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. He joined the brand in March of 2023 as an editor before being promoted to senior editor in January 2024. Fitch graduated from Youngstown State University in Youngstown, Ohio in 2020 with a degree in telecommunications and journalism. He started his career as a news and sports videographer before becoming an on-air sports anchor at the NBC-affiliated news station in Youngstown. Fitch briefly worked as a national content writer for a Chicago-based national television station before joining the 

team. He can be reached at: jfitch@mjhlifesciences.com.

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 and joined the MJH Life Sciences team in December 2019. She graduated from Youngstown State University in 2019 with a bachelor's degree in journalism and a minor in political science. Prior to graduating, Morgan worked as the editor-in-chief of her college newspaper. She went on to work as an assignment editor at a broadcast news station in Youngstown, Ohio before joining 

 You can reach her at mpetronelli@mjhlifesciences.com.

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Two-month-old boy with divot in the lower back, shown here with the gluteal crease relaxed (A) and spread (B). Infant is a product of an uncomplicated pregnancy and delivery. Nursery stay uneventful. Subsequent feeding and growth normal. Parents report no problems with urination or defecation.

Sacral Epidermal Anomalies in an Infant

**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.

This case was presented by Giridhar Guntreddi, MD FAAP, FAPHM; Achuth Jayasankar Kondoor, Taylor Boske, Neelima P. Theella, MD, and Jayasree Vasudevannair, MD MPH FAAP. 

A healthy 12-month-old girl presented with one small skin lesion over the right heel (Image 1) for one month. On examination, her right lateral heel showed a round, white, pearl-like, hard, tiny lesion with a smooth appearance without any redness or itching. The patient's mother denied any pain, swelling, itching or fever. No significant travel, bites, heel stick injuries were reported in the history. No systemic symptoms suggested any underlying systemic diseases. The infant is closely monitored at subsequent well visits and re-checked. After 3 months, the child showed full resolution of the skin lesion over the heel area (Image 2).

Below, take your best guess at diagnosing this patient.

click here for the full case presentation, differential diagnosis, and correct patient diagnosis. 

Thank you for taking this Contemporary Pediatrics poll! Want more puzzler case studies? 

Can you diagnose this patient? Take our poll and find out! Then check back for the full case, differential diagnosis, and correct diagnosis.

Diagnose this infant with an asymptomatic pearl-like nodule on the heel

Then, visit our website on Wednesday, May 7, 2025 at 12:00 PM Eastern Time or later for the full case presentation, differential diagnoses, and correct patient diagnosis.

This case was provided by Akash Deswaney, MD, Neil Copeland, MD, and John Bishara, DO.

An 18-day-old female presented to the ED with concerns of apnea, cyanosis, and decreased feeding. The mother reported intermittent cyanosis of the lips, pale-appearing skin, and suspected apnea episodes. Since birth, Mom states patients had retractions since birth, which the PCP reassured her was normal periodic breathing. She had nasal flaring and grunting a couple of days after discharge from the nursery. Mom has noticed she breathes quickly, in the 60s or 70s at times.

Initial vitals in the ED showed hypoxemia, tachypnea, and fluctuating oxygen saturations were between 65-100% on room air. A chest X-ray is shown (

Click here for the full case presentation, differential diagnoses, and correct patient diagnosis.

Can you diagnose this patient? Take our poll and find out! Then check back for the full case, differential diagnosis, and correct diagnosis. 

Diagnose this 18-day-old female with apnea, cyanosis, decreased feeding concerns

This case was presented by Rutva Vora, BS; and Monica Guirguis, DO.

A 2-month-old female was born after an uneventful pregnancy at 40 weeks’ gestation via vacuum-assisted vaginal delivery to a G2P1011 female. The patient’s APGAR scores were 7 and 9 at 1 and 5 minutes, respectively, at birth. No bleeding or other complications were reported during delivery. The newborn and mother were discharged two days after delivery without requiring NICU stay or interventions. The infant briefly developed a small soft palpable scalp swelling that resolved within days after delivery. The patient followed an otherwise uncomplicated growth progression since birth. She did exhibit mild reflux symptoms, which were managed with supportive care measures. Physical examination after delivery and subsequent exams revealed no abnormalities, including no signs of scalp swelling or injury.

At 8 weeks of age, the patient presented to the Emergency Department with a 3-day history of new-onset scalp swelling. The parents decided to seek medical attention after the swelling became noticeably enlarged. Parents denied any changes in her mental status, vomiting, fevers, lethargy, irritability, or any other new concerns. She did have symptoms of gassiness and fussiness that were unchanged from baseline. No history of trauma was reported, and there were no concerning signs suggestive of nonaccidental trauma. The patient appeared well, with a soft, fluctuant palpable subcutaneous fluid collection overlying the parieto-occipital scalp, without crossing suture lines. The anterior fontanelle was soft and non-bulging, and there was no hemotympanum.

Bleeding disorder (e.g. Von Willebrand Disease)

Diagnose this 2-month-old with scalp swelling

 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.

Christy Blake, RNC, MSN

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