Contributor: Geoff Hogan MD

Educational Pearls:

• Penicillin allergies are relatively uncommon despite their frequent reports

• • 10% of the population reports a penicillin allergy but only 5% of these cases are clinically significant

  • 90-95% of patients may tolerate a rechallenge after appropriate allergy evaluation

• Penicillin Allergy Decision Rule (PEN-FAST) on MD Calc

• • Useful tool to assess patients for penicillin allergies

  • Five years or less since reaction = 2 points (even if unknown)

  • Anaphylaxis or angioedema OR Severe cutaneous reaction = 2 points

  • Treatment required for reaction (e.g. epinephrine) = 1 point (even if unknown)

• A score of 0 on PEN-FAST indicates a less than 1% risk of a positive penicillin allergy test

• • A score of 1 or 2 indicates a 5% risk of a positive penicillin allergy test

• A low score on PEN-FAST should prompt clinicians to proceed with the best empiric antibiotic for the patient’s infection

References

1. Broyles AD, Banerji A, Barmettler S, et al. Practical Guidance for the Evaluation and Management of Drug Hypersensitivity: Specific Drugs [published correction appears in J Allergy Clin Immunol Pract. 2021 Jan;9(1):603. doi: 10.1016/j.jaip.2020.10.025.] [published correction appears in J Allergy Clin Immunol Pract. 2021 Jan;9(1):605. doi: 10.1016/j.jaip.2020.11.036.]. J Allergy Clin Immunol Pract. 2020;8(9S):S16-S116. doi:10.1016/j.jaip.2020.08.006

2. Piotin A, Godet J, Trubiano JA, et al. Predictive factors of amoxicillin immediate hypersensitivity and validation of PEN-FAST clinical decision rule [published correction appears in Ann Allergy Asthma Immunol. 2022 Jun;128(6):740. doi: 10.1016/j.anai.2022.04.005.]. Ann Allergy Asthma Immunol. 2022;128(1):27-32. doi:10.1016/j.anai.2021.07.005

3. Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin Allergy: A Review. JAMA. 2019;321(2):188-199. doi:10.1001/jama.2018.19283

4. Trubiano JA, Vogrin S, Chua KYL, et al. Development and Validation of a Penicillin Allergy Clinical Decision Rule. JAMA Intern Med. 2020;180(5):745-752. doi:10.1001/jamainternmed.2020.0403

Summarized & edited by Jorge Chalit, OMS3

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Contributor: Travis Barlock, MD

Educational Pearls:

• Key clinical considerations when managing heart transplant patients due to their unique pathophysiology

• 1. Arrhythmias

• • A transplanted heart is denervated, meaning it lacks autonomic nervous system innervation

  • • The lack of vagal tone results in an increased resting heart rate

    • Adenosine can be used since it primarily slows conduction through the AV node

    • Atropine is ineffective in treating transplant bradyarrhythmia because its mechanism is to inhibit the vagus nerve - but the heart lacks vagal tone

  • Allograft rejection can also cause tachycardia

  • • Consult transplant surgery - treatment is usually 500 mg methylprednisolone

• 2. Rejection

• • Transplant patients are administered immunosuppressants

  • Clinical presentation of acute rejection looks similar to heart failure with increased BNP, increased troponin, and pulmonary edema

  • Cardiac allograft vasculopathy is a form of chronic rejection

  • Patients will not report chest pain due to denervated heart

  • • Symptoms are usually weakness and fatigue

• 3. High risk of infection due to immunosuppression

• • Increased risk of infections which includes CMV, legionella, tuberculosis, etc

  • Immunosuppressants have side effects such as acute kidney injury or pancytopenia

• 4. Radiographic Cardiomegaly

• • A study found that radiographic cardiomegaly does not connote heart failure

  • They hypothesized it is instead the result of a mismatch between the size of the transplanted heart and the space in the thoracic cavity

References

1. Murphy JD, Mergo PJ, Taylor HM, Fields R, Mills RM Jr. Significance of radiographic cardiomegaly in orthotopic heart transplant recipients. AJR Am J Roentgenol. 1998 Aug;171(2):371-4. doi: 10.2214/ajr.171.2.9694454. PMID: 9694454.

2. Park MH, Starling RC, Ratliff NB, McCarthy PM, Smedira NS, Pelegrin D, Young JB. Oral steroid pulse without taper for the treatment of asymptomatic moderate cardiac allograft rejection. J Heart Lung Transplant. 1999 Dec;18(12):1224-7. doi: 10.1016/s1053-2498(99)00098-4. PMID: 10612382.

3. Pethig K, Heublein B, Wahlers T, Dannenberg O, Oppelt P, Haverich A. Mycophenolate mofetil for secondary prevention of cardiac allograft vasculopathy: influence on inflammation and progression of intimal hyperplasia. J Heart Lung Transplant. 2004 Jan;23(1):61-6. doi: 10.1016/s1053-2498(03)00097-4. PMID: 14734128.

Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3

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Contributor: Taylor Lynch, MD

Educational Pearls:

• Pediatric febrile seizures are defined as seizures that occur between the ages of six months to five years in the presence of a fever greater than or equal to 38.0 ºC (100.4 ºF). It is the most common pediatric convulsive disorder, with an incidence between 2-5%

• What are the types of seizures?

• • Simple: Tonic-clonic seizure, duration <15 minutes, only one occurrence in a 24-hour period, ABSENCE of focal features, ABSENCE of Todd’s paralysis

  • Complex: Duration >15 minutes, requires medication to stop the seizing, multiple occurrences in a 24-hour period, PRESENCE of focal features, PRESENCE of Todd’s paralysis

• What are the causes?

• • Caused by infectious agents leading to fever. Seen with common childhood infections.

  • It is debated whether the absolute temperature of the fever or the rate of change of temperature incites the seizure, but current evidence points to the rate of change of the temperature being the primary catalyst

• What are the treatment considerations?

• • For simple febrile seizures, work-up is similar to any pediatric patient presenting with a fever between the ages of six months and five years

  • Thorough physical exam to rule out any potential of meningeal or intracranial infections

  • Prophylactic antipyretics are not believed to prevent the occurrence of febrile seizures

• Disposition?

• • If the patient has returned to normal baseline behavior following a simple febrile seizure, and the physical exam is reassuring, the patient can be discharged home.

  • Additional labs, electroencephalogram, or lumbar punctures are not indicated in simple febrile seizures as long as the physical exam is completely normal

  • Any evidence of a complex seizure requires further workup

• Fast Facts:

• • Patients with a familial history of febrile seizures and developmental delays have a higher risk of developing febrile seizures

  • If a child has one febrile seizure, there is a 30-40% chance of another febrile seizure by age 5

  • Only 2-7% of children with febrile seizures go on to develop epilepsy

References:

1. Berg AT, Shinnar S, Hauser WA, Alemany M, Shapiro ED, Salomon ME, et al. A prospective study of recurrent febrile seizures. N Engl J Med. 1992 Oct 15;327(16):1122–7.

2. Schuchmann S, Vanhatalo S, Kaila K. Neurobiological and physiological mechanisms of fever-related epileptiform syndromes. Brain Dev. 2009 May;31(5):378–82.

3. Nilsson G, Westerlund J, Fernell E, Billstedt E, Miniscalco C, Arvidsson T, et al. Neurodevelopmental problems should be considered in children with febrile seizures. Acta Paediatr. 2019 Aug;108(8):1507–14.

4. Subcommittee on Febrile Seizures, American Academy of Pediatrics. Neurodiagnostic evaluation of the child with a simple febrile seizure. Pediatrics. 2011 Feb;127(2):389–94.

5. Pavlidou E, Panteliadis C. Prognostic factors for subsequent epilepsy in children with febrile seizures. Epilepsia. 2013 Dec;54(12):2101–7.

6. Huang CC, Wang ST, Chang YC, Huang MC, Chi YC, Tsai JJ. Risk factors for a first febrile convulsion in children: a population study in southern Taiwan. Epilepsia. 1999 Jun;40(6):719–25.

7. Hashimoto R, Suto M, Tsuji M, Sasaki H, Takehara K, Ishiguro A, et al. Use of antipyretics for preventing febrile seizure recurrence in children: a systematic review and meta-analysis. Eur J Pediatr. 2021 Apr;180(4):987–97.

Summarized by Dan Orbidan, OMS1 | Edited by Dan Orbidan & Jorge Chalit, OMS3

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