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His mother reported that the nail had developed a green discoloration and had begun to detach approximately 1 week prior to the visit.

A green nail after trauma in an 8-year-old boy

Efficacy for the kinase inhibitor was based on the ReNue (NCT03962543 ) trial that featured 58 adults and 56 pediatric patients. 

FDA approves mirdametinib for patients 2 years, older with neurofibromatosis type 1

A review of current guidelines in treatment and thromboprophylaxis.

Direct oral anticoagulants for venous thromboembolism in pediatrics

Samantha Dallefeld, MD, is an assistant professor in the Department of Pediatrics at Dell Medical School at The University of Texas at Austin and Dell Children’s Medical Center, both in Austin, Texas.

M pneumoniae infection is not a reportable disease, and testing is often not performed in the outpatient setting, limiting estimates of clinical prevalence and delaying recognition of community epidemics.

Atypical presentations of Mycoplasma pneumoniae amid a local outbreak

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The pediatrician's role is to support both the child with spina bifida and the family as they come to terms with this chronic illness. This article presents the 10 actions that are most important in preparing for and caring for a child with this complex health need.

Spina bifida: Top 10 things for physicians to know

**Editor's Note** Please note that starting January 1, 2025, we will be switching to an online-exclusive publication process. This will allow us to publish case submissions quicker without having to deal with the variables that come along with print publication. All cases will still be eligible for print publication consideration, but publication in our print magazine is not guaranteed and will be up to the editor's discretion. 

Do you have a puzzling pediatric case that you’d like to share with the readers of 

We are looking for intriguing diagnoses that have stumped the experts—a diagnostic “Puzzler”—to help our physicians enhance their day-to-day practices. If you have such a story to tell, tell us.

Here’s what to do: Before you begin, we suggest that first you review the Puzzler 

https://www.contemporarypediatrics.com/case-studies

. Please note the specific style required for writing Puzzler manuscripts.

Next, prepare a draft of your case, including a summary of the presenting symptoms, a case overview, a 

table of the differential diagnosis (MANDATORY)

, and the special aspects of your case that qualify it as a Puzzler, and send it to us. Please note that the differential diagnosis table should also be discussed in the body text. We’ll review your draft and let you know what you need to add or revise before we send the manuscript to peer review for evaluation.

Puzzlers vary in length, and we suggest a minimum of 1,200 words up to a maximum of 2,000 words, but that is because of the complexity of some cases and whether some patients returned for many assessments before their diagnoses were determined. Also, some authors describe the pathophysiology of the differentials in great detail. Please also note no more than 3 authors are allowed per article.

What's most important is to show us the process that you used to analyze the case, including:

Why you decided to order certain tests and why you did not order others.

Peer consultations or why you elected to contact other specialists.

Lab values including vital signs or blood tests.

Labs and values if your patient was attended to in the emergency department or other hospital departments such as radiology or neurology.

Discussion related to the possible diagnoses.

Final diagnosis, treatment, prognosis, and follow-up.

Remember to indicate numbered citations within the body of the text and include a complete list of corresponding literature/references at the end of the manuscript. (Do not use any citation management programs or unlink them.) 

Limit references to 25. No references (unless it is a seminal study) can be older than 10 years.

We prefer primary research as references, but some cases are so obscure that authors will need to pull from a variety of sources. However, 

. Be advised that peer reviewers are adamant that the disease/disorder you describe was actually diagnosed and not determined by index of suspicion on the basis of ruling out various differentials. We use AMA11 as our publication style, which uses superscript citation numbers and a corresponding numbered reference list. Please create your citations and references in this style.  Check this recent article posted online at 

https://www.contemporarypediatrics.com/view/the-rx-of-adhd

 for examples of reference style. IMPORTANT NOTE WITH AMA 11TH EDITION: PLEASE PUT DOI OR WEBSITES/URLS AT THE END OF THE REFERENCE LINE.

When you send your draft manuscript, also 

. These image files must be high-resolution jpg or tiff files (minimum of 300 dpi) and as large in size as possible. We suggest a minimum of 7 horizontal inches. The images must be original photos with clear permissions to use, not images from copyrighted sources. Send as separate attachments with your e-mail submission; do not embed images into your manuscript document.

After we receive your manuscript, our editors and peer reviewers will review your draft and let you know if we accept your submission for publication. 

Puzzler is one of the departments for which we receive the most submissions, so it may be several months after submission before you receive feedback from us.

If we do accept your submission for publication, we will contact you with further instructions.

Send your submissions in Microsoft Word format to 

, via e-mail to mpetronelli@mjhlifesciences.com

Guidelines for PUZZLER, Contemporary Pediatrics

 poll. Take a look at the following case below. After reading through the description, choose a multiple choice answer and try to guess the correct patient diagnosis. 

 on Wednesday, January 29 at 12:00 PM ET for the full case presentation, differential diagnoses, and the correct patient diagnosis. 

This case was provided by Nicholas W. Kieran, MS and Annuradha Goel, MD.

A 14-year-old girl presented to her primary care office with 2 weeks of vomiting that began when she tried to eat breakfast. She said she was feeling well up until that point, but then developed sudden onset vomiting and constant, 7/10, non-radiating chest pain centrally located at about the level of the second rib that remained unchanged since onset and slightly worsened when trying to eat. 

She was able to take in liquids but vomited all food, despite having an appetite. She denied feeling the food get stuck in her throat and endorsed continued vomiting of meals within 2 minutes of eating. She denied blood in the vomit and denied any abdominal pain. 

Urination was unchanged, and stools, although infrequent because of a lack of eating, continued to have their normal consistency and color. The patient did endorse some mild shortness of breath. This started around the same time as the other symptoms, but did not find it very bothersome. Her last sexual encounter was 3 months prior to this visit, just prior to Nexplanon (etonogestrel implant) insertion. Her last menstrual period was 2months prior to the visit.

On review of systems, she did not endorse palpitations, syncope, lightheadedness. She had increased her vape use recently but did not disclose when she started or how much she vaped. She had no recent travel and had not identified any extremity swelling. She was unsure if she had lost weight but had not been trying to lose any.

website on Wednesday, January 29, 2025, at 12:00 PM ET or later for an article featuring the full case presentation, differential diagnosis, and correct patient diagnosis.

The patient had increased her vape use recently, but did not disclose when she started, or how much she vaped. 

News

Case Studies

14-year-old girl presents with chest pain, 2-week history of vomiting

 poll. Take a look at the following case below. After reading through the description, choose a multiple choice answer and try to guess the correct patient diagnosis.

on Monday, January 6 at 12:00 PM ET for the full case presentation, differential diagnoses, and the correct patient diagnosis. 

This case was provided by Amar Davé, MD, FAAP and Pahroul Davé, APRN

A boy aged 10 years presented to the outpatient office with a history of painful nodules on the plantar surface of his bilateral feet 8 to 10 hours after spending time in a hot tub. He was unable to bear weight or put on socks and shoes due to his pain. The photos were taken soon after the painful and red papules appeared. The lesions affected the whole plantar aspect of both feet. Over the following 4 days, the nodules became less painful and red. 

Medical advice was sought on the fifth day of symptoms, and by this time, the child was improving clinically. He was stable with subcutaneous, mildly painful, fleshy nodules mostly populating the medial arch of the foot. His remaining clinical examination results were within a normal range. Further questioning of the child’s mother revealed that other children exposed to the hot tub experienced painful feet but without lesions. 

Due to the patient’s improving symptoms and the self-limiting nature of the illness, no tests or labs were ordered as the child was not acutely ill. No peer consultations or specialists were utilized.

Click here for the full case presentation, differential diagnoses, and the correct patient diagnosis, in a separate article.

The photos in this case were taken soon after the painful and red papules appeared.

Can you diagnose this boy with painful nodules on his feet?

A 14-year-old girl presented to her primary care office with 2 weeks of vomiting that began when she tried to eat breakfast. She said she was feeling well up until that point, but then developed sudden onset vomiting and constant, 7/10, non-radiating chest pain centrally located at about the level of the second rib that remained unchanged since onset and slightly worsened when trying to eat. She was able to take in liquids but vomited all food, despite having an appetite. She denied feeling the food get stuck in her throat and endorsed continued vomiting of meals within 2 minutes of eating. She denied blood in the vomit and denied any abdominal pain.

Urination was unchanged, and stools, although infrequent because of a lack of eating, continued to have their normal consistency and color. The patient did endorse some mild shortness of breath. This started around the same time as the other symptoms, but did not find it very bothersome. Her last sexual encounter was 3 months prior to this visit, just prior to Nexplanon insertion. Her last menstrual period was 2 months prior to the visit.

She had a past medical history including Nexplanon insertion eight weeks prior to presentation for this visit. She was told she had asthma as a younger child but had no documented diagnosis or history of treatment. She took no medications and had no allergies. She had no drug or alcohol use outside of vaping. She lived with her foster mother and was unaware of her family history.

The patient was afebrile, normotensive, with a pulse of 126 and an SPO2 of 95% on room air. Her weight was 51kg with a BMI of 20.86. Her weight 6 weeks prior to this visit was 53.1kg. She appeared uncomfortable but not in acute distress, and was able to answer questions appropriately. On respiratory exam, she had wheezing throughout all lung fields with an inspiratory pop and poor air movement. She did not use any accessory muscles for respiration. After receiving an albuterol treatment in office there was no improvement on exam, although the patient did feel subjective improvement. A cardiovascular exam demonstrated normal S1 and S2 without murmurs, rubs, or gallops. The Abdominal exam was soft and nontender throughout with normal bowel sounds and without distension.

Urinalysis was obtained, which demonstrated increased specific gravity, protein, ketones urobilinogen, and small bilirubin with negative nitrites and leukocyte esterase (

). A urine B-HCG was also performed and was negative.

Differential diagnosis at this stage included gastritis vs gastroenteritis, gastric ulcer, asthma, EVALI, and pneumonia (

). Gastritis and gastroenteritis could explain the vomiting but would be atypical causes of the shortness of breath. The patient also had no diarrhea or abdominal pain that may be associated with these diagnoses. Both asthma and e-cigarette and vaping product use-associated lung injury (EVALI) in the setting of active vape use could explain the pulmonary symptoms but were less likely causes of the vomiting. Finally, pneumonia could cause the shortness of breath and cough, but no crackles were heard on pulmonary exam, and the patient had no fever for the duration of the two-week presentation. She also said that vomiting occurred after eating, unrelated to her cough.

Given her lack of objective improvement with albuterol treatment, an SPO2 of 95% on room air, and lack of explanation for the inability to take in food, she was referred to an imaging center for a chest X-Ray. Results demonstrated a left lingular pneumonia with minimal left pleural effusion and perihilar peribronchial thickening (

Vomiting is a frequent cause of healthcare visits in the pediatric population and includes a wide differential diagnosis, frequently from gastrointestinal infections that resolve without provider intervention

. While the pathophysiology of vomiting is multifaceted, one pathway is mechanical, by which excessive stretching or irritation of the wall of the intestine results in increased activation of serotonin and neurokinin receptors and subsequent vomiting

Community acquired pneumonia is a relatively rare diagnosis in the pediatric patient that most commonly presents with fever, cough, tachypnea, and occasionally abdominal pain

. Sequela of typical community-acquired pneumonia (CAP) can include abscess formation, necrotizing pneumonia, and sepsis. While the presentation of pneumonia can vary widely, vomiting as the primary chief complaint is rare. Given the proximal nature of the stomach and lung in the pediatric patient, it is possible that mechanical disruption of the stomach by infected or inflamed lung tissue could result in such a presentation.

For patients with a possible diagnosis of CAP, differential diagnosis frequently includes asthma, as it is highly prevalent in children. With the increased use of e-cigarettes (vapes), e-cigarette and vaping product use-associated lung injury (EVALI) is an increasingly frequent diagnosis, with over 2900 diagnoses and 68 deaths attributed to EVALI from the first diagnosed case in June of 2018 to February 2020

. The treatment of each of these diseases differs widely, and thus accurate diagnosis is imperative for symptom resolution.

The patient was prescribed a 7-day course of Augmentin for her lingular pneumonia identified on chest X-Ray. Given her significant wheezing on exam and possible history of asthma, she was prescribed an albuterol inhaler for at home use and a 5-day course of oral prednisone 60mg. She was instructed to use the albuterol inhaler three puffs every 4 hours for 2 days, followed by 3 puffs, 3 times per day for 3 days.

She and her foster mother were called one day after diagnosis to assess her status. She expressed improvement in her shortness of breath and an ability to eat very small bites of food without vomiting. One week later, she returned for in-office evaluation, and she expressed significant improvement. She was able to eat without issue and felt that her shortness of breath had improved with antibiotic, albuterol, and steroid use. She had not vaped since her previous visit. On exam, she did have continued wheezing, though air movement was noted to be improved compared to her previous visit. Given her continued wheezing, she was instructed to continue using her albuterol inhaler at 2 puffs, 3 times daily for the next 5 days, followed by as-needed use.

This patient’s presentation of vomiting with only mild shortness of breath had a wide differential. Her subjective presentation of vomiting immediately after food intake with only mild shortness of breath was a highly unique presentation of pneumonia. Her objective presentation was similarly abnormal, with exam findings of tachycardia with decreased SPO2 of 95% without fever and with diffuse wheezing without crackles. The gastrointestinal aspect of her presentation led us to expect a gastritis or gastroenteritis, but the overlying pulmonary symptoms led us towards EVALI or asthma, with a combination of the two as the presumed diagnosis.

Without benefit from a nebulizer treatment, our differential expanded to include more atypical causes, including the eventual diagnosis of pneumonia. Pneumonia has previously been identified as a cause of vomiting in the pediatric patient, but it most often presents with post tussive vomiting

In this case, the working hypothesis for cause of the vomitus is that the lingula of the lung, inflamed by infection, pressed against the stomach, such that when she tried to eat and the stomach received the food bolus or contracted, the irritation caused immediate vomiting.

To our knowledge, this is a unique presentation of pneumonia that has not been previously published, and with the vagueness of symptoms and immediate need for antibiotics to allow for any amount of oral intake, is an important clinical situation for providers to be aware of.

While amoxicillin is considered the first line treatment for CAP in adolescents who are fully vaccinated 

, Augmentin was prescribed for broader coverage in case of aspiration given her excessive vomiting. While identifying the causative organism of such a presentation would have been of interest, a sputum sample was not collected.

The role of vape use in this case is unclear; it is possible that vaping contributed to the entrance of pathogens to the lung parenchyma and facilitated the infectious process, or that chronic inflammation caused by sudden use of the vape impaired the immune response. Notably, the patient’s duration and extent of vape use could not be elucidated during the patient interview, so it is unclear exactly how much this may contribute.

This case presented a unique case of lingular pneumonia in a 14-year-old patient with overlying asthma, possibly worsened by vape use. It is imperative to include pneumonia in the differential for illnesses that may not be explained by more common diagnoses, and which do not respond to initial treatment, even when hallmark signs and symptoms of pneumonia (fever, crackles on exam) are not present. 

We would like to acknowledge the patient and her foster mother for giving us permission to publish this case study. 

Shields TM, Lightdale JR. Vomiting in Children. 

. 2018;39(7):342-358. doi: https://doi.org/10.1542/pir.2017-0053

Zhong W, Shahbaz O, Teskey G, et al. Mechanisms of Nausea and Vomiting: Current Knowledge and Recent Advances in Intracellular Emetic Signaling Systems. 

International Journal of Molecular Sciences

. 2021;22(11):5797. doi: https://doi.org/10.3390/ijms22115797

Fotsch DM, Fox J, Snedden TR. Unexpected Pneumonia Diagnosis From Pediatric Abdominal Pain: A Case Report. 

. 2022;36(2):170-173. doi: https://doi.org/10.1016/j.pedhc.2021.10.005

Corcoran A, Carl JC, Rezaee F. The importance of anti‐vaping vigilance—EVALI in seven adolescent pediatric patients in Northeast Ohio. 

. 2020;55(7):1719-1724. doi: https://doi.org/10.1002/ppul.24872

Chee, E., Huang, K., Haggie, S., & Britton, P. N. Systematic review of clinical practice guidelines on the management of community acquired pneumonia in children. 

Jodi K Wenger, MD

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