Henoch–Schönlein purpura (HSP) is characterized by nonthrombocytopenic palpable purpura, arthritis or arthral­gia, and gastrointestinal and/or renal involvement. Gastrointestinal symptoms are reported in 50%-75% and they are related to a previous group A streptococcal infection in 40%. A healthy 5-year-old girl presented with a three-week history of a recurrent purpuric rash on the lower limbs, ar­thralgia and angioedema, without renal involvement. During the third relapse, she had severe, diffuse and persistent abdominal pain and bloody stools. An abdominal ultrasound revealed transmural edema of the last ileal segment, compatible with ileitis. She received prednisolone for five days, with full clinical recovery. Antistreptolysin O titer was elevated. The remaining laboratory tests were normal (antinuclear, anti-neutrophil and anti-Saccharomyces cerevisiae antibodies; rheumatoid factor; stool cultures, parasitological examination and viral antigen tests). One month later, an abdominal ultrasound revealed no abnormalities. Terminal ileitis is a very rare complication of HSP in children but has a good prognosis.

Lipschütz ulcers (LU) are non-sexually related genital ulcers, rarely reported. We describe a healthy 11-year-old girl, who presented with fever and a painful vulvar ulcer associated with erythematous tonsillitis. Throat swab test for Group A Streptococcus (GAS) was positive. She was treated with amoxicillin. Further investigation was negative, including Herpes Simplex virus DNA from ulcer swab and serology for Epstein-Barr virus, cytomegalovirus and Antistreptolysin O titre was high. The ulcer healed in 2 weeks, with no recurrence in a 1 year follow-up period. The association of LU with GAS tonsillitis is very rare.

Non-typhoidal Salmonella osteomyelitis in healthy children is a very rare condition. A previously healthy 7-year-old boy presented with foot pain following a small injury. Local inflammatory signs of the foot were observed, with a normal radiograph. Two weeks before, he had had gastroenteritis. Assuming cellulitis, flucloxacillin was began. Early during admission, surgical subcutaneous abscess drainage was performed and Salmonella enteritidis was identified. According to bacterial susceptibility, antibiotherapy was changed to ceftriaxone. A foot radiograph and an MRI scan, performed on the 9th and the 12th days, revealed findings suggestive of osteomyelitis of the metaphysis of the fifth metatarsal. Clinical worsening persisted and surgical extensive debridement was needed. A 6-week antibiotic treatment was completed, with a good outcome. Osteomyelitis with a poor evolution in children with risk factors (prior gastrointestinal illness, warm weather and previous exposure to antibiotics) can raise the possibility of a non-typhoidal Salmonella infection.

Vaginal bleeding can occur shortly after delivery in 3%–5% of newborns as a consequence of placental hormone withdrawal . Although usually benign, its differential diagnosis includes central precocious puberty, tumours and other pathological conditions. A girl born at 26 weeks of gestation presented with five episodes of vaginal bleeding, each lasting less than a week, initiated at 4 months of age. Luteinising hormone and oestradiol levels were in the pubertal range. Later, she exhibited breast development, with no other pubertal signs. An ultrasonography test revealed an impregnated endometrium and a right ovarian cyst with 43 mm of diameter. A cranioencephalic MRI was unremarkable. Clinicians adopted expectant management and there was clinical, hormonal and radiological resolution in 3 months. The spontaneous resolution suggested mini-puberty of infancy. This is usually an asymptomatic condition, but to date, four cases of an exacerbated form in extremepremature infants have been reported. Long-term follow-up data are missing.A girl born at 26 weeks of gestation presented with five episodes of vaginal bleeding, each lasting less than a week, initiated at 4 months of age. Luteinising hormone and oestradiol levels were in the pubertal range. Later, she exhibited breast development, with no other pubertal signs. An ultrasonography test revealed an impregnated endometrium and a right ovarian cyst with 43 mm of diameter. A cranioencephalic MRI was unremarkable. Clinicians adopted expectant management and there was clinical, hormonal and radiological resolution in 3 months. The spontaneous resolution suggested mini-puberty of infancy. This is usually an asymptomatic condition, but to date, four cases of an exacerbated form in extremepremature infants have been reported. Long-term follow-up data are missing.

INTRODUCTION: Pediatric acute osteomyelitis (AO) is a serious condition and a challenging diagnosis. It mainly affects previously healthy individuals and Staphylococcus aureus is the leading causative agent. The objective of this study was to characterize all pediatric AO cases admitted to a second-level hospital during a six-year period.METHODS: Retrospective single-center study, including all children under 18 years-old with a primary diagnosis of AO. Descriptive statistics analysis was performed.RESULTS: Ten cases were identified, 60% males. The median age was 6.7 years. Previous trauma was referred by five. Affected locations were foot (n=3), tibia (n=3), femur (n=2), sacrum (n=1) and hand (n=1). All presented with local pain and limping or inability to walk (except one case with hand involvement). Four patients had fever and inflammatory signs, namely erythema and edema, were reported by four. At admission, nine had elevated inflammatory markers and six out of eight had normal radiographs. Magnetic resonance imaging confirmed the diagnosis in seven. Blood cultures were positive for Staphylococcus aureus (n=3) and Streptococcus pyogenes (n=1). Salmonella enteritidis was isolated from pus (n=1) and there was one presumed Kingella kingae AO defined as a positive polymerase chain reaction test from an oropharyngeal swab. The average duration of parenteral and oral antibiotherapy was 14.7 days 3.9 weeks, respectively. The antibiotic of choice was flucloxacillin. Two patients developed local complications.DISCUSSION: An unspecific and subacute clinical and radiological presentation together with low positive blood culture rates difficults timely diagnosis and management. An early empirical parenteral antibiotherapy is mandatory, followed by an oral regimen for at least four weeks.