Search

During the age of enlightenment in the 18th century, radical changes were occurring in the Western world in science, medicine, philosophy, religion, and socioeconomic concepts. In medicine, major advances had already been underway since the days of Vesalius.

A 2-year-old African American male presented with a 3-day history of low-grade fever, nasal congestion, and decreased appetite. One day prior to admission, he developed tachypnea and grunting with a temperature of 102°F. He presented to an outside hospital, where a chest radiograph was obtained. He was diagnosed with acute suppurative otitis media and was discharged home with a prescription for amoxicillin. The next day, he was called back to the hospital due to abnormal findings identified on the chest radiograph by the radiologist. Past Medical History

Cerebrospinal fluid (CSF) access device placement in the pediatric population presents challenges due to the development of infections following placement, access or revision, and/or shunt malfunctions. Here we report an unusual pediatric case of L. monocytogenes ventriculitis/VP shunt (VPS) infection and associated pseudocyst with an emphasis on the importance of VPS removal in clearing the infection due to biofilm formation.

Objective.Newborns in a hospital nursery were exposed to a mother whose sputum was direct-smear negative for acid-fast bacilli but culture positive forMycobacterium tuberculosis. Given the low risk for exposure, the high susceptibility of infants toM. tuberculosisinfection, and the possibility of hepatotoxicity due to isoniazid therapy, a decision analysis model was used to determine whether administration of isoniazid prophylaxis against tuberculosis is preferable to no administration of prophylaxis.Design.A decision analysis tree was constructed with software, using probabilities from the literature and costs from local health facilities. The expected values for each strategy were obtained, and sensitivity analyses were performed.Results.For the strategy in which prophylaxis was administered under direct observation (DO), the probability for survival was 0.999980. For the strategy in which no prophylaxis was administered, the probability of survival was 0.999950, which corresponds to 3 more deaths per 100,000 patients than with the DO prophylaxis strategy. The incremental cost-effectiveness of the DO prophylaxis strategy was $21,710,000 per death prevented. Sensitivity analysis for survival showed that the DO prophylaxis strategy was preferable to the strategy in which no prophylaxis is given if the probability of infection was >0.0002, the probability of tuberculous disease in an infected infant who did not receive prophylaxis was greater than 0.12, the probability of dying from tuberculosis was greater than 0.025, the probability of hepatotoxicity was less than 0.004, and the probability of dying from hepatotoxicity was less than 0.04. For the strategy in which prophylaxis was administered under non-DO conditions (ie, by parents), the incremental cost-effectiveness was $929,500 per death prevented, which is approximately 5% of the incremental cost-effectiveness of the DO prophylaxis strategy.Conclusion.This model provides a structure for determining the preferable prophylaxis strategies for different risks of exposure to tuberculosis in a nursery. Administration of prophylaxis is preferable to no administration of prophylaxis, unless the probability of infection is extremely low.

A neonate and his mother presented with fever and erythroderma. The mother met full diagnostic criteria for staphylococcal toxic shock syndrome, whereas the neonate lacked hypotension and multiorgan dysfunction. A wound culture from the neonate's circumcision site grew methicillin-resistant Staphylococcus aureus containing the tst gene. This provides evidence of the first reported case of toxic shock syndrome caused by methicillin-resistant Staphylococcus aureus in a mother-newborn pair.

We report a case of Escherichia coli meningitis complicated by spinal cord dysfunction in a neonate. This very rare complication of bacterial meningitis was probably caused by ischemia of the cord resulting from vasculitis. We review the 22 other reports of patients with this complication and discuss its pathogenesis.

Antibiotic resistance in bacteria has emerged as a medical catastrophe. This results from the speed at which bacteria multiply and are spread, and the ease with which they can change their genetic material or acquire new genes. They exert biochemical resistance by preventing entry of the drug, by rapidly extruding the drug, or by enzymatically inactivating the drug or altering its molecular target. The presence of antibiotics in the internal environments of human beings and animals provides a selective pressure for any resistant organisms to become predominant. Examples of antibiotic resistance in several important human pathogens are Streptococcus pneumoniae, enterococci, staphylococci, enteric bacilli, Haemophilus influenzae, Neisseria gonorrhoeae, Neisseria meningitidis, and Mycobacterium tuberculosis.

The sources of these cases are as follows: The majority are derived from my own clinical experience. Because this experience covers a period of 30 years, many of these are reconstructed from memory, and therefore some of the details, especially the child's age and sex, may not be accurate. Three cases are based on reports in the Morbidity and Mortality Weekly Reviews (MMWR). This is indicated by “(MMWR)” with the number of the case and in the reference. Several cases are composites of different cases from my experience. These are indicated by (“COMP”). The remainder of the cases are hypothetical, based on current knowledge of the clinical manifestations of a particular illness. These include cases in which I have constructed a clinical scenario to match a photograph. These are indicated by (“HYP”). Where names of the cases have been used, they are not the patients' real names, but they contain clinically important information. CASE 1. A previously well 13-year-old girl presents with a history of nausea, anorexia, abdominal pain, and dark urine for 3 days. On examination she has mild right upper quadrant discomfort. Jaundice cannot be detected. The rest of the examination is normal. What is your differential diagnosis? What quick (2-minute) test can you do to help you? further studies might you do? The differential diagnosis in this patient includes the following: acute hepatitis cholecystitis, cholangitis, cholelithiasis gastritis and peptic ulcer disease pancreatitis pyelonephritis hepatic sludging/sequestration if she has sickle cell disease liver abscess

In view of the widespread use of third generation cephalosporins in hospitalized infants, we attempted to determine whether their use was associated with the emergence of resistance in fecal Gram-negative bacilli. Stools from infants hospitalized for varying durations were cultured on MacConkey agar containing 4 micrograms/ml of cefotaxime. All isolates growing on this medium were identified and their susceptibilities to 29 antimicrobial agents were determined. Sixty-five infants were studied of whom 44 were receiving a third generation cephalosporin, 7 another antibiotic and 14 no antibiotic. Thirty-one strains resistant to third generation cephalosporins (minimal inhibitory concentrations > or = 16 micrograms/ml) to cefotaxime, ceftriaxone or ceftazidine) were isolated from 26 infants. The proportions of infants with resistant strains were not significantly different whether they were: (1) receiving a third generation cephalosporin or not; (2) hospitalized for longer or shorter than 2 days or not; (3) older or younger than 3 months or not. Notably 8 infants harbored resistant strains within 24 hours of admission. The commonest resistant strains isolated belonged to the genera Enterobacter (10), Citrobacter (6), Serratia (3), Cedecea (3) and Chromobacterium (3). In conclusion hospitalized infants had a high incidence of fecal colonization with Gram-negative bacilli resistant to third generation cephalosporins. These bacteria were predominantly those known to produce broad spectrum beta-lactamases. This colonization was not necessarily associated with the infant receiving such antibiotics or with prolonged hospitalization.

Background. There have been several recent reports that cat-scratch disease (CSD) causes a multiplicity of atypical clinical syndromes. We recently diagnosed hepatosplenic CSD in a child who was seen with fever and abdominal pain. We report this case and 10 other patients with hepatosplenic CSD and highlight the importance of abdominal pain in this clinical entity. Methods. This was a retrospective review of charts of patients with a diagnosis of cat-scratch disease at Egleston Children's Hospital between January, 1985, and June, 1996. From these cases patients with hepatosplenic CSD were selected for study. Results. Seven children (64%) had significant abdominal pain, and in three children abdominal pain was their chief complaint. All children in the study had pathologic evidence of CSD or elevated titers of antibodies to Bartonella henselae. Ultrasound examination showed that all children had microabscesses in the spleen, and eight had abscesses in the liver. Conclusions. One of the most remarkable findings in this large series of cases of hepatosplenic CSD was that 64% of the patients complained of abdominal pain. All children in this study received antibiotics. It was our clinical impression that once antibiotics had been started, the patients appeared to improve very quickly. With an increased index of suspicion, the use of B. henselae serology and an abdominal ultrasound examination, the diagnosis of this underrecognized disease might be more readily made.

We studied retrospectively the predisposing factors and signs of infective endocarditis (IE) in neonates and infants younger than 3 months of age, and we suggest diagnostic criteria. The charts of 16 infants less than 3 months of age, diagnosed with IE during a 5-year period, were reviewed for possible maternal and infant risk factors and for pathognomonic clinical and laboratory features. No apparent maternal risk factors were noted. Infant risk factors were congenital heart disease (4), patent ductus arteriosus (PDA) (5), and the use of central venous catheters (14). The main clinical findings were cardiac murmurs (12), petechiae (2), skin abscesses (7), arthritis (2), hepatomegaly (9), and splenomegaly (2). Echocardiography revealed a mass or vegetation in nine patients. Of the 27 microorganisms isolated from blood, the most common were staphylococci (15) and Candida sp. (6). Urine cultures were positive in six patients and cerebrospinal fluid cultures were positive in one. Other laboratory findings were not of diagnostic value. We conclude that the main risk factors for neonatal IE are central venous catheters and congenital heart disease, including PDA. The main causative microorganisms are staphylococci and Candida sp. The main investigations of diagnostic value are blood and urine cultures and echocardiography. We propose the diagnostic categories of definite, probable, and possible cases of neonatal IE, based primarily on clinical, blood culture, and echocardiographic data.

Different cause-and-effect relationships between hemolytic and infectious processes are categorized in a clinically useful manner as follows: infections causing hemolysis by invasion of red blood cells (RBCs), by hemolysins, or by immune mechanisms; oxidative damage to RBCs during infections; hemolysis secondary to infection-induced pathologic processes; hemolytic effects of antimicrobial therapy; and predisposition of an individual to infection caused by an underlying hemolytic disorder or therapy for that disorder. The mechanisms of these interrelationships are discussed in detail.

Nosocomial infections in infants and children were prospectively studied in the general wards of a hospital serving a developing community. Of 1350 admissions in 5 months, 193 (14.3%) developed 302 infections (22.4/100 admissions). The major risk factors were malnutrition, age less than 2 years and prolonged hospitalization. The most common sites of infection were the lower respiratory and gastrointestinal tracts. The most frequently isolated organisms were Staphylococcus aureus and Klebsiella species and the site of most frequent isolation was the lower respiratory tract for which the method most commonly used was endotracheal aspiration. Seventy percent of isolates were resistant in vitro to conventional antibiotics. Thirty-one percent of infections developed while the patient was awaiting a diagnostic procedure or waiting to be sent home. During the study period 60 patients (4.4% of admissions) were admitted with a nosocomial infection acquired elsewhere (31 at this hospital and 29 from other hospitals). Measles and its complications accounted for 28 of these cases and 7 deaths. This study provides information on nosocomial infections in children from a developing community.

Article de synthese suyr la biochimie des exotoxines bacteriennes: classification, structure, fonction

The Jarisch-Herxheimer reaction, characterized by high fever and chills followed by hypotension and sweating, is a recognized complication of treatment of spirochetal infections, such as borreliosis and syphilis, and of bacterial infections, such as brucellosis and tularemia. 1 We report a case of this reaction developing during treatment of meningococcal meningitis. Endotoxin Assay .—Plasma endotoxin levels were determined by the Limulus amebocyte lysate test. 2 Briefly, plasma was incubated with lysate, the protein precipitate was measured by relative light scatter, and this was compared graphically with that produced by endotoxin of Escherichia coli 055:B5. Report of a Case .—A 9-year-old girl was admitted to Baragwanath Hospital, Johannesburg, Republic of South Africa, on Sept 23, 1981, with a history of fever and confusion beginning on the previous day. Examination showed that she had a temperature of 38.2 °C, a pulse rate of 110 beats per minute, and a BP of 120/70

During a one-year period, 315 of 5,397 children admitted to the general pediatric wards of a hospital had bacteremia. The commonest causative organisms were Streptococcus pneumoniae, Salmonella enteritidis, Hemophilus influenzae, and Escherichia coli. Most episodes of bacteremia were associated with gastroenteritis, pneumonia, or meningitis. Seventy-eight episodes occurred in children with severe protein-energy malnutrition, and 46 episodes were hospital acquired. The overall case fatality rate was 23.2%, being highest in children with severe malnutrition and in those with other underlying conditions. The high proportion of bacteremias due to S pneumoniae and S enteritidis possibly reflects infections occurring in a lower socioeconomic group living in a temperate climate in crowded conditions. The most appropriate antimicrobial therapy for children who have suspected bacteremia in association with gastroenteritis or severe malnutrition is a combination of ampicillin sodium and gentamicin sulfate.

Ten black South African children with infective endocarditis seen over a 2-year period are reported. In five cases, including two neonates, the infection was nosocomial and in five cases it occurred in children with previously normal hearts. Of the bacteria isolated from nine cases, five were Staphylococcus aureus (all from nosocomial cases), one was Haemophilus influenzae and three were corynebacteria. The unusual aspects of this series are discussed, with an emphasis on preventing nosocomial cases and on making the diagnosis in children without underlying heart disease.

In Reply .—Dr Slater indicates that the symptoms and signs of the patient we recently described may not have been caused by generalized anaphylaxis but rather by hypoglycemia or hypocalcemia. The most likely alternative diagnosis, we believe, would have been a vasovagal attack 1,2 ; however, none of these conditions would have resulted in swelling of the lips. We performed the in vitro studies to demonstrate the presence of circulating anti-cytarabine IgE in an attempt to provide other evidence, albeit circumstantial, that the reaction was indeed anaphylaxis. As Dr Slater points out, the results do not stand up to statistical analysis, which was clearly not attempted. Several methods have been used to provide nonclinical evidence of immediate hypersensitivity reactions, including the demonstration of circulating specific IgE antibodies. 3 The method we used, namely, demonstration of anti-cytarabine IgE antibodies in the patient's serum by an enzyme-linked immunosorbent assay, was one readily available to

Observation chez une petite noire de 16 mois attaquee par un coq et presentant quelques jours plus tard un œdeme de la face. Traitement par penicilline G et corticoides par voie intraveineuse et vaccin antitetanique. Malgre le traitement l'enfant meurt au bout de 6 jours. Une craniotomie est pratiquee et sont isoles Streptococcus bovis, Clostridium tertium et Asperfillus niger

• In a young child with acute promyelocytic leukemia, treatment with a variety of chemotherapeutic agents produced an acute anaphylactic reaction. When cytarabine was removed from the chemotherapeutic regimen, no further anaphylaxis occurred. Employing an enzyme-linked Immunosorbent assay with cytarabine coated onto the wells in bovine serum albumin, specific IgE antibodies to this drug could be demonstrated. Similar antibodies could not be demonstrated in the serum of normal controls or of two other patients receiving cytarabine. We therefore document anaphylactic shock mediated by specific IgE antibodies to cytarabine. ( AJDC 1987;141:1000-1001)