Patient Presentation
A 6-year-old male came to clinic for his health maintenance visit. His mother asked about how much fish he should or could be eating. She had recently seen something on social media about how children should not have fish because of the risk of mercury.

The pertinent physical exam showed normal vital signs and growth parameters were in the 10-25%. His examination was normal.

The diagnosis of a healthy male was made. The pediatrician recommended that the family could eat fish in moderation like once or twice a week as it had good protein and nutrition in it. But that eating a lot of it could put the family at risk for mercury or other possible toxins. “It’s okay for him to eat the fish he and your husband catch in the lake, but not every day. There should be a balance of different types of food over the week, just like you should have a variety over a day too” he recommended.

Discussion
Mercury (Hg) is a heavy metal that is used for a variety of products as it is very dense requiring small spaces. It is a liquid at room temperature and easily can expand therefore it is used for thermometers and barometers. It is also used in fluorescent lighting as it is electroconductive. Mercury also has anti-infective properties. Hg is also highly toxic and can affect all organ systems but is especially neurotoxic. It can result in organ failure or permanent damage. There is no specific Hg level that is considered safe at any age. However, Hg in the environment is common because of manufacturing and a large reservoir in the world’s marine systems.

Toxicity depends on many variables, all of which are not fully elucidated.

• Mercury types
  • Elemental mercury (Hg⁰) in its liquid state is poorly absorbed, but in its vapor state (which it can easily do at room temperature) is very easily absorbed by the lungs. Elemental Hg can pass through cell membranes including the placental and blood brain barrier.
  • Mercuric ion – Elemental mercury in the blood stream though is oxidized to mercuric ion (Hg²⁺) which does not cross cell membranes as well including the blood brain barrier. Hg²⁺ still interacts with a variety of cellular functions.
  • Methyl mercury (MeHg) is mercury that has been vaporized and then absorbed and methylated by the earth’s marine systems. MeHg then moves through the food chain and is ingested in the form of fish and other marine products. (Note that this can take a long time and therefore it can be difficult to measure the amount of Hg and also what its effects are.) It is the most common type of dietary mercury.
    MeHg is highky absorbable by the intestine and also highly absorbed across the placenta and blood brain barrier.
• Timing of exposure – fetus and young children have growing neurological systems and therefore are more at risk for the potential neurotoxin effects.
• Amount of exposure – higher amounts of Hg of MeHg or Hg²⁺ and other states increases the risk of problems.
• Individual genetics – there is some data supporting that some individuals have more or less risk of toxic effects because of their genetics.

Learning Point
A systematic review of prenatal mercury exposure and neurological development of the exposed children up to age 5 years reported “..the evidence for an association …. was weak. No pattern was identified by the age of child or study methodology. Any adverse effects may also be too small to be clinically detectable. Fish contains many essential nutrients involved in brain development, so where fish is the main source of dietary Hg, these other nutrients may compensate against the toxic effects of mercury. ” In this statement the authors are not discounting that there can be toxic effects, but are noting that the conclusions of individual studies may not be as robust or as clear to say that prenatal exposure is causing neurodevelopmental problems. It is a good example of trying to disentangle the multiplicity of the issues involved in understanding the potential Hg risks.

Fatty fish have higher levels of mercury and therefore the pros and cons of eating fatty fish must be balanced with the overall nutrition and risk of Hg. Two servings of fatty fish (3-4 ounces/serving) are recommended weekly that is broiled or baked. Frying is not recommended. High levels of mercury are found in shark, swordfish, king mackerel, and tile fish (also called golden snapper or golden bass) but low levels are found in anchovies, catfish, sardines, salmon, pollock, clams, oysters and shrimp. The fish listed as having high levels of mercury are not recommended to be consumed during pregnancy, breastfeeding and for young children.

Questions for Further Discussion
1. What heavy metals are considered the “big 5” for potential toxicity for humans?
2. What are the classes of environmental pollutants? A review can be found here
3. What are the benefits of Omega-3 fatty acids? A review can be found here

Related Cases

Disease: Mercury

Symptom/Presentation: Health Maintenance and Disease Prevention

Specialty: Nutrition / Dietetics | Pharmacology / Toxicology |
Physical Medicine and Rehabilitation / Physical Therapy

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Mercury

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Andreoli V, Sprovieri F. Genetic Aspects of Susceptibility to Mercury Toxicity: An Overview. IJERPH. 2017;14(1):93. doi:10.3390/ijerph14010093

Kadawathagedara M, de Lauzon-Guillain B, Botton J. Environmental contaminants and child’s growth. J Dev Orig Health Dis. 2018;9(6):632-641. doi:10.1017/S2040174418000995

Dack K, Fell M, Taylor CM, Havdahl A, Lewis SJ. Prenatal Mercury Exposure and Neurodevelopment up to the Age of 5 Years: A Systematic Review. IJERPH. 2022;19(4):1976. doi:10.3390/ijerph19041976

Fish and shellfish. nhs.uk. February 23, 2022. Accessed November 4, 2024. https://www.nhs.uk/live-well/eat-well/food-types/fish-and-shellfish-nutrition/

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Patient Presentation
A 5-year-old African-American female came to clinic for her kindergarten well-child exam. Her mother had no concerns until the physician reviewed the family history. She then became tearful as she said her mother had just been diagnosed with sarcoidosis and was having a lot of respiratory problems. She was worried that her daughter could also get it when she was older. The past medical history showed a history of mild intermittent asthma that was well-controlled with albuterol. The family history also showed the grandmother’s sister had died of some unknown lung problem in her 40s. There was diabetes in both sides of the family, and heart disease and stroke on the parental side. The review of systems was negative.

The pertinent physical exam revealed a talkative school-age child with growth parameters around the 75% and tracking. Her vital signs were normal. Her examination was normal.

The diagnosis of a healthy kindergartener was made and immunizations and patient education was given. The pediatrician noted that sarcoid was not very common but was more common in African-American patients. The mother also disclosed that she had a lingering cough from a recent upper respiratory infection and was afraid that she may also have sarcoidosis. They talked more about some of her fears including not wanting to see her own doctor because she was afraid. In the end the mother said she was going to make an appointment with her own doctor, and lived close enough to go with her mother to her next doctor’s appointment. “Maybe hearing it first-hand I can understand better and get some piece of mind for myself,” she said.

Discussion
Sarcoidosis is a chronic granulomatous disease causing multiorgan system disease of unknown pathophysiology. It appears that it has a genetic predisposition that may be triggered by an environmental cause such as contact with organic and inorganic materials.

Sarcoid is rare in adults and even rarer in children. The exact epidemiology is difficult to discern because of the rarity and also lack of international databases to chronicle the disease. In series, the incidence decreases with decreasing age generally. Estimates include 0.29 – 4.9/100,000 pediatric-aged patients. Some studies show male and female genders are the same, but other support an increased incidence in females. Also black children usually have higher incidence but it also depends largely on the population the patients are drawn from. There is a strong familial predisposition. Peak incidence is in 25-40 year olds.

There is no specific test for sarcoidosis. Chest radiograph shows a range of disease from nothing to intraparenchymal fibrosis. Mediastinal lymphadenopathy is common. Ultrasound of the liver and spleen may identify organ involvement. Skin, lymphatic and joint manifestations may be easier to note from physical examination. Laboratory testing is non-specific but may show signs of inflammation with elevated erythrocyte sedimentation rate, inflammatory anemia, hypergammaglobulinemia, and elevated transaminases. Angiotensin converting enzyme may be elevated as well. Biopsy of identified granulomas may show the more typical central follicle with peripheral macrophages and no necrosis. Biopsy also helps to rule out other diagnoses.

Treatment is based on adult disease and usually involves using corticosteroids. Other immunomodulator/suppressor therapy also is used. Although many children will have remission with no active disease and no treatment, it is a chronic disease which may recur and patients need to be monitored for long periods of time. There are no specific prognostic factors but children with pulmonary problems and those with more severe pulmonary problems, unsurprisingly, appear to have worse outcomes.

Some other diseases which have granulomatous manifestations include:

• Crohn’s disease
• Drug induced
• Granuloma annulare
• Immunodeficiency states
  • Chronic granulomatosis disease
  • Histiocytosis
  • Tumor
• Pneumonitis – aspiration, hypersensitivity
• Mycobacterium infections including tuberculosis
• Wegner’s granulomatosis

Learning Point
Sarcoid commonly presents with non-specific symptoms including fever, fatigue, weight loss or non-weight gain are very common. Chest problems include cough, chest pain and dyspnea.
Other potential signs include lymphadenopathy, hepatomegaly, splenomegaly, eye changes (uveitis), joint pain, and skin problems (nodules, plaques and papules).
Other systems can be affected as well but are less common. Young children often present with more non-specific symptoms and adolescents present more similar to adults which have more pulmonary manifestations.

Questions for Further Discussion
1. What is in the differential diagnosis of chronic cough? A review can be found here
2. What is in the differential diagnosis of weight loss or not gaining weight? A review can be found here
3. What are indications for a genetics consultation?

Related Cases

Disease: Sarcoidosis

Symptom/Presentation: Health Maintenance and Disease Prevention

Specialty: Allergy / Pulmonary Diseases | Immunology

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Sarcoidosis

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Lakdawala N, Ferenczi K, Grant-Kels JM. Granulomatous diseases: Kids are not just little people. Clinics in Dermatology. 2017;35(6):555-565. doi:10.1016/j.clindermatol.2017.08.006

Nathan N, Sileo C, Calender A, et al. Paediatric sarcoidosis. Paediatric Respiratory Reviews. 2019;29:53-59. doi:10.1016/j.prrv.2018.05.003

D’Ascenzi F, Valentini F, Pistoresi S, et al. Causes of sudden cardiac death in young athletes and non-athletes: systematic review and meta-analysis. Trends in Cardiovascular Medicine. 2022;32(5):299-308. doi:10.1016/j.tcm.2021.06.001

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

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Patient Presentation
A 3-year-old male came to clinic with a history of runny nose for 5 days. He had had some mild fever up to 38.2°C for the first 36 hours but hadn’t been bothered by it. He was drinking, urinating and playing well. “He just had a lot of clear runny nose and he keeps waking up at night and coming into our bed,” complained the mother. “Since he started at preschool he always seems to have a cold, and my mother was just diagnosed with sinusitis, so we’re both worried now,” his mother went on. The review of systems was positive for an occasional cough, but no emesis, rash, muscle pain or other pain.

The pertinent physical exam showed a healthy appearing boy with normal vital signs, and he was tracking at the 50% for weight. HEENT showed mild clear rhinorrhea of the nares bilaterally, no facial pain, and some clear rhinorrhea in the back of his throat. Ears and lungs were normal.

The diagnosis of a preschooler with a viral upper respiratory infection was made. The pediatrician discussed that sinusitis required a longer period of time to diagnose, and that he needed to have more significant symptoms. She discussed recent respiratory illnesses and ways to help the patient. She also discussed sleep hygiene techniques to help the patient stay in his own bed at night.

Discussion
Sinusitis and rhinitis are not the same thing. “Sinusitis is swelling of the sinus mucous membrane and/or exudate into the sinuses. Rhinitis is inflammation, engorgement or excessive secretions from the nasal mucous membranes that line the interior of the nasal cavity.” Sinusitis requires radiological imaging to diagnose but unfortunately there is huge overlap of radiological sinus changes that are not due to sinusitis itself. “…[S]ymptoms attributed to sinusitis correlate poorly with radiological evidence of sinus inflammation and radiological evidence of sinus inflammation correlates poorly with symptoms attributed to rhinitis.”

Similarly, clinical symptoms often attributed to sinusitis also have huge overlap with other problems including colored nasal discharge (green/yellow), headache, and facial pain. An author points out in one study that “Green snot was somewhat more likely to be associated with sinusitis by X-ray, but almost 30% of those without radiologic evidence of sinusitis also had green snot.”

It can be very difficult for the outpatient primary care clinician to make the diagnosis of acute bacterial sinusitis. Parents and patients appropriately want relief from symptoms that are causing discomfort. Children in childcare settings and school often have overlapping upper respiratory infections and those symptoms are almost identical to acute bacterial sinusitis. In general most URIs will improve within 10 days and may have a more benign course. However that may not necessarily be true for all patients.

Learning Point
Acute bacterial sinusitis is considered for patients with symptoms 12 weeks of symptoms. Chronic bacterial sinusitis is not further discussed here.

The American Academy of Pediatrics (AAP) Clinical Practice Guidelines has the following recommendations for the diagnosis and treatment of acute bacterial sinusitis in children:

Diagnosis of acute bacterial sinusitis can be made if one of the following scenarios is present:

• Persistent illness of > 10 days without improvement
  • Symptoms of nasal discharge of any quality or daytime cough
  • Antibiotic treatment is recommended to be started or additional 3 day outpatient monitoring can be offered as some patients will continue to improve on their own during this time
  • Worsening course after initial improvement
• Symptoms of worsening or new onset of nasal discharge, daytime cough or fever
• Antibiotic treatment is recommended to be started
• Severe onset
  • Symptoms of concurrent fever > 39°C and purulent nasal discharge for at least 3 days
  • Antibiotic treatment is recommended to be started

The usual bacteria cultured are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis. Initial antibiotic treatment is amoxicillin with or without clavulanic acid. Most patients will improve in 3 days. If not antibiotics can be changed to add clauvulanic acid or use other regimes.

The AAP also recommends that radiological imaging studies should not be obtained for the diagnosis of acute bacterial sinusitis but should be used for evaluation of potential complications.

Potential complications include:

• Orbital – 60-75% of complications
  • Abscess – orbital or subperiosteal
  • Cellulitis – orbital or preseptal
  • Cavernous sinus thrombosis
• Central nervous system
  • Abscess – brain, subdural or epidural
  • Cerebritis/encephalitis
  • Meningitis
• Bone
  • Osteomyelitis

Questions for Further Discussion
1. How often do you treat acute bacterial sinusitis?
2. What are surgical treatment options for complications of acute bacterial sinusitis?
3. What radiological studies would you order for possible complications of acute bacterial sinusitis?

Related Cases

Disease: Common Cold | Sinusitis

Symptom/Presentation: Rhinitis

Specialty: General Pediatrics | Infectious Diseases | Otolaryngology

Age: Preschooler

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Sinusitis

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-280. doi:10.1542/peds.2013-1071

Ramadan HH, Chaiban R, Makary C. Pediatric Rhinosinusitis. Pediatric Clinics of North America. 2022;69(2):275-286. doi:10.1016/j.pcl.2022.01.002

Weinberger M. Whither Sinusitis? Clin Pediatr (Phila). 2018;57(9):1013-1019. doi:10.1177/0009922818764927

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa