Pediatrics

A Case of Balanitis Secondary to Trauma

PATIENT BACKGROUND

Patient Initial : MAAge : 5.4 yoGender : MaleRace : MalayDOA : 21/4/15

CDC Growth Chart:Stature : 90% percentileWeight : 75% percentile

(Height: 115cm Weight: 19.3kg )

CHIEF COMPLAINT Penis swelling HISTORY OF PRESENTING ILLNESSPenis swelling x 1/7Not increasing in size, associated with pain and itchiness History of trauma where penis accidently hit over bathroom tiles while bathing

PAST MEDICAL HISTORY History of admission for viral fever at 3 year old

SOCIAL/ FAMILY HISTORY Youngest child with one sister Father is a self-employed Mother is a house-wife

DRUG ALLERGY Penicillin

IMMUNISATION HISTORY Unknown

REVIEW OF SYSTEMBP: 100/59 mmHg (SBP: 95-105 ; DBP: 53-66)RR: 28 b/min (18-30 b/min)PR: 81 p/min (60-140 p/min) T: 37.5 C

Lab Investigation (FBC)

Normal ranges Day 1 InterpretationWBC6-15 x10^9 /L11.9NormalHb10.5-14.0 g/100ml12.3RBC4.5-6.3 x 10^54.61HCT 33 42%36.1Platelet 150 400 x 10^9/L352MCV70-74 fL74.3MCH25-31 Pg26.7MCHC31-369 g/dL34.1Neutrophil4551.0Neutrophilia suggest of infection Lymphocyte3837.9Normal

Input-Output Chart Date: 21/4/15Total input: 1400mLTotal output: 930mLBalance: +470mLUrine output = 470mL 19.3 kg 24hours= 1.01mL/kg/hours (normal)

Time line

In Ward Medications

Drug/ RegimenDate start Date stop Indication IV cefuroxime 482mg TDS21/421/4Cellulitis at penisSyrup Erythromycin 290mg BD21/4ContinueBalanitis

Syrup Paracetamol 289mg QID21/4Continue Pain at wound siteSyrup Chlorpheniramine 1.9mg QID21/421/4Itchiness at the wound site Syrup Chlorpheniramine 1.9mg TDS21/4Continue

DIAGNOSIS

Balanitis secondary to trauma

Pathophysiology 1. Injury tissues damaged 2. Activate body natural response- Inflammation to heal the damage tissues Tissue swelling presses on nerves

3. PAIN& itchiness

Uncircumcised children with poor personal hygiene are most affected by balanitis. Lack of aeration and irritation because of smegma and discharge surrounding the glans penis causes inflammation and edema. Complications of balanitis: phimosis and cellulitis.

TREATMENT STRATEGY- BALANITIS

Goal of Therapy Evidence-based medicine/ recommendation PrescribedTreatment Monitoring parameters-To eradicate the causative microorganism

-To minimize urinary dysfunction

-To alleviate the symptoms

-To prevent re-infection

Bacterial infection may arise from overgrowth of normal preputial flora secondary to trauma. In a study of uncircumcised children, the common organisms found by preputial swab in children age 3-6 years were staphylococcus aureus, E.coli and proteus mirabilis.

(Agartan CA, Kaya DA, Ozturk CE, Gulcan A, 2005)

According to Edwards, Bunker, Ziller & van der Meijden in European guideline for the management of balanoposthitis (2014). Balanoposthitis associated with streptococci spp and syaphylococcus spp should be given penicillin group antibiotic as first line therapy. Macrolides groups given as an alternative for penicillin allergy patient.

Dose of syrup erythromycin ethylsuccinyl for children: 30-50 mg/kg/day PO divided doses every 6 hours.

-Syrup Erythromycin ethylsuccinate 290mg BD

-Heart Rate-GI side effect -Liver function test -Renal profile-C&S result

Comparison of 3 types of Macrolides

Old generationNew generationErythromycinAzithromycinClarithromycinLess bioavailability , less stable (more GI S/E) and less toleratedBetter bioavailability, more stable (lesser GI S/E) and more tolerated Narrower spectrumBroader spectrum More drug-drug interactionsFewer drug-drug interactions (does not inhibit CYP3A)More drug-drug interactionsPoor penetration to tissuesBetter penetration to tissuesMultiple daily oral doseSingle daily doseTwice daily oral dosesLess expensive More expensiveMore palatableLess palatableUpper and lower respiratory tract infectionsskin and soft tissue infectionsCAPStreptococcal pharyngitis/tonsillitisPharyngitis/TonsillitisDisseminated mycobacterial infections





According to World Health Organization Guideline on the pharmacological treatment of persisting pain in children with medical illnesses, 2012.For children assessed as having mild pain, acetaminophen and ibuprofen should be considered as first options.

Up to date, yet there are no conclusive data comparing the efficacy and safety of acetaminophen and ibuprofen. Although some studies have concluded ibuprofen to be superior analgesic and anti-pyretic, literature reviews typically have concluded that the drugs were equally effective but that acetaminophen should be preferred because its safety seemed more assured.

(Litalien & Jacqz-Aigrain, 2001; Renn E, 2000; Pierce & Voss, 2010)

Recommended Dose:Acetaminophen :10-15mg/kg every 4-6 hours(maximum 4 doses/ day)

Ibuprofen: 5-10mg/kg every 6-8 hours (maximum 40mg/kg/day) (cannot be given to children less than 3 month)-Syrup acetaminophen 289mg QID-Temperature -liver function test -pain score





According to Yosipovitch study in Therapy of Pruritus (2010), he stated that the two main type of treatment for pruritus are topical treatment as well as systemic treatment. The choice of therapy is depend on the pathophysiology of pruritus. This statement also supported by Yvette A. & Rubenstein RM., 2009.

Based on Shim & Oh, 2008 in study of Histamine-induced itch and its relationship with pain, they found that itchiness and pain has relationship with histamine. Pain sensation is stimulated by histamine sensitive nociceptor.

According to the national cancer institute, pruritus (2015) showed that oral antihistamine is effectively provide symptomatic relief in histamine-related itching.

Recommended Dose: 0.1 mg/kg/day (Age 2-6 years: maximum 6mg/day)-syrup chlorpheniramine 1.9mg QID (stop)

-syrup chlorpheniramine 1.9mg TDS-Sign and symptoms of CNS depression or excitation

-GI side effects

-Improvement of symptoms

Pharmaceutical care issue

Date Pharmaceutical issues Pharmacist intervention Follow-up 21/4/15Inappropriate frequency of syrup Chlorpheniramine maleate. According to Frank Shann, 16th edition 2014,

Chlorpheniramine: 0.1mg/kg 6-8HPatient Weight: 19.3kg0.1mg/kg x 19.3kg = 1.93mg 6-8H

British National Formulary, max. dose/day for children age 2-6 year old = 6mg

The patient given 1.93mg QID (7.72mg).

Comments:It should decrease the frequency from QID to TDS. -Vital Signs-Sign and symptoms of CNS depression or excitation-GI side effects

Patient outcome Patient feeling better with no complaint of pain and itchiness Low grade fever subside, and temperature has reduced to normal body temperature (37C)Allow to discharged on 22/4 morning Follow up and schedule a day for circumcision Plan: to be admitted one day before circumcision Discharged medication: Syrup Erythromycin 150mg BD x 5/7Sitz Bath TDS

Sitz Bath A sitz bath is a warm, shallow bath that cleanses the perineum (the space between the rectum and scrotum).It can used for everyday personnel hygiene, also can provide relief from pain or itching in the genital area.

For more information: http://www.healthline.com/health/sitz-bath#Overview1

Circumcision Circumcision is the surgical removal of the skin covering the tip of the penis and it is fairly common in certain parts of the world including Malaysia and also United States.Circumcision may be performed for:Religious reasonsMedical reasons Circumcision slightly lower the risk of developing cancer of the penis in later life also showed to have WHO: Maintains that circumcision is a personal decisionCDC: The scientific evidence is clear that the benefits outweigh the risks. (Dr. Jonathan Mermin). This is in line with the American Academy of Pediatrics, which revised its position to also say the benefits outweigh risks in 2012.

Patient Education To educate the caregiver and patient to practice good hygiene

Wash the glans carefully every day, make sure to clean under the foreskin gentlyDo not use perfumed shower gels. Using water and a mild soap, is sufficient to clean the penisAlternatively, use aqueous cream as soap substitute, to avoid irritation Make sure fully dry the penis before getting dressed.

To educate the patient and caregiver to finish the antibiotic course as prescribed by the physician to avoid resistance.

References Agartan CA, Kaya DA, Ozturk CE, Gulcan A. Is aerobic preputial flora age dependent? Japanese Journal of Infection Disease 2005. 58:276

Alvarez-Elcoro S, Enzler MJ. 1999. The macrolides: erythromycin, clarithromycin, and azithromycin. Mayo Clin Proc. 74(6):613-34.

British National Formulary Edition 62, September 2011.

Christopher w. James, PharMd, and Cheryle Gurk-Turner, RPH. 2001. Cross-reactivity of beta-lactam antibiotics. BUMC PROCEEDINGS. 14:106107

Edwards, S., Bunker, C., Ziller, F., & van der Meijden, W. (2014). 2013 European guideline for the management of balanoposthitis. International Journal Of STD & AIDS, 25(9), 615-626.

References Frank Shann, 16th edition 2014

Healthline,. (2015). Sitz Bath. Retrieved 26 April 2015, from http://www.healthline.com/health/sitz-bath#Overview1

Litalien, C., & Jacqz-Aigrain, E. (2001). Risks and Benefits of Nonsteroidal Anti-Inflammatory Drugs in Children. Paediatric Drugs, 3(11), 817-858.

Pierce, C., & Voss, B. (2010). Efficacy and Safety of Ibuprofen and Acetaminophen in Children and Adults: A Meta-Analysis and Qualitative Review. Annals Of Pharmacotherapy, 44(3), 489-506.

References Shim, W., & Oh, U. (2008). Histamine-induced itch and its relationship with pain. Molecular Pain, 4(1), 29.

Yosipovitch, G. (2010). Chronic pruritus: a para-neoplastic sign. Dermatologic Therapy, 23(6), 590-596.

Yvette, A., & Rubenstein, RM. (2009). Pruritus: An updated look at an old problem. Journal Of Clinical Aesthetic Dermatology, 2(7), 30-36. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2924137/pdf/jcad_2_7_30.pdf

WHO Guidelines on the pharmacological treatment of persisting pain in children with medical illnesses, 2012.

injury caused to living tissue from an extrinsic agentPhysical trauma can result from injuries such as falls, cuts, burns, and anything else that damages tissues.Inflammation is the bodys natural response to heal damaged tissues

*(amoxicillin/ clauvulanic acid 15-25mg/kg TDS)

**Muscle twitchingConvulsionsUnconsciousnessComaRespiratory depression and arrestCardiovascular depression and collapse

*religious reasons circumcision is a common practice in the Jewish and Islamic faiths, and is also practised by many African communities as a tribal or ethnic traditionmedical reasons, although alternative treatments are usually preferred to circumcision

*

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