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The etiology of community-acquired pneumonia (CAP) in a children's hospital was studied among 209 previously healthy children treated from August 1, 2001 to July 31, 2002. A total of 26 children (12.4%) with a diagnosis of chlamydial infection were included in this study. The diagnosis of chlamydial infection was based on either a positive immunofluorescent assay result for chlamydial antigen in sputum, or positive serologic results for immunoglobulin M (IgM), an IgG titer/=1:640 or a 4-fold rise in IgG titer by microimmunofluorescence test. Fourteen patients (53.8%) were female and 20 (76.9%) were less than 5 years of age. The onset of infection occurred between August and January in 21 cases (80.7%). Twenty one patients (80.8%) had other pathogens identified. Fever and cough were the most common presenting symptoms. The signs and symptoms were similar for the children with and without coinfection except for tachypnea and wheezing sound, which were significantly more common in patients with mixed infection. None of the laboratory parameters seemed to be specific for chlamydial infection; however, serum C-reactive protein level was significantly higher in cases with mixed infection. Among the 26 children, 12 (46.2%) needed respiratory therapy, and most of them (91.7%, 11/12) had coinfection. Two patients (7.7%) with mixed infection were admitted to the pediatric intensive care unit. One had lobar pneumonia with pleural effusion and the other had necrotizing pneumonia requiring surgical intervention. None of the patients died. In conclusion, Chlamydia sp. was identified in 12.4% of children with CAP in this series, and mixed infections were common (80.8%) among these patients. The clinical course of chlamydial pneumonia was not serious in most patients, but alertness is needed to the possibility of developing severe pneumonia in cases with bacterial coinfection.

We report here the first successful transplant of unrelated umbilical cord blood (UCB) for a child with beta-thalassemia major in Taiwan. A total of 2.48 x 10(5)/kg CD34 cells were infused into a 3(1/2)-year-old girl following conditioning with a pre-transplant cytoreductive/immunosuppressive regimen of busulfan and cyclophosphamide. The absolute neutrophil count first exceeded 0.5 x 10(9)/l on day 17, and the patient became red cell- and platelet-independent on days 34 and 49, respectively. Engraftment of donor hematopoietic populations was documented by cytogenetic analysis, hemoglobin electrophoresis, Southern blot analysis for thalassemia markers, and molecular analysis of short tandem repeats sequences. The patient was ex-thalassemic for more than 15 months post transplant. From this experience, it is postulated that UCB will indeed allow us to expand the available donor pool for recipients with an HLA DRB1 mismatched at one locus and reduce the risk of graft-versus-host disease.

Enterovirus 71 (EV71) can sometimes cause fatal or disabling diseases in children; therefore EV71-infected children with cardiopulmonary failure were investigated at Chang Gung Children's Hospital to discover the prognostic predictors.We investigated 27 EV71-infected children with cardiopulmonary failure from May 2000 to September 2001 and analyzed their clinical data to find predictors associated with unfavorable outcomes of deaths or ventilator dependence.Of the 27 patients, 8 (30%) died and 10 (37%) were ventilator-dependent. Troponin I levels correlated most strongly with fatality, with 5 of the 6 children with troponin I levels40 ng/ml dying (P = 0.001). Other factors correlated with fatality were cerebrospinal fluid white blood cell countor =100/microL (P = 0.002) and initial systolic pressureor =100 mm Hg (P = 0.05). Of the 19 survivors, 10 (53%) were left with central hypoventilation, dysphagia and/or limb weakness plus atrophy. The factors associated with ventilator dependence included higher inotrope equivalent (P0.001), duration of hypotensionor =40 hours, initial blood systolic pressureor =100 mm Hg, positive EV71 isolation and ageor =12 months.Poor prognostic factors were related to cardiovascular and neurologic damage; therefore physicians may consider advanced cardiovascular support for EV71-infected children with cardiopulmonary failure.

To determine whether different brands of intravenous immunoglobulin (IVIG) administered to children with Kawasaki disease (KD) result in different outcomes.We analyzed children with KD and divided them into 4 groups according to the brand of IVIG. A coronary artery abnormality (CAA) was defined as having a lumen diameter (inner border to inner border) ofor =3 mm in KD cases5 years old andor =4 mm in casesor =5 years old, and giant aneurysm was defined as a lumen diameteror =8 mm. Patients were considered nonresponsive to IVIG therapy if fever persisted longer than 2 days after completion of treatment and needed retreatment with IVIG.We collected 437 cases, 29 (6.6%) were nonresponsive, 17 (3.9%) had CAA at convalescence, and 3 (0.7%) had giant aneurysm, 2 of whom had development of myocardial infarcts. Patients receiving Brand C IVIG, prepared with beta-propiolactone, had higher rates (10%, 9/93, P = .01) of CAA at convalescence and nonresponsiveness (13%, 12/93, P = .001); giant aneurysm occurred in 3/93 (3%) receiving Brand C IVIG and in 0/344 who received the other 3 brands (P = .008).IVIG, prepared with beta-propiolactone, was most significantly associated with nonresponsiveness, CAA at convalescence, and giant aneurysm. Physicians should be cautious when using IVIG prepared with beta-propiolactone or enzyme digestion to treat KD.

Background and Objective:Methicillin-resistantStaphylococcus aureus(MRSA) has become an important nosocomial pathogen in our neonatal intensive care units (NICUs) and accounts for almost allS. aureusclinical isolates. The objective of this study was to assess the relatedness of these MRSA strains.Design:MRSA clinical isolates were collected from infants hospitalized in our NICUs. Pulsed-field gel electrophoresis withSmaI digestion was used to fingerprint these isolates.Setting:Level-III NICUs in a university-affiliated children's hospital.Results:Between 1998 and 2000, a total of 122 MRSA clinical isolates were collected from 104 infants hospitalized in our NICUs. Fifteen infants had multiple isolates (range, 2 to 4 isolates). The sources of specimens included blood (72), pus (23), sputum (15), body fluids (3), and catheter tips (9). A total of 4 genotypes with 20 subtypes were identified. There were 2 genotypes in 1998, 2 genotypes in 1999, and 4 genotypes in 2000. All but 2 isolates belonged to either genotype A (63.1%; 7 subtypes) or genotype C (35.2%; 11 subtypes). Among the 15 infants with multiple isolates, the genotypes of the isolates from a single episode of MRSA infection were different in 2 of 12 cases, and reinfection with a new strain was noted in 3 of 5 cases with recurrent infections.Conclusions:Two predominant MRSA clones prevailed in our NICUs between 1998 and 2000. Polyclonal bacteremia and reinfection with a new strain were noted.

BackgroundDuring the acute phase of severe acute respiratory syndrome (SARS), mononuclear cells infiltration, alveolar cell desquamation and hyaline membrane formation have been described, together with dysregulation of plasma cytokine levels. Persistent high-resolution computed tomography (HRCT) abnormalities occur in SARS patients up to 40 days after recovery.MethodsTo determine further the time course of recovery of lung inflammation, we investigated the HRCT and inflammatory profiles, and coronavirus persistence in bronchoalveolar lavage fluid (BALF) of 12 patients at recovery at 60 and 90 days.ResultsAt 60 days, compared to normal controls, SARS patients had increased cellularity of BALF with increased alveolar macrophages (AM) and CD8 cells. HRCT scores were increased and correlated with T-cell numbers and their subpopulations, and inversely with CD4/CD8 ratio. TNF-α, IL-6, IL-8, RANTES and MCP-1 levels were increased. Viral particles in AM were detected by electron microscopy in 7 of 12 SARS patients with high HRCT score. On day 90, HRCT scores improved significantly in 10 of 12 patients, with normalization of BALF cell counts in 6 of 12 patients with repeat bronchoscopy. Pulse steroid therapy and prolonged fever were two independent factors associated with delayed resolution of pneumonitis, in this non-randomized, retrospective analysis.ConclusionResolution of pneumonitis is delayed in some patients during SARS recovery and may be associated with delayed clearance of coronavirus, Complete resolution may occur by 90 days or later.

In a nasal culture survey of school children, 5 (1.9%) of 262 school children and 18 (13%) of 137 health care workers (HCWs) were colonized with methicillin-resistant Staphylococcus aureus (MRSA). One common genotype accounted for most isolates from the school children and from the HCWs. Based on genotyping, MRSA strains circulating in the community in Taiwan were similar to the hospital strains.

Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infection in children without health care-associated risk factors has emerged. To evaluate the clinical features and genotyping analysis of CA-MRSA in children in Taiwan, we conducted this study.Between July 2000 and June 2001, 198 episodes of S. aureus infection were identified in 191 children hospitalized at Chang-Gung Children's Hospital. The medical records of these children were retrospectively reviewed. The MRSA clinical isolates from each episode of infection, if available, were collected for pulsed-field gel electrophoresis (PFGE) typing and staphylococcal cassette chromosome mec (SCCmec) type determination.Among the 198 episodes of S. aureus infection, MRSA accounted for 47% of 114 CA infections and 62% of 84 hospital-acquired (HA) infections, respectively. Among 54 CA-MRSA infections, 32 episodes (59%) occurred in children without risk factors. Similar to HA-MRSA isolates, these CA-MRSA isolates were also multiresistant, with a high rate of resistance to clindamycin (93%) and erythromycin (94%), but 91% of them were susceptible to trimethoprim/sulfamethoxazole. Superficial soft tissue infection was the most common presentation, accounting for 65% of CA-MRSA infections. All 54 children with CA-MRSA infection recovered without sequelae, though 63% of 35 children with superficial soft tissue infection were treated with in vitro nonsusceptible antibiotics. Of the 83 clinical isolates (40 CA, 22 with no identified risk) available for analysis, 6 genotypes with 30 subtypes were identified. Three major PFGE patterns were identified, accounting for 94% of the isolates (92.5% for CA isolates, 95% for HA isolates). Type IV SCCmec was carried by 25 and 40% of CA and HA isolates, respectively.In Taiwan, MRSA was prevalent among pathogens of CA infections in children, and these CA isolates were multiresistant and genetically associated with HA isolates. In an area with a high prevalence of methicillin resistance, for children with putative S. aureus infection, even community-acquired, a glycopeptide-containing regimen should be considered for initial empirical therapy in the case of serious infection.

The diagnostic value of serum C-reactive protein (CRP) levels in children with perforated appendicitis was prospectively studied in 78 consecutive patients with histologically confirmed appendicitis. The patients were divided into two groups: group A included 56 patients with perforated appendicitis and group B consisted of 22 patients with simple appendicitis. Serum CRP level and leucocyte count were assayed in all and abdominal ultrasonography was performed in 75. The mean age group A patient was significantly lower than that of group B patients (7.5 vs. 10.4 years, P0.001). Group A patients had a significantly higher mean serum CRP levels than group B patients (92 vs. 31 mg/l, P0.001), while the mean leucocyte count was comparable in the two groups. Of 75 examined patients, 73 (97%) had a pre-operative sonographic diagnosis of appendicitis.Perforation is a common complication in children with appendicitis, especially in those of young age and with prolonged pain duration. Greatly increased serum CRP levels (or = 50 mg/l) and abdominal ultrasonography are important diagnostic aids in such patients.

The clinical presentations of laboratory-confirmed Bordetella pertussis infection in Chang Gung Children's Hospital during 1997 and 2001 were analyzed. Of the 46 cases, 25 (54.3%) were male. The patients ages ranged from 24 days to 37 years, with a mean and median of 4.3 years and 10.5 years, respectively. Forty four patients had vaccination records, among them 23 patients (52.2%) had receivedor = 3 doses of pertussis vaccine. Of the patients who were partially vaccinated (received 1 or 2 doses vaccine) or unvaccinated, 16 (69.6%) presented with whooping cough, 5 (22.2%) with post-tussive vomiting, and 13 (59.1%) with cyanosis. Leukocytosis (white blood cellsor = 15,000 cells/microL) and lymphocytosis (lymphocytesor = 10,000 cells/microL) were observed in 17 (47.2%) and 16 (44.4%) of the patients, respectively. Fourteen patients (30.4%) developed complications, among which pneumonia was the most common (92.3%). Among infantsor = 1 year of age, 95.2% were partially vaccinated (20/21), compared with 5% (1/20) of the patients1 year of age (p0.05). The overall complication rate was 37.5%, compared with 18.2% for patients1 year of age (p0.05). One 2-month-old patient required ventilatory support after the development of cardiopulmonary failure. There was no mortality in this study. In summary, pertussis most commonly occurred in infants who were unvaccinated or partially vaccinated. These patients usually presented with atypical symptoms such as cyanosis or apnea. The importance of vaccination still cannot be overemphasized because immunized patients usually present with milder disease than those who are not immunized.

This retrospective study included 18 pediatric cases (median age, 3 years) with pathologically proved hemophagocytic syndrome (HPS) from a single institution during 1992 and 2001. There were 9 males and 9 females. Prolonged fever, cytopenia, liver dysfunction and hepatomegaly were the most common features at presentation. Sixteen (88.9%) cases were previously healthy. The case fatality rate was 61.1%, and all fatal cases died within 2 months of disease onset. The infectious agents associated with HPS were identified in 11 cases (61.1%), and 8 (72.7%) of them had evidence of Epstein-Barr virus (EBV) infection or reactivation. Underlying immunologic disorder or neoplastic disease was identified in 11.1% of the cases. Children less than 3 years of age with HPS were more vulnerable to neutropenia-associated bloodstream infection (85.7% vs 27.3%; p=0.025). Pseudomonas aeruginosa (3) and Candida tropicalis (2) were the 2 most commonly isolated pathogens. Regarding specific management of HPS, intravenous immunoglobulin and steroids were the first-line agents and were administered in 16 cases and 11 cases, respectively, while etoposide was administered in 5 refractory cases during the late phase of disease. Most HPS occurred in previously healthy children, and a substantial proportion of cases rapidly progressed to death. Most cases were associated with viral infection, particularly EBV, and young children tended to develop neutropenia-associated bacteremia during the active phase of the disease.

To determine the prognostic value of myoclonic jerk in children with enterovirus 71 (EV71) infection, a retrospective study was conducted on 665 enterovirus culture-confirmed patients admitted to Chang Gung Children's Hospital from January 2000 to September 2001. The mean age was 35.0 months +/- 32.2 months, ranging from 1 day to 15 years and 416 (62.6%) of them were male. Among these patients, 140 (21.1%) had EV71 isolated, and 150 (22.6%) had myoclonic jerk. Fifty one percent (72/140) of EV71 cases and only 15% (78/525) of non-EV71 cases had myoclonic jerk (p0.001). The age of enterovirus patients with myoclonic jerk was younger than that of patients without myoclonic jerk (23.2 +/- 17.6 vs 38.4 +/- 34.6 months, p=0.005). The hospitalization and fever durations were significantly longer in the EV71 group than in the non-EV71 group (8.3 +/- 13 vs 4.2 +/- 2.7 days, p0.001; 5.9 +/- 4.8 vs 4.2 +/- 3.0 days, p=0.009, respectively). Patients with myoclonic jerk also had higher percentages of severe illness, and neurologic sequelae (20% and 9%, respectively) than those without myoclonic jerk (5% and 1%, respectively) [p0.001]. The positive predictive values of myoclonic jerk for EV71 infection, severe cases, and neurologic sequelae were 0.48, 0.20, and 0.09, respectively; the negative predictive values for severe cases and neurologic sequelae were 0.95 and 0.99, respectively. This study demonstrated that myoclonic jerk and EV71 infection are both independently associated with more severe disease and higher incidence of neurologic sequelae.

This retrospective study was conducted in order to determine the clinical and microbiologic features of infection with Salmonella enterica serotype Choleraesuis. Between March 1999 and December 2002, 55 patients with 66 isolates were enrolled for analysis. The ratio of males to females was 2.2:1. Most patients were older than 60 years (56%) and had underlying diseases (78%), such as diabetes mellitus, malignancy, and peptic ulcer. Fever (85%) was the most common clinical manifestation, followed by abdominal pain/fullness (31%). The gastrointestinal manifestations, including nausea/vomiting or diarrhea, accounted for only 13% and 11% of patients, respectively. S. enterica serotype Choleraesuis was extremely invasive, with a high predilection to cause bacteremia (78% of the isolates were from blood). Various types of metastatic focal infections were found, including infected arterial aneurysm, osteomyelitis, septic arthritis, urinary tract infection and wound infection. The crude mortality rate was 18% (10 deaths in 55 cases). Nearly all isolates were susceptible to the third-generation cephalosporins. A higher resistance rate to commonly used antimicrobial agents was found with ampicillin (85%, 56/66), trimethoprim-sulfamethoxazole (81%, 40/49), chloramphenicol (96%, 47/49), and ciprofloxacin (49%, 30/61). In view of the emergence of fluoroquinolone resistance, the third-generation cephalosporins appear to be the best choice for treatment of invasive infections caused by this organism.

Ludwig's angina is a rare but potentially lethal cellulitis of the submandibular space that occurs most often in young adults with predisposing odontogenic infection. In contrast to adult cases, most children with Ludwig's angina have no initiating factor. We report a case of Ludwig's angina in a 15-month-old boy which developed after an episode of herpetic gingivostomatitis. Under close monitoring of respiratory status, the condition was successfully managed with antibiotic treatment. This case illustrates that Ludwig's angina can develop in association with herpetic gingivostomatitis, which is a common and usually self-limited disease in pediatric patients. Prompt recognition and aggressive management of this rare and severe secondary bacterial infection are the keys to avoiding unnecessary morbidity and mortality.

Summary Salmonella enterica serotype choleraesuis ( S choleraesuis ) usually causes systemic infections in man that need antimicrobial treatment. We isolated a strain of S choleraesuis that was resistant to ceftriaxone and ciprofloxacin from a patient with sepsis. Ciprofloxacin resistance was associated with mutations in gyrA and parC , whereas the ampC gene ( bla CMY-2 ), responsible for ceftriaxone resistance, was carried by a transposon-like mobile element. This element was found inserted into finQ of a potentially transmissible 140 kb plasmid, with an 8 bp direct repeat flanking the junction regions. The appearance of this resistant S choleraesuis is a serious threat to public health, and thus constant surveillance is warranted.

ContextAlthough enterovirus 71 has caused epidemics associated with significant morbidity and mortality, its transmission has not been thoroughly investigated.ObjectivesTo investigate enterovirus 71 transmission and determine clinical outcomes within households.Design, Setting, and ParticipantsProspective family cohort study to investigate patients at a children's hospital in Taiwan and family members of these patients who had signs and symptoms suggestive of enterovirus 71 between February 2001 and August 2002. Patients and household members underwent clinical evaluations, virological studies, questionnaire-based interviews, and were followed up for 6 months.Main Outcome MeasuresEnterovirus 71 infection, defined as a positive viral culture from a throat or rectal swab, or the presence of IgM or a 4-fold increase in neutralizing antibody in serum; and clinical syndromes, defined as asymptomatic; uncomplicated symptomatic; and complicated; with unfavorable outcomes of sequelae or death.ResultsNinety-four families (433 family members) had at least 1 family member with evidence of enterovirus 71 infection. The overall enterovirus 71 transmission rate to household contacts was 52% (176/339 household contacts). Transmission rates were 84% for siblings (70/83); 83%, cousins (19/23); 41%, parents (72/175); 28%, grandparents (10/36); and 26%, uncles and aunts (5/19). Of 183 infected children, 11 (6%) were asymptomatic and 133 (73%) had uncomplicated illnesses (hand, foot, and mouth disease, herpangina, nonspecific febrile illness, upper respiratory tract infection, enteritis, or viral exanthema). Twenty-one percent (39/183) experienced complicated syndromes including the central nervous system or cardiopulmonary failure. During the 6-month follow-up, 10 died and 13 had long-term sequelae consisting of dysfunction in swallowing, cranial nerve palsies, central hypoventilation, or limb weakness and atrophy. Age younger than 3 years was the most significant factor associated with an unfavorable outcome in children (P = .004). Among 87 infected adults, 46 (53%) were asymptomatic, 34 (39%) had nonspecific illnesses of fever, sore throat, or gastrointestinal discomfort, and 7 (8%) had hand, foot, and mouth disease. There were no complicated cases in adults.ConclusionsEnterovirus 71 household transmission rates were high for children in Taiwan and severe disease with serious complications, sequelae, and death occurred frequently. In contrast, adults had a much lower rate of acquisition of the infection and much less adverse sequelae.

During July 2000 and October 2001, a total of 595 clinical isolates of methicillin-resistant Staphylococcus aureus (MRSA) were collected from six medical centers distributed in northern, central, and southern Taiwan. Specimen sources included blood ( n = 279), pus ( n = 173), sputum ( n = 94), body fluids ( n = 21), catheter tips ( n = 20), and urine ( n = 8). Pulsed-field gel electrophoresis (PFGE) with Sma I digestion was used to fingerprint these isolates. A total of 31 genotypes with 97 type-subtypes were identified. Subtypes could be identified in 7 genotypes. While there were 6 to 15 genotypes in each hospital, 433 isolates (73%) were shown to belong to a major type (genotype A, with 29 subtypes). This genotype was not only the type prevailing in all six hospitals but also the predominant clone in each hospital, accounting for 46 to 89% of all isolates in each hospital. Genotype C (16 subtypes) was the second dominant genotype, accounting for 9% of all isolates, and was distributed in five hospitals. Genotypes D (11 subtypes), E (5 subtypes), and B (6 subtypes) were distributed in five, four, and three hospitals, respectively. The other 26 types (30 type-subtypes) were minor. We conclude that the majority of MRSA clinical isolates shared a common PFGE pattern, indicating the presence of a single, epidemic MRSA clone prevailing in major hospitals in Taiwan.

A 15-year-old girl with a spontaneous pneumothorax presented with a cough and worsening chest pain. Re-expansion pulmonary oedema developed 20 minutes after chest tube drainage. Immediate resuscitation was started for hypotension and bradycardia. Hypoxaemia was managed by BiPAP mask ventilation; respiratory failure and pulmonary oedema showed dramatic improvement 8 hours later.

OBJECTIVE There is a high fatality rate in enteroviral infection with central nervous system involvement. Our aim was to investigate the change in intracranial blood flow to disclose the characteristic findings in the early stage of critical enteroviral infection. METHODS We examined 27 patients in critical condition with enteroviral infection in our pediatric intensive care unit. We performed transcranial Doppler sonography within 12 hours of admission to the unit. The data were compared with those of a group of 11 patients with nonenteroviral encephalitis. RESULTS The peak systolic, end-diastolic, and mean velocities of the critical enteroviral infection group were significantly higher than those of the control group (P < .05). Gosling pulsatility index and Pourcelot resistive index values for the right and left middle cerebral arteries (pulsatility index, [mean +/- SD], 0.68 +/- 0.22 and 0.77 +/- 0.19, respectively; resistive index, 0.48 +/- 0.01 and 0.52 +/- 0.01) in patients with critical enteroviral infection were significantly lower than those of patients with nonenteroviral encephalitis (pulsatility index, 1.10 +/- 0.30 and 0.98 +/- 0.22; resistive index, 0.62 +/- 0.01 and 0.60 +/- 0.01; P < .05). CONCLUSIONS Low pulsatility index and resistive index values for cerebral blood flow were observed in the early stage of critical enteroviral infection. This characteristic finding of cerebral blood flow might be associated with the increased sympathetic discharge induced by a brain stem-involved systemic inflammatory response and dysfunction of autoregulation caused by the infection or other disorders of autoregulation that might cause severe or fatal complications.

Aeromonas hydrophila sepsis and pneumonia are rare diseases in children that carry a high mortality rate. We report a case of fatal bacteremic pneumonia caused by A. hydrophila in a previously healthy 5-year-old child. The source of infection was not determined and the child died within 4 hours of admission. In children who develop a fulminant disease of pneumonia with or without sepsis, particularly those who have underlying medical conditions, a possible A. hydrophila infection, though rare, should be considered. More reported cases are needed to establish the epidemiologic features of this disease in children.

Neonatal enterovirus infections have diverse manifestations, from asymptomatic to fatal. An understanding of the risk factors associated with severe cases might help to reduce enterovirus-related morbidity and mortality.From July 1989 through June 1998, neonates with virus culture-confirmed nonpolio enterovirus infection at Chang Gung Children's Hospital were enrolled in the study and divided into three groups: nonspecific febrile illness; aseptic meningitis; and hepatic necrosis with coagulopathy (HNC). Demographic factors, clinical manifestations, laboratory data and outcome were analyzed to reveal factors associated with clinical severity and fatality.There were 146 cases including 43 neonates with nonspecific febrile illness, 61 with aseptic meningitis and 42 with HNC. By multiple logistic regression analysis, the most significant factors associated with HNC were prematurity, maternal history of illness, earlier age of onset (or =7 days), higher white blood cell count (WBCor =15 000/mm3) and lower hemoglobin (or =10.7 g/dl). In 10 (24%) of 42 cases, HNC was fatal. In comparison with nonfatal cases of HNC, fatal cases had higher WBC, lower hemoglobin, higher bilirubin and higher incidence of concurrent myocarditis. Multivariate analysis showed the most significant factors associated with fatality from HNC to be total bilirubin14.3 mg/dl (adjusted odds ratio, 29.1; 95% confidence interval, 2.5 to 355.5; P = 0.007) and concurrent myocarditis (adjusted odds ratio, 13.7; 95% confidence interval, 1.1 to 177.2; P = 0.04). Intravenous immunoglobulin did not correlate with clinical outcomes in cases with HNC.Prematurity, maternal history of illness, earlier age of onset, higher WBC and lower hemoglobin are significant factors associated with HNC; higher total bilirubin and concurrent myocarditis were most significantly associated with fatality from HNC.

Combined vaccines are urgently needed to ensure compliance with the increasing number of recommended vaccines for children. We evaluated the safety and antibody response to a diphtheria, tetanus, and acellular pertussis-inactivated poliovirus vaccine/Haemophilus influenzae type b (DTaP-IPV/Hib) combination vaccine administrated to infants at 2, 4, and 6 months of age.Sixty healthy infants between 6 and 12 weeks of age were enrolled. One group of vaccines received the DTaP-IPV/Hib in a single injection, while another group concurrently received DTaP-IPV and Hib at separate injection sites. Solicited adverse events were monitored by parental observation and were recorded on a diary card. Levels of serum antibodies to DTaP and polyribosyl-ribitolphosphate-tetanus (PRP-T) antigens were collected before the first vaccine dose and 1 month after the third vaccine dose.The combined-injection group tended to have lower local reactions, and there was no increase in reactogenicity when compared with the separate-injection group. Seroconversion rates were 100% in both groups for all antigens, except for the anti-polio 2 antibody in the combined-injection group (96.4%). The combined-injection group had lower antibody levels of PRP (8.45 microg/ml) than did the separate-injection group (20.61 microg/ml). However, the percentage of vaccines achieving protective levels of antibody to PRP (or = 0.15 microg/ml oror = 1.0 microg/ml) was similar in both groups.DTaP-IPV/Hib may be safely and effectively administered to healthy infants, using a 2-, 4-, and 6-month vaccination schedule. This combined vaccine is cost-effective, more acceptable to parents and physicians, and minimizes distress to infants.

From September 1997 to March 2002, a total of 84 children were admitted to Chang Gung Children's Hospital due to influenza A virus infection. Influenza A virus infection was documented in 61 cases by viral isolation from throat and in 23 cases by serologic studies. The mean age of patients was 43.8 months, ranging from 20 days to 16 years. Forty-one (49%) patients were male. Lower respiratory tract infection (53 of 84 cases) was the most common clinical manifestation, occurring predominantly in children younger than 5 years (49 of 53 cases). The types of lower respiratory tract infection included bronchiolitis/bronchopneumonia in 33 cases, pneumonia in 17, and croup in 3. Central nervous system dysfunction was noted in 26 patients, predominantly in older children (18 of 26 cases). This included encephalopathy in 11 cases, encephalitis in 10, aseptic meningitis in 2, psychosis in 1, febrile convulsions in 1, and acute disseminated encephalomyelitis in 1. Gastrointestinal symptoms were mild in most patients. Diarrhea occurred in 18.4% of the children younger than 5 years, compared with only 8.4% of the older children. By contrast, abdominal pain was more common in older children (16.7%) than in younger children (6.7%). Ten children had leukocytosis (white blood cellor = 15000 /microL) and 9 of them were younger than 5 years. Eleven children had a C-reactive protein level greater than 100 mg/L and 10 of them were younger than 5 years. The mean duration of fever and hospitalization were 4.6 +/- 2.8 days and 7.4 +/- 5.7 days, respectively. The clinical outcomes were excellent in all but 1 patient who died from intractable pulmonary hemorrhage. The frequency and duration of hospitalization due to influenza A virus is much greater than generally thought in Taiwan, suggesting an urgent need for educational programs to increase awareness of the characteristics and risks for this illness.

Enterovirus 71 is an important pathogen that causes high morbidity and mortality in children in Taiwan. Virus isolation in cell cultures has been the standard method for enterovirus 71 identification in Clinical Virology Laboratories. However, virus isolation takes 5–10 days when using cell culture. A microchip for enterovirus 71 detection was developed as an alternative diagnostic method. The novel approach is based on hybridization of amplified DNA specimens with oligonucleotide DNA probes immobilized on a microchip. Two oligonucletides were used as detection probes, the pan-enterovirus sequence located in the 5′-noncoding region (5′-NCR) and the enterovirus 71-specific sequence located in the VP2 region. The diagnostic procedure takes 6 h. One hundred specimens identified as enteroviruses by viral cultures were tested using this microchip, including 67 enterovirus 71 specimens. The sensitivity of the novel method is 89.6% and its specificity is 90.9%. The enterovirus 71-microchip can detect the amplicon derived from viral RNA corresponding to 1–10 virions in a clinical specimen. Microchip array is a potential diagnostic method for identification of enterovirus in the future.

Human infections due to Yersinia enterocolitica have been reported worldwide, predominantly in Europe. However, there have been few reports of Yersinia enterocolitica infection in Taiwan. We report a case of Y. enterocolitica sepsis in a 15-year-old Taiwanese girl with Cooley's anemia and insulin-dependent diabetes mellitus. She presented at admission with fever, shock and consciousness disturbance. She had symptoms of abdominal pain, vomiting and diarrhea for three days before admission. Blood pressure stabilized after intravenous normal saline rescue. Blood culture yielded Y. enterocolitica 2 days later and ceftriaxone was administered according to the results of sensitivity tests. She recovered well after a course of antibiotic treatment. Though Y. enterocolitica sepsis is rare in Taiwan, clinicians should be aware of its tendency to develop in patients with Cooley's anemia, fever and enterocolitis and that its clinical course may include sepsis leading to shock.

Background: Viruses are a frequent cause of upper respiratory tract infections in children. Like Taiwan, there were few virological surveillance systems for respiratory viral infections among children in developing countries. Materials and methods: During August 1995 and July 1997, 6–10 throat swab specimens per week were taken from pediatric outpatients with acute, febrile upper respiratory tract infections (URTI). The specimens were randomly obtained by two pediatricians at Chang Gung Children’s Hospital and sent for virus isolation and identification. Results: A total of 910 specimens were collected and 365 specimens (40%) were positive for at least 1 virus and included 81 enterovirus, 73 adenovirus, 58 influenza B virus, 54 influenza A virus, 48 cytomegalovirus (CMV), 25 herpes simplex virus-1 (HSV-1), 7 parainfluenza virus, 3 respiratory syncytial virus (RSV) and 16 mixed viruses. Adenovirus and enterovirus were identified throughout the study period. No seasonal variation was noted for adenovirus while enterovirus peaked between May and July and also during September and November. Influenza viruses, both A and B, were identified during two periods, respectively and altogether, influenza viruses could be detected almost throughout the year. An association between the virus type identified and the mean age of patients was found ( P -value = 0.0001 by ANOVA test). The mean age of patients infected with influenza viruses, either A or B, was significantly higher than those of patients infected with adenovirus, HSV-1, CMV and enterovirus. Conclusion: The results of this study demonstrate that adenovirus and enterovirus are the two most common viruses isolated from pediatric outpatients with acute, febrile URTIs and can be identified throughout the year in northern Taiwan. Influenza viruses also can be identified throughout the year and during the epidemic, a child older than 5 years of age with acute febrile URTI is likely to be a case of influenza.

During the period from July 1, 1999 to September 30, 2000, 9 children with severe adenovirus infection were treated at Chang Gung Children's Hospital. The mean age was 22 months (range, 5-50 months). All of them had lower respiratory tract infections, which manifested as lobar or segmental pneumonia and pleural effusion. Eight (88.9%) of the 9 patients required intensive care and 4 of them required mechanical ventilation. Abnormal laboratory findings included leukocytosis, elevated C-reactive protein, anemia, and prolonged prothrombin time and partial thromboplastin time. Extrapulmonary complications included hepatitis (6 cases), encephalitis (3), conjunctivitis (3), periorbital ecchymosis (1), and coagulopathy (2). One patient died, resulting in a mortality rate of 12.5%. Follow-up at 3 months postdischarge, 5 patients (62.5% of survivors) had bronchiolitis obliterans and/or organizing pneumonia. Seven patients were infected by serotype 3 adenovirus, 1 patient by serotype 2, and another by serotype 11. In conclusion, the clinical, laboratory, and radiographic features of severe adenovirus infection may mimic bacterial infection. Rapid progression of the clinical course despite antibiotic therapy and the presence of unusual extrapulmonary symptoms are important clinical clues in the diagnosis of severe adenoviral infection.

We report on a female neonate with severe onset of congenital cytomegalovirus (CMV) infection. She was noted to have cerebral ventriculomegaly on antenatal ultrasound, and presented with petechia after birth. Laboratory tests revealed severe thrombocytopenia (platelet count, 11,000/mm3) and hypoglycemia (serum glucose level, 5 mg/dl). Hepatosplenomegaly with elevated hepatic enzymes, retinitis, conjugated hyperbilirubinemia, and diffuse brainstem anomaly were also found in subsequent examinations. The diagnosis was confirmed by positive CMV-IgM from serum and the isolation of CMV from a urine sample. The patient received intravenous ganciclovir and human anti-CMV immunoglobulin during admission. She was discharged at the age of 61 days and followed-up monthly at our clinics. Symptoms and signs subsided except for mild cerebral ventriculomegaly at her last visit. We demonstrate a successful treatment with the combined use of ganciclovir and anti-CMV immunoglobulin.

Five children, ages 3 to 6 years, developed visual hallucination and inappropriate behavior within 3 days of the onset of an influenza-like illness. Electroencephalographic examinations showed generalized slow waves in all five cases. Evidence of acute influenza A viral infection was documented in all five cases. Within 8 days all five children were discharged in stable condition. Influenza A-associated central nervous system dysfunction may be more common than previously recognized, and the prognosis is not necessarily poor.

Outbreaks of sepsis associated with have been rarely reported in neonatal intensive care units (NICUs). We describe such an outbreak in a NICU, and the results of molecular epidemiologic investigations are presented.Between August and September 2000, 6 premature infants hospitalized in a pediatric NICU developed sepsis. Three additional cases had infections during November and December. For an environmental culture survey, 94 environmental specimens and hand washings of all 43 health care workers involved in this unit were examined for the presence of this organism. Two genotyping methods, pulsed field gel electrophoresis of genomic DNA digested with I and infrequent restriction site polymerase chain reaction, were used to analyze the 9 bacteremic isolates and any isolates obtained from the environmental survey and the hand washings. Another 3 bacteremic isolates of collected in the same NICU in 1999 were incorporated as controls.The 9 infants were premature and had birth weights of1,500 g. Before onset of sepsis 9 infants had received total parenteral nutrition, and 8 infants had had central venous catheters and received intrafat emulsion. Five (5.3%) environmental specimens and 10 (23.3%) hand washing specimens were positive for the organism. Except for the strain from Case 9, the results of both genotyping methods were concordant; 11 patterns were identified by infrequent restriction site polymerase chain reaction and 10 patterns by pulsed field gel electrophoresis. One major genotype was demonstrated in the first 6 bacteremic isolates as well as 3 hand washing isolates. The genotypes of the other 3 bacteremic isolates, the 3 control strains, the 5 environmental isolates and 7 other hand washing isolates were distinct from the genotype of outbreak strains.An outbreak of bacteremia in a NICU was clearly demonstrated by the molecular epidemiologic investigation and was possibly transmitted via the hands of health care workers.

This study compared safety, tolerability, and immunogenicity of the Oka/Merck varicella vaccine and VARILRIX [Oka-RIT strain SmithKline Beecham Biologicals] in healthy children 12-24 months of age. Subjects were randomized in this double blind study to receive either a single dose of Oka/Merck varicella vaccine, (approximately 50,000 plaque forming units (PFU), Group A or approximately 16,000 PFU, Group B) or 1 dose of VARILRIX, (approximately 40,000 PFU/dose, Group C). Safety profiles in each treatment group were similar. The proportions of subjects achieving a 6-week postvaccination titeror = 5 gpELISA units in Groups A, B or C were 97.1, 95.2 and 85.6%, respectively.

Due to the high incidence of antimicrobial-resistant Salmonella in Taiwan, the emergence of multidrug-resistant Salmonella has become of particular concern. This retrospective study assessed the clinical features of patients with multidrug-resistant Salmonella treated from January 1998 through June 2000. A total of 201 children and 33 adults with multidrug-resistant Salmonella infections treated during a 2.5-year period were included. Sixty-percent of these patients had used antibiotics before multidrug-resistant Salmonella infection developed. The incidence of extra-intestinal infections was higher in adults (51.4%) than in children (4.9%). Infection with an invasive serotype of Salmonella, such as Salmonella choleraesuis, and host factors appeared to be predisposing factors for bacteremia or extra-intestinal infections. None of the patients had mortality attributable to multidrug-resistant salmonellosis. The increasing rate of resistance to third-generation cephalosporins and fluoroquinolones and the high multidrug-resistant rate of S. choleraesuis found in this study indicate the importance of judicious use of antimicrobial agents in both humans and animals to reduce the selection and spread of resistant strains.

Objective. In 1998, an enterovirus 71 (EV71) epidemic in Taiwan was associated with hand, foot, and mouth disease (HFMD)/herpangina and in- volved 78 fatal cases. We measured EV71 seroprevalence rates before and after the epidemic and investigated risk factors associated with EV71 infection and illness. Methods. Neutralizing antibodies to EV71 were as- sayed for 539 people before the epidemic and 4619 people of similar ages after the epidemic. Questionnaires, which were completed during household interviews after the epidemic, solicited demographic variables, exposure his- tory, and clinical manifestations. Results. A total of 129 106 cases of HFMD were re- ported during the epidemic. Age-specific pre-epidemic EV71 seroprevalence rates were inversely related to age- specific periepidemic mortality rates (r 0.82) or severe case rates (r 0.93). Higher postepidemic EV71 sero- positive rates among children who were younger than 3 years positively correlated with higher mortality rates in different areas (r 0.88). After the epidemic, 51 (56%) of 91 younger siblings of elder siblings who were EV71- seropositive were EV71-seropositive; otherwise, 2.2% (4 of 186) of younger siblings were EV71-seropositive (matched odds ratio (OR): 10; 95% confidence interval (CI): 3.4 -29). Stepwise multiple logistic regression re- vealed other factors associated with EV71 infection to be older age (adjusted OR: 2.5; 95% CI: 1.9 -3.4), attendance at kindergartens/child care centers (adjusted OR: 1.8; 95% CI: 1.3-2.5), contact with HFMD/herpangina (adjusted OR: 1.6; 95% CI: 1.2-2.1), greater number of children in a family (adjusted OR: 1.4; 95% CI: 1.1-1.7), and rural res- idence (adjusted OR: 1.4; 95% CI: 1.2-1.6). Twenty-nine percent of preschool children who were infected with EV71 developed HFMD/herpangina. Younger age and contact with HFMD/herpangina were significant factors for the development of EV71-related HFMD/herpangina in these children. Conclusions. An increased incidence of EV71 infec- tion in young children occurred more often in geographic areas with increased mortality rates. Intrafamilial and kindergarten transmissions among preschool children were major modes of disease transmission during the widespread EV71 epidemic in Taiwan in 1998. Pediatrics 2002;109(6). URL: http://www.pediatrics.org/cgi/content/ full/109/6/e88; enterovirus 71; hand, foot, and mouth dis- ease; seroprevalence; transmission; risk factors; symptom- atic ratio; reemerging infectious disease; Taiwan.

We investigated the prevalence of minor psychiatric morbidity in a group of women who were pregnant during or immediately after a major earthquake disaster and we investigated the prognostic factors that may have influenced the perinatal outcome of the pregnancy. The study was initiated 6 months after the earthquake and enrolled 171 women in a town near the epicentre. A Post-Earthquake Questionnaire, Chinese Health Questionnaire (CHQ-12) and posttraumatic stress disorder (PTSD) symptoms checklist were completed before delivery while the perinatal data were retrieved from hospital obstetrical records. The prevalence of minor psychiatric morbidity (MPM) was 29.2%. Women with starvation experience, higher negative attitude scores about the influence of earthquake on pregnancy and more casualties among relatives were significantly correlated with high CHQ. A significant positive correlation between the MPM and PTSD scores was noticed. Among the 115 pregnancies with known perinatal outcome, there were nine (7.8%) low-birth weight neonates, defined as birth weight < or = 2500 g. Maternal history of abdominal injury, spouse casualty and instability in living condition were significantly correlated with low birth weight. Spouse casualty was the only significant factor that predicts neonatal low birth weight.

The most recently discovered enterovirus, enterovirus 71 (EV71), is neurotropic and may cause severe disease and sudden death in children. In 1998, a large outbreak of enterovirus infection occurred in Taiwan that resulted in 405 severe cases in children and 78 deaths. Of the 78 children who died, 71 (91%) were

Hand, foot and mouth disease is a common illness in children and is usually caused by coxsackievirus A 16 and enterovirus 71. It has been noted that enterovirus 71 infection is more severe with significantly greater frequency of serious complications and fatality than coxsackievirus A 16. Therefore, it is important to develop a rapid and specific assay for discriminating coxsackievirus A 16 and enterovirus 71 in hand, foot and mouth disease outbreaks. In this study we designed two sets of RT-PCR primers specific for coxsackievirus A 16 and enterovirus 71. One hundred and eighty-nine viruses were evaluated for this molecular diagnosis assay. Among 110 enterovirus 71 strains, the enterovirus 71 specific primers gave clear signal for 107 clinical enterovirus 71 isolates and three reference enterovirus 71 strains. None of coxsackievirus A 16, other enteroviruses or non-enteroviruses show signal for enterovirus 71-specific primers. On the other hand, among 28 coxsackievirus A 16 strains, the coxsackievirus A 16-specific primers detect 27 clinical isolates and one reference strain but show no cross-reaction with other viruses. The molecular assay developed in this study provides a sensitive and specific way to distinguish coxsackievirus A 16 and enterovirus 71 induced hand, foot and mouth disease, which will be a useful rapid diagnostic method in future outbreaks.

Salmonella enterica serotype choleraesuis is a cause of serious systemic infections. Because fluoroquinolones are the drug of choice for the treatment of severe salmonella infections, the emergence and dissemination of fluoroquinolone-resistant S. enterica serotype choleraesuis have clinical consequences.In Taiwan, a hospital-based surveillance system has been in place since 1987 to monitor the incidence of S. enterica serotype choleraesuis infections and the antimicrobial susceptibility of the isolates. We investigated the rapid emergence of fluoroquinolone resistance in this serotype in 2000 and 2001. Pigs in Taiwan were evaluated as a potential source of the resistant salmonella.A total of 501 clinical isolates of S. enterica serotype choleraesuis were recovered in our hospital from 1987 through 2000. The proportion of total salmonella isolates made up by S. enterica serotype choleraesuis decreased from an average of 8.4 percent before 1995 to 2.7 percent in 1996 through 1998. During 1999 and 2000, this proportion increased significantly, to an average of 5.0 percent. Ciprofloxacin resistance in S. enterica serotype choleraesuis has been observed since 2000. In the third quarter of 2001, 60 percent of isolates were resistant to ciprofloxacin. Molecular typing indicated that the primary source of S. enterica serotype choleraesuis isolates was herds of swine. All the resistant isolates from humans and swine had mutations that led to the substitution of phenylalanine for serine at position 83 and asparagine for aspartic acid at position 87 in the gene for DNA gyrase A.This investigation in Taiwan indicates that fluoroquinolone-resistant S. enterica serotype choleraesuis can spread from swine to humans. The use of fluoroquinolones in food animals should be prohibited.

The objective of this article is to assess the distribution of minimal inhibition concentrations (MIC) for candidal isolates from bloodstreams in neonates and to assess the correlation of clinical outcome with antifungal susceptibility testing. Of the 62 episodes of neonatal candidemia in a Children's Hospital between January 1994 and July 1998, 38 stocked isolates from 38 infants' bloodstreams were available and underwent antifungal susceptibility test according to National Committee for Clinical Laboratory Standards M27-A document. Correlation of clinical response with in vitro results was assessed in 37 patient-episode-isolate events. No less than 90% of these isolates tested were susceptible to amphotericin B, flucytosin, and fluconazole. The ranges of amphotericin B MICs and flucytosin MICs were narrow, ranging from 0.25 to 2 microg/mL, respectively. The range of fluconazole MICs was broad, ranging from 0.25 to >64 microg/mL. Successful therapy was achieved in 18 (62%) of 29 amphotericin B-treated patient-episode-susceptible isolate (MIC < or =1 microg/mL) events and 9 (64%) of 14 fluconazole-treated patient-episode-susceptible isolate events, respectively. Most isolates from the bloodstreams of neonates with candidemia were susceptible to antifungal agents tested but a low MIC of the antifungal agent did not predict successful therapy in this study. Correlating MICs with clinical outcome in neonatal candidemia requires complex evaluation of other factors.

Nine isolates of Klebsiella pneumoniae, obtained from one colonized and eight bacteraemic patients on a paediatric ward, were shown to be identical by PFGE, indicating an outbreak. Screening for extended-spectrum beta-lactamase (ESBL) production using the double-disc synergy test, Etest for ESBLs and agar diffusion tests indicated ESBL production. The isolates showed reduced susceptibility to cefotaxime but not to other third-generation cephalosporins. Molecular studies revealed production of TEM-1 and SHV-1 but no ESBLs were identified. Deficiency in expression of an outer membrane protein (OmpK35) was also observed. These observations led us to postulate that the extremely low level of OmpK35 expression and the co-existence of TEM-1 and SHV-1 resulted in an increased MIC of cefotaxime and the false designation of the isolates as ESBL producers. All the infected infants were treated with either third-generation cephalosporins alone or multiple antibiotics including a third-generation cephalosporin, and recovered and were discharged without sequelae.

Background. Most invasive group A streptococcal (GAS) disease occurs sporadically. Reports of family clusters of these infections are scanty, and most invasive disease occurs in adults. We describe a family cluster of streptococcal toxic shock syndrome (STSS) involving 3 children and present the results of an epidemiologic investigation. Patients and Methods. During a 16-day period, 3 children in a family developed STSS with an interval of 7 and 9 days, respectively, between the onset of disease. Cases 2 and 3 had GAS isolated from blood culture. Case 2 was fatal. Pharyngeal culture survey of the family members and schoolchildren was conducted. Antibiogram, serotyping, detection of exotoxin genes, and random amplified polymorphic DNA patterns of the disease strains and survey strains were examined. Results. One of 15 family members sampled—the sister of the index case—and 7 (5.6%) of 125 schoolchildren sampled had GAS isolated from pharyngeal cultures. Of the 10 strains examined, 2 isolates from the patients, 1 from the sister of index case, and 2 from the classmates of case 2 (the fatal case) had an identical pattern of both genotype and phenotype. Conclusion. We describe a family cluster of STSS involving 3 children caused by a single clone and provide additional data regarding invasive GAS infection subsequent to household contact. Additional studies should be conducted in conjunction with surveillance to define better the magnitude of risk in household contacts and to identify settings in which subsequent infections may occur.

Maternal chickenpox around the time of delivery can cause severe and even fatal illness in the newborn but an effectively preventive method has not yet been established. We proposed that a combination of intravenous immunoglobulin (IVIG) and acyclovir (ACV) intravenously could effectively prevent perinatal varicella. A group of 24 newborn infants whose mother had developed a varicella rash within 14 days before and after delivery were studied. Some 15 infants whose mothers' rash appeared within 7 days before and 5 days after delivery were categorised as an at-risk group and received IVIG prophylaxis (500 mg/kg) administered soon after birth or post-natal contact either alone or with intravenous acyclovir (5 mg/kg every 8 h) for a total of 5 days starting from 7 days after the onset of maternal rash. Of four infants receiving IVIG alone, two developed clinical varicella. None of ten infants receiving both IVIG and ACV contracted varicella. One infant receiving ACV alone had no varicella vesicles either. Of nine infants in the not at-risk group four had undetectable varicella-zoster virus antibody on admission and developed clinical varicella subsequently.The combination of intravenous immunoglobulin given soon after birth and prophylactic acyclovir intravenously administered 7 days after the onset of maternal rash can effectively prevent perinatal varicella.

To evaluate the risk factors for intestinal perforation in children with toxic megacolon caused by non-typhi Salmonella infection.During an 11-year period we reviewed the records of children treated for non-typhi Salmonella infection. All of the subjects had positive stool culture for non-typhi Salmonella and were treated with intravenous ceftriaxone during hospitalization. Clinical data reviewed included demographic features, clinical manifestations, laboratory findings, radiologic findings, microbiology, therapeutic effect of hydration and rectal tube placement and the operative findings. Patients with toxic megacolon were defined as those having toxic appearance, diarrhea, high fever (39 degrees C) and marked colon dilatation with maximal diameter1.5 times the width of the vertebra body of the first lumbar spine (L1-VB). To define the risk factors for patients with toxic megacolon complicated by intestinal perforation, patients were divided into two groups for analysis: P group, those complicated with intestinal perforation; and NP group, those without intestinal perforation. Differences in age, sex, severity of diarrhea, duration of fever, hemogram and its differential, culture, stool analysis, serum C-reactive protein (CRP), electrolytes, maximal colon diameter, medical therapy and timing of rectal tube insertion between the two groups were analyzed. Statistical analyses were conducted with chi square tests and multiple logistic regression.A total of 75 patients (P group, 27 patients; NP group, 48 patients) ages 4 months to 6 years were evaluated. With chi square analysis 7 variables were found to be significantly associated with intestinal perforation: age1 year; fever5 days; ratio of immature to total neutrophils20%; serum CRP200 mg/l; colon diameter2.5 times the width of L1-VB; inadequate early hydration; and delay in rectal tube insertion. With multivariate analysis age1 year, serum CRP200 mg/l and colon diameter2.5 times of width of L1-VB, inadequate early hydration and delay in rectal tube insertion were the most significant factors associated with intestinal perforation.Identification of patients with toxic megacolon associated with non-typhi Salmonella infection at risk for further intestinal perforation is possible. Early effective fluid resuscitation and rectal tube insertion may be helpful to prevent the occurrence of intestinal perforation.

We report a fatal case of enterovirus type 71 (EV 71) infection in an 8-year-old girl during a summer outbreak of hand, foot, and mouth disease in 1998 in Taiwan. The clinical course was rapidly progressive, with manifestations of hand, foot, and mouth disease, aseptic meningitis, encephalomyelitis, and pulmonary edema. The patient died 24 hours after admission. Postmortem study revealed extensive inflammation in the meninges and central nervous system and marked pulmonary edema with focal hemorrhage. Brain stem and spinal cord were most severely involved. The inflammatory infiltrates consisted largely of neutrophils involving primarily the gray matter with perivascular lymphocytic cuffing, and neuronophagia. The lungs and heart showed no evidence of inflammation. EV 71 was isolated from the fresh brain tissues and identified by immunofluorescence method with type-specific EV 71 monoclonal antibody. It was also confirmed by neutralization test and reverse-transcriptase polymerase chain reaction with sequence analysis. The present case was the first example in which EV 71 was demonstrated to be the causative agent of fatal encephalomyelitis during its epidemic in Taiwan.

Enterovirus 71 (EV 71) infections have high neurovirulence and fatality. Immune responses were assessed in 78 patients with EV 71 infection. EV 71 meningoencephalitis occurred more frequently in younger children and in boys. C-reactive protein levels were not elevated, although total leukocyte counts were increased in these patients. The CD40-ligand expression on T cells significantly decreased in children with meningoencephalitis (P=.041). Polymorphism of the cytotoxic T lymphocyte antigen-4 (CTLA-4) at position 49 of exon 1 showed a higher frequency of G/G genotype in patients with EV 71 meningoencephalitis than in those without meningoencephalitis (18/31 vs. 14/47; P=.045) and in control subjects (18/31 vs. 25/93l; P=.007). Specific EV 71 neutralizing antibody titers were detectable but did not differ in children with and without meningoencephalitis in the acute and convalescent stages. Results from this study suggest that younger children with a certain CTLA-4 polymorphism and altered cellular but not humoral response may be linked to EV 71 meningoencephalitis.

To investigate the nasal carriage of antibiotic-resistant pneumococci by children, anterior nasal swabs were done for 4963 children

Objectives : Candidaemia caused by Candida parapsilosis (CP) is being increasingly reported among infants in neonatal intensive care units (NICU). To assess relative severity, clinical manifestations of candidaemia caused by C. albicans (CA) and CP in a NICU were compared. Methods : Between January 1994 and July 1997, episodes of candidaemia occurring among infants hospitalized in the NICU were identified in a children's hospital. The demographic characteristics, associated risk factors, clinical manifestations and outcome of the infants with CP fungaemia were collected and compared with those of the infants with CA fungaemia. Results : Twenty-four episodes caused by CA and 22 episodes caused by CP were included in this study. No significant differences were found between the two groups for gestational age, birth weight, male gender, post-natal age at onset of candidaemia, frequency of antecedent neonatal events, prior duration of antibiotic therapy and hyperalimentation, as well as presence of central venous catheter (CVC). Infants with CA fungaemia were significantly more likely than those with CP fungaemia to present with hypoxaemia, bradycardia and respiratory distress requiring intubation, and have a longer prior duration of indwelling CVC and a higher dissemination rate. The eradication rate of candidaemia and overall case fatality rate were comparable in both groups, but CP fungaemia did not appear to cause acute lethal events. Conclusions : The presenting signs of CP fungaemia are relatively not so severe, but CP fungaemia, which is relatively difficult to eradicate, increases the morbidity and mortality of the infants.

Osteomyelitis is rarely complicated by an infected cephalohematoma. We report a case of an infected cephalohematoma associated with Escherichia coli sepsis and osteomyelitis of the skull. This 37-day-old boy had E. coli sepsis, which had a poor response to antibiotic treatment. An infected cephalohematoma was found when he was 43 days old. Cranial computed tomography (CT) scanning showed cephalohematoma with abscess formation and underlying bony destruction over the left parietal region. Antibiotics alone could not eradicate the infection. Extensive incision, drainage, and debridement of the necrotic bone resulted in prompt improvement. Three weeks of ceftizoxime administered intravenously, followed by 3 weeks of cefixime given orally completed the treatment course.