe hypercalcemia, therapeutic strategies other than hyperhydration, such as the use of bisphosphonates, have been described.Case presentationWe present the case of a previously healthy 12-year-old boy who was admitted to the emergency department due to fatigue, hypo-responsiveness, and progressively worsening poor appetite for the previous 19 days. Initial laboratory tests revealed severe hypercalcemia (total calcium: 19 mg/dl), hyperphosphatemia, elevated creatinine, and hyperuricemia. Management with hyperhydration and xanthine oxidase inhibitor (allopurinol) was provided. The patient was transferred to the pediatric intensive care unit where treatment with furosemide, systemic corticosteroid, and zoledronic acid was started. Metabolic, infectious, renal, and endocrinological causes were excluded. Follow-up paraclinical studies showed a progressive hematologic involvement with heterogeneous hypochromic microcytic anemia, thrombocytopenia, and elevated lactic dehydrogenase. Bone marrow aspiration and biopsy were performed, which confirmed the diagnosis of B-precursor acute lymphoblastic leukemia. Hypercalcemia was resolved 72 h after the application of bisphosphonates.ConclusionHypercalcemia as an oncological metabolic emergency in the onset of acute lymphoblastic leukemia is uncommon in children. The use of intravenous bisphosphonates is an effective therapy in the early resolution of the condition. We present the case of a 12-year-old patient with malignant hypercalcemia who responded favorably to the use of a single dose of bisphosphonates.

Introduction. Acute respiratory infections represent one of the main causes of preventable infant mortality and morbidity in children, and although a significate proportion of cases are of viral etiology, antibiotic treatment is the overly-excessive norm. Studies suggest that the combined use of serum procalcitonin (PCT) and polymerase chain reaction (PCR) multiplex (FilmArray) may be used to guide antibiotic therapy. Methods. A prospective cohort study was conducted of patients between 1 month and 17 years of age with acute respiratory infection hospitalized in the PICU with a negative viral panel report and both respiratory FilmArray and procalcitonin performed in the first 72 hours of hospitalization. A diagnostic algorithm was then applied to these patients, tailored to the result of both tests. Results. Of the total 326 patients recluted, 110 met the inclusion criteria; 23 patients were excluded for infections other than respiratory origin. Of the 87 remaining patients, all had a respiratory FilmArray performed prior to the PCT sample, demonstrating a diagnostic yield of over 80%. Procalcitonin was requested in slightly more than half of the patients and was positive in a third of these cases. When combined in the diagnostic algorithm, FilmAray and PCT lead to changes in treatment plan in 30% of patients in terms of antibiotic management prescribed on admission, with the most frequent treatment plan change being suspending the antibiotic altogether (from 41.4% to 10.3%, for a total of 89.7% of patients without antibiotic therapy following the algorithm. None of the patients died and only 1/87 patients required re-initiating antibiotics after having suspended treatment. The interaction between the identification of a viral pathogen in the FilmArray and a negative PCT result yielded statistically significant results (p=0.004) and affected the change in treatment management mainly in antibiotic discontinuation.Conclusions. The combined use of FilmArray and serum PCT as tools in the diagnostic algorithm is a safe way to guide tailored antibiotic therapy in pediatric patients with ARI in critical state.