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Dissecting cellulitis of the scalp (DCS) is a rare inflammatory condition that progresses from papules and pustules to nodules and abscesses, ultimately leading to cicatricial alopecia. It primarily affects African men between the ages of 15 and 62, with exceptionally low prevalence in children. A milder form, described as "alopecic and aseptic nodules of the scalp" (AANS), presents as aseptic nodules associated with non-scarring alopecia and has a good prognosis. We report two atypical cases of DCS in Hispanic pediatric patients: an 18-month-old female infant and an 11-year-old male child who had a rapid and favorable clinical resolution consistent with AANS.

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BACKGROUND: Tuberculosis (TB) infectiousness decreases significantly with only a few days of treatment, but delayed diagnosis often leads to late treatment initiation. We conducted a sequential explanatory mixed methods study to understand the barriers and facilitators to prompt diagnosis among people with TB. METHODS: We enrolled 100 adults who started TB treatment in the Carabayllo district of Lima, Peru, between November 2020 and February 2022 and administered a survey about their symptoms and healthcare encounters. We calculated total diagnostic delay as time from symptom onset to diagnosis. We conducted semi-structured interviews of 26 participants who had a range of delays investigating their experience navigating the health system. Interview transcripts were inductively coded for concepts related to diagnostic barriers and facilitators. RESULTS: Overall, 38% of participants sought care first from public facilities and 42% from the private sector. Only 14% reported being diagnosed with TB on their first visit, and participants visited a median of 3 (interquartile range [IQR] health facilities before diagnosis. The median total diagnostic delay was 9 weeks (interquartile range [IQR] 4-22), with a median of 4 weeks (IQR 0-9) before contact with the health system and of 3 weeks (IQR 0-9) after. Barriers to prompt diagnosis included participants attributing their symptoms to an alternative cause or having misconceptions about TB, and leading them to postpone seeking care. Once connected to care, variations in clinical management, health facility resource limitations, and lack of formal referral processes contributed to the need for multiple healthcare visits before obtaining a diagnosis. Facilitators to prompt diagnosis included knowing someone with TB, supportive friends and family, referral documents, and seeing a pulmonologist. CONCLUSIONS: Misinformation about TB among people with TB and providers, poor accessibility of health services, and the need for multiple encounters to obtain diagnostic tests were major factors leading to delays. Extending the hours of operation of public health facilities, improving community awareness and provider training, and creating a formal referral process between the public and private sectors should be priorities in the efforts to combat TB.

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Pemphigus foliaceus (PF) is an autoimmune blistering disorder which affects the superficial layers of the epidermis with rare mucosal involvement. We present the case of a 12-year-old girl with PF involving the eyes and eyelids. A literature review of pediatric nonendemic PF revealed another two cases with ocular manifestations. Eyelid involvement is an uncommon feature of PF that should be properly identified and treated.

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BACKGROUND: The COVID-19 pandemic disrupted TB services worldwide, leading to diagnostic delays. There have been few published reports describing how the pandemic affected people's pathway to diagnosis from their own perspectives. We sought to evaluate the impact on the pandemic on people's experiences obtaining a TB diagnosis. METHODS: We performed a mixed-methods study, enrolling newly diagnosed TB patients from 12 health centers in Lima, Peru. We used structured surveys to quantify diagnostic delay, defined as the time between symptom onset and diagnosis, and in-depth interviews to understand the ways in which the pandemic affected the pathway to care. We compared diagnostic delay between patients enrolled during the first year of the pandemic to those diagnosed after using a Wilcoxon rank-sum test. We used an inductive content analysis approach to analyze interview content related to the pandemic. RESULTS: We enrolled 51 patients during November 2020-April 2021 (during the first year of the pandemic) and 49 patients during October 2021-February 2022. Median diagnostic delay was longer for patients diagnosed during the first year of the pandemic (median 15 [IQR 5-26] weeks compared to 6 [IQR 3-18] weeks, p = 0.027). Qualitative analysis of 26 interviews revealed that the pandemic affected participants' care-seeking behavior and their ability to access to TB diagnostic services, particularly for those diagnosed in the first year of the pandemic. Many participants initially had their symptoms attributed to COVID-19, resulting in delayed TB evaluation and additional costs for COVID-19 treatment. CONCLUSIONS: The COVID-19 pandemic impacted multiple steps in the pathway to care for TB patients in Lima, causing delays in TB diagnosis. These findings demonstrate how the shifting of health care resources to prioritize COVID-19 can lead to collateral damage for people with TB and other conditions.

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Mobile screening units can help close tuberculosis case detection gaps. Placing screening units where people at high risk for undiagnosed tuberculosis preferentially spend time could make screening more resource-effective. We conducted a case-control study in Lima, Peru to identify locations where people with tuberculosis were more likely to spend time than community controls. We surveyed participants about activity locations over the past 6 months. We used density-based clustering to assess how patient and control activity locations differed, and logistic regression to compare location-based exposures. We included 109 tuberculosis patients and 79 controls. In density-based clustering analysis, the two groups had similar patterns of living locations, but their work locations clustered in distinct areas. Both groups were similarly likely to use public transit, but patients predominantly used buses and were less likely to use rapid transit (adjusted odds ratio [aOR] 0.31, 95% confidence interval [CI] 0.10-0.96) or taxis (aOR 0.42, 95% CI 0.21-0.85). Patients were more likely to have spent time in prison (aOR 11.55, 95% CI 1.48-90.13). Placing mobile screening units at bus terminals serving locations where tuberculosis patients have worked and within and around prisons could help reach people with undiagnosed tuberculosis.

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Morphea and facial capillary malformations (port-wine stains) are distinct conditions that can affect the pediatric population. Early localized morphea mimicking a capillary malformation is an uncommon clinical presentation. We present two new cases of girls, aged 2 and 3 years, who presented with erythematous patches, initially diagnosed as capillary malformations, which were later diagnosed as morphea. We also performed a literature review, yielding 12 additional cases that underscore that the unusual presentation of morphea may delay correct diagnosis. Although early management of morphea reduces long-term sequelae, it is important to delay laser treatment for selected acquired vascular malformations, until the diagnosis of morphea is excluded.

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The present study examined the association of juvenile psychopathy features and treatment response in a sample of 102 youth, court adjudicated for sexual offenses and followed up more than 11 years in the community. The Psychopathy Checklist: Youth Version (PCL: YV) was rated from comprehensive archival sources, along with a youth sexual offense risk assessment and treatment planning measure scored pre-and posttreatment. The PCL: YV converged with domains of sexual offense risk and change in conceptually meaningful ways, and significantly predicted nonsexual violent, general violent, and any recidivism; it did not significantly predict sexual recidivism. Higher levels of psychopathy-related personality features were significantly associated with noncompletion of youth sexual offense-specific treatment, while changes in risk were associated with decreased recidivism controlling for PCL: YV score and baseline risk at p < .10. The findings underscore the importance of intervention and support services for youth convicted of sexual offenses as well as the clinical and risk relevance of the juvenile psychopathy construct to decrease violent victimization to others.

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Fibroepithelial polyps are common tumors of mesodermal origin. However, only a few case reports of giant fibroepithelial polyps have been published, and they have mainly involved adults. This case report describes a 3-month-old boy with a pedunculated mass in the scrotum. To our knowledge, this is the first report of a giant congenital fibroepithelial polyp on this location.

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RESUMEN Choque séptico con disfunción multiorgánica tiene una tasa de mortalidad mayor de 50%. Se presenta el caso de un varón que cursó con choque séptico con disfunción multiorgánica, secundario a bacteriemia por Staphylococcus aureus meticilino sensible, con foco de partida dérmico - partes blandas, quien presentó lesiones alveolo nodulares, pericarditis supurativa, lesiones embolicas a nivel dérmico, ocular y renal; recibió soporte en la unidad de cuidados intensivos, tratamiento antibiótico con oxacilina más vancomicina, pericardiectomia subtotal y drenaje pleural. Salió de alta estable para continuar tratamiento. Presentamos este caso para destacar la gravedad de la bacteriemia por Staphylococcus aureus meticilino sensible, con compromiso multiorgánico y así poder tomar medidas terapéuticas agresivas para disminuir la morbilidad y mortalidad por el mismo.

SUMMARY Septic Septic shock with multi organ dysfunction is associated with a mortality above 50%. We present here the case of a young male patient who presented with septic shock and multi organ dysfunctions secondary to methicillinsusceptible Staphylococcus aureus from a skin and soft tissue infection presenting with alveolar-nodular pulmonary lesions, purulent pericarditis and septic embolic lesions on the skin, eyes and kidneys. The patient was admitted to the ICU receiving antibiotic coverage with oxacillin and vancomycin, subtotal pericardiectomy and pleural drainage, and was discharged clinically stable. We present this case to draw attention to the severity of S. aureus bacteremia to initiate prompt aggressive therapeutic measures to ameliorate associated morbidity and mortality.

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BACKGROUND AND OBJECTIVES: Skin diseases are a common reason for emergency department (ED) consultations; however, few studies have focused on pediatric patients. Diagnostic consistency between ED physicians and dermatologists varies from 43% to 58%, meaning many patients seeking emergency care may receive incorrect diagnoses and treatments. We aimed to determine the diagnostic concordance between ED physicians and pediatric dermatologists. METHODS: We conducted a prospective study including all pediatric patients (<18 years) who were seen for a skin condition at the ED from December 1, 2017, to June 1, 2018, and consented to participate. We classified diagnoses according to their etiology. Patients were diagnosed by ED trainees and attending physicians, followed by blinded pediatric dermatology trainees and attending physicians. We evaluated concordance using Fleiss's kappa coefficient (κ) with a 95% confidence interval. We further stratified the data by level of training. RESULTS: We included 185 patients. Inflammatory conditions were the most common reason for consultation, followed by infections; 10 patients required hospitalization. Concordance between diagnoses given at the ED and at the dermatology clinic was moderate (κ 0.472, 95% CI: 0.389-0.455) with 62.7% agreement. Concordance between different diagnostic categories was lowest for autoimmune disorders and drug reactions (κ 0.392 with 95% CI: 0.248-0.536 and κ 0.258 with 95% CI: 0.114-0.402). CONCLUSIONS: Diagnostic concordance between ED physicians and dermatologists was moderate and differed according to training level and diagnoses. Dermatological education for ED providers, specifically focusing on autoimmune disorders and drug reactions, may improve diagnostic accuracy and patient care.

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BACKGROUND/OBJECTIVES: Bart syndrome was initially described as association of congenital absence of skin (CAS), nail abnormalities, and epidermolysis bullosa (EB). Further reports of patients with CAS and EB have been made with wide clinical heterogeneity among them. Current guidelines recommend the elimination of eponyms and use of the descriptive term EB with CAS. METHODS: We performed a PubMed and Medline database search of patients with Bart syndrome or EB with CAS. We included case reports or case series that contained clinical and demographic information. RESULTS: After review, 55 articles were included, reporting 96 patients. CAS involved the lower extremities in all patients, with additional upper limb, trunk, or head involvement in 17%. In all patients, the time to healing ranged from 2 weeks to 6 months; most received only conservative treatment. The subtype and frequency of associated EB most frequently reported were recessive dystrophic EB (41.4%) and dominant dystrophic EB (22.8%). Extracutaneous features were present in 29 patients; with pyloric atresia and ear malformations being the most common. The prognosis varied based on the subtype of EB and the presence of additional comorbidities; 50% of the patients with junctional EB with pyloric atresia and CAS died during the first months of life, while mortality among those with recessive dystrophic EB was 6.8%. CONCLUSION: Epidermolysis bullosa with CAS is a clinically heterogeneous disorder, most often associated with recessive dystrophic EB, but other EB subtypes may occur. Further investigations are necessary to better establish a pathological mechanism for CAS, and its association with EB.

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Actinic prurigo (AP) is an immune-mediated photodermatosis that usually starts in childhood and is predominant among American indigenous and mestizo communities. In adults with AP, thalidomide is the treatment of choice; however, there is little information on its use in pediatric patients. We report the case of a 10-year-old girl with AP treated successfully with thalidomide.

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The present study examined the validity and reliability of a youth sexual offense risk assessment and treatment planning tool, the Violence Risk Scale-Youth Sexual Offense Version (VRS-YSO), on a sample of 102 court-adjudicated youth referred to assessment and/or treatment outpatient services followed up an average of 11.7 years in the community. VRS-YSO scores demonstrated "good" to "excellent" interrater reliability (intraclass correlation coefficients [ICCs] = .64-.83). Exploratory factor analysis (EFA) of the static and dynamic items identified three latent dimensions consistent with the extant risk literature labeled Sexual Deviance, Antisocial Tendencies, and Family Concerns. VRS-YSO scores showed strong patterns of convergence with scores from the Estimate of Risk for Adolescent Sexual Offense Recidivism (ERASOR), Juvenile Sex Offender Assessment Protocol-II (J-SOAP-II), and the Juvenile Sexual Offense Recidivism Risk Assessment Tool-II (J-SORRAT-II). VRS-YSO scores, in turn, demonstrated moderate to high predictive accuracy for sexual, violent (sexual and nonsexual), and general recidivism (significant areas under curve [AUCs] = .67-.88). Examination of pre-posttreatment change data on the subset of youth who attended treatment services found VRS-YSO change scores to be significantly associated with reductions in general recidivism, but not other recidivism outcomes. Future research and clinical applications of the VRS-YSO in youth sexual offense assessment and treatment planning are discussed.

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Resumen: Introducción: El ataque cerebrovascular (ACV) es una lesión del parénquima cerebral por compromiso vascular, pudiendo ser hemorrágico o isquémico. Presenta alta morbimortalidad, siendo la segunda causa de muerte a nivel mundial, tercera en nuestro país, que genera además elevados costos sanitarios. Conocer las etiologías más frecuentes de esta patología, su asociación con factores de riesgo y el tratamiento realizado, podría contribuir a la correcta elaboración de estrategias de prevención primaria y secundaria. Objetivos: Conocer la/s etiología/s del ACV en pacientes internados en salas de medicina interna del Hospital Pasteur, sus características epidemiológicas; la asociación entre los factores de riesgo, paraclínica solicitada y tratamiento sugerido al alta. Metodología: Estudio descriptivo, transversal, observacional. Se incluyeron pacientes mayores de 18 años con diagnóstico de ACV internados en las salas de medicina del Hospital Pasteur, entre el 15 de Julio y el 30 de Septiembre del 2019. Se realizó la recolección de datos a partir de las historias clínicas por medio de un formulario precodificado, que analizó variables categóricas como factores de riesgo, presentación clínica, paraclínica solicitada y tratamiento. Resultados y discusión: Se incluyeron 30 pacientes, 18 de sexo femenino. La media de edad fue 70,48 años. La naturaleza isquémica predominó en un 90%. Los principales factores de riesgo fueron hipertensión arterial, dislipemia, diabetes mellitus y tabaquismo. El síndrome piramidal fue la forma de presentación clínica más frecuente. La etiología más prevalente fue de causa indeterminada, seguida por la ateroesclerótica y cardioembólica. En algunos pacientes no se realizó el algoritmo diagnóstico completo. El tratamiento realizado fue el adecuado de acuerdo a las causas planteadas. Conclusiones: La etiología más frecuente fue de causa indeterminada, seguida por la aterotrombótica. Los factores de riesgos más prevalentes fueron la hipertensión arterial, la dislipemia, la diabetes mellitus y el tabaquismo. La mayoría de los pacientes tenían más de 3 factores de riesgo asociados, de esta forma concluimos que la sumatoria de factores de riesgo incrementa la incidencia de ACV.

Abstract: Introduction: A stroke is a parenchymal cerebral lesion due to vascular compromise. This could be either hemorrhagic or ischemic. It presents high morbidity and mortality, being the second cause of death in the world and third in Uruguay, causing elevated health expenses. Recognizing the most frequent etiologies, their association with different risks factors and treatments applied could help to create better primary and secondary prevention strategies. Objectives: recognized stroke`s etiologies in patients hospitalized in Hospital Pasteur`s rooms, their epidemiologic characteristics, risk factors associated, the requested paraclinic and the treatment before they leave the hospital. Methods: Descriptive, observational and transversal study. We included patients older than 18 years old, with a stroke diagnosis, admitted into Hospital Pasteur medical`s rooms, between July 15 and September 30, 2019. Data were collected from medical records by accepting an informed consent, which analyzed variables such as risk factors, clinical presentation, requested preclinical and treatment. Results and discussion: 30 patients were included, 18 were female. The average age was 70,48 years. Ischemic strokes were predominated by 90%. Hypertension, dyslipidemia, diabetes mellitus and smoking were the predominant risk factors. Pyramidal syndrome was the most frequent clinical presentation. Undetermined stroke was the principal etiology, followed by atherosclerotic and cardioembolic. There were some patients that the algorithm was not completed. Treatments were adequate according to the causes. Conclusions: The most frequent etiology was the undetermined cause, followed by atherothrombotic. Prevalent risk factors were hypertension, dyslipidemia, DM and smoking. Most of the patients had more than 3 associated risk factors, so we conclude that the sum of risk factors increases the incidence of stroke.

Resumo: Introdução: O ataque cerebrovascular (AVC) é uma lesão do parênquima cerebral por comprometimento vascular, podendo ser hemorrágico ou isquêmico. Apresenta alta morbimortalidade, sendo a segunda principal causa de morte no mundo, a terceira em nosso país, o que também gera altos custos de saúde. Conhecer as etiologias mais frequentes dessa patologia, sua associação com fatores de risco e o tratamento realizado, poderia contribuir para o correto desenvolvimento de estratégias de prevenção primária e secundária. Objetivos: Conhecer a etiologia / s do AVC em pacientes internados nas salas de medicina interna do Hospital Pasteur, suas características epidemiológicas; a associação entre fatores de risco, solicitou tratamento paraclínico e sugerido no momento da alta. Metodologia: Estudo descritivo, transversal, observacional. Entre 15 de julho e 30 de setembro de 2019, foram incluídos pacientes com idade superior a 18 anos com diagnóstico de AVC admitidos nas salas médicas do Hospital Pasteur. Os dados foram coletados dos prontuários por meio de formulário pré-codificado, que analisou variáveis ​​categóricas como fatores de risco, apresentação clínica, solicitação paraclínica e tratamento. Resultados e discussão: foram incluídos 30 pacientes, 18 do sexo feminino. A idade média foi de 70,48 anos. A natureza isquêmica predominou em 90%. Os principais fatores de risco foram pressão alta, dislipidemia, diabetes mellitus e tabagismo. A síndrome piramidal foi a apresentação clínica mais frequente. A etiologia mais prevalente foi de causa indeterminada, seguida de aterosclerótica e cardioembólica. Em alguns pacientes, o algoritmo diagnóstico completo não foi realizado. O tratamento foi adequado de acordo com as causas. Conclusões: A etiologia mais frequente foi de causa indeterminada, seguida de aterotrombótica. Os fatores de risco mais prevalentes foram hipertensão, dislipidemia, DM e tabagismo. A maioria dos pacientes apresentou mais de três fatores de risco associados, concluindo que a soma dos fatores de risco aumenta a incidência de acidente vascular cerebral.