Biomedical subjects
Publications and source records attributed to K H Rhodes.
Gastrointestinal mucormycosis has been a uniformly fatal disease in children. Diagnosis has been difficult, resulting in inadequate therapy. Histologic and bacteriologic confirmation of invasive infection, followed by systemically administered amphotericin B and surgical excision, are the hallmarks of effective treatment.
Three children with the rare occurrence of zygomycosis are descibed: two had involvement of a solitary lesion of gangrenous cellulitis on the buttocks, and th third was a neonate with gastric performation and a gangrenous appendicitis. All three patients were compromised hosts (two with leukemia and one a premature infant with respiratory distress syndrome). All three patients appeared to have acquired the same organism. Rhizopus oryzae, from the same fomites, elastic bondages (Elastoplast). The Center for Disease Control has received several other reports of zygomycosis traceable to the same material. Alll three of our patients were cured of their infections. Early diagnosis and a combined surgical and chemotherapeutic approach appear to prevent death from zygomycosis.
In a prospective study of 42 cases of childhood meningoencephalitis occurring in 1974 and 1975, a diagnosis of an infectious agent was made in 30 (71%). California virus infections were most common; they were serious illnesses but had few sequelae. Benign illnesses with enteroviruses were also common. Miscellaneous and unknown agents accounted for the most seriously ill patients and for both deaths. Persistent neurologic deficits were unusual. Headaches, malaise, and changes in behavior were common but transient.
The cause of diarrhea in a Rochester, Minnesota, pediatric population was studied by examining specimens for the presence of enterotoxigenic strains of Escherichia coli and reovirus-like agents, in addition to parasites and other bacteria and viruses. Reovirus-like agents were detected by electron microscopy in the feces of 11 of 31 patients, but none was found from specimens collected during convalescence or from 16 asymptomatic matched controls (P less than 0.01). Infection due to reovirus-like agents occurred significantly more often during the winter months in patients 6 to 18 months of age. Vomiting and diarrhea most often occurred simultaneously. All patients recovered without significant complications or sequelae, although one child was hospitalized for 3 days. Mean duration of illness was 9 days. No enterotoxigenic strains of E. coli were detected from symptomatic or control groups. Our results show that of the 16 organisms detected in stool specimens (11 reovirus-like agents, 3 salmonellae, and single isolates of adenovirus and enterovirus), the reovirus-like agent was the most frequent (69%) and was the probable etiologic agent in 35% of the cases of diarrhea in Rochester children.
The diagnosis of hematogenic osteomyelitis is often delayed in children if it involves uncommon sites such as the pelvis, clavicle, or calcaneus. Although parenterally administered antibiotics may control the disease process in the acute stage, abscess formation requires incision and drainage. Staphylococcus aureus was the most common organism in this series, and it usually was penicillin resistnat. When the condition is diagnosed early and is properly treated with at least 3 weeks of antibiotic therapy and judicious surgical intervention, recurrences are rare and morbidity is minimal.
An otherwise normal 11-year-old boy had reately reduced acral pain and temperature sensation with associated trophic damage. The disorder was present at birth, and there was no family history of similar problems. The patient also exhibited complete anhidrosis. The case may an "overlap" between what has been termed as hereditary sensory neuropathy (HSN) type 2 and type 4.
Guidelines for the use of antibiotics in infants and children must take into account drug absorption, distribution, metabolism, and excretion. In the developing human being, these factors may differ significantly from those in the adult, and so there are differences in therapeutic efficacy and toxicity. Certain drugs should be avoided in the neonate because of known toxicity; these include the sulfonamides, tetracycline, and high doses of chloramphenicol. Antibiotic therapy should be modified in neonates in several ways because of the biologic immaturity of systems important for the termination of drug action, such as the liver and kidney. Because of poor conjugation, inactivation, or excretion, the administration of many antibiotics results in higher and more prolonged serum levels than those produced in older infants. Thus, in the neonate, the dosages of many antibiotics have to be lower and intervals between administration longer. In the case of gentamicin, studies in the 6-month to adult age group have shown that children less than 5 years old require almost twice as much of the drug as do children older than 10 years or adults to achieve similar peak concentrations. The appearance throughout the United States of strains of Haemophilus influenzae, type b, that are resistant to ampicillin has necessitated a change in the initial antibiotic therapy given to children with bacterial meningitis. There are few uses for tetracycline in pediatric practice.
A young man with X-linked chronic granulomatous disease of childhood, who is of the rare McLeod phenotype with antibodies in his serum shown to be hemolytic and reactive against all red cells with normal expressions of the Kell antigens, developed a severe Nocardia pneumonia with abscess formation and was subsequently treated successfully with granulocyte transfusions in spite of the presence of anti-KX in the patient's serum. The anti-KX did not appear to alter significantly the effectiveness of the transfused granulocytes; it did, however, cause a mild hemolytic transfusion reaction. The patient made a remarkable recovery from this episode and his condition has progressed to a state satisfactory enough for him to donate his own blood for storage and possible use in the future.
Of thirty-seven children treated at the Mayo Clinic for suppurative arthritis of the hip and followed for at least one year (average, 8.3 years), nineteen had a satisfactory result and eighteen, an unsatisfactory result. An analysis of the records of the thirty-seven children revealed the following: (1) duration of symptoms was the most important prognostic feature, there being no unsatisfactory results if treatment was instituted less than four days after onset of symptoms; (2) fourteen of sixteen patients with associated osteomyelitis and six of eight with so-called penicillin-resistant Staphylococcus aureus had unsatisfactory results; (3) if symptoms had been present for more than ten days or if there was osteomyelitis, at least two weeks of parenteral antibiotics with arthrotomy and continuous irrigation offered the best prognosis; and (4) the prognosis has improved in recent years, possibly due to a move vigorous policy of early arthrotomy.
The case described here represents the first laboratory-confirmed case of inclusion blennorrhea at the Mayo Clinic since laboratory isolation of Chlamydia trachomatis was instituted in 1974. Treatment with a sulfonamide preparation proved effective. Further aspects of the diagnosis and treatment of inclusion blennorrhea are discussed.
When septic arthritis involves the hip, the prognosis is much worse than with any other joint. Approximately 50 per cent of the results were unsatisfactory with hip involvement compared to 12 per cent unsatisfactory results with involvement of the other joints. The erythrocyte sedimentation rate is a much more helpful diagnostic test than the leukocyte count or differential cell count. The most important prognostic factors are the duration of symptoms prior to treatment, a penicillinase-producing organism (penicillin-resistant) as the etiologic agent, and evidence of associated metaphyseal osteomyelitis. Early decompression and cleansing of the joint by aspiration or arthrotomy are essential for a good result. Long-term parenteral antibiotic therapy improves the prognosis when osteomyelitis is an assoicated feature. Arthrotomy with continuous irrigation appears to be more effective in decreasing long-term residual effects than arthrotomy alone. Almost all secondary surgical procedures are directed toward correcting the sequelae of septic arthritis of the hip.
Optimal antibiotic management of children with acute bone and joint infections depends on early clinical diagnosis, careful search for the infecting organism, and institution of vigorous surgical therapy. Because antibiotic treatment must be initiated before confirmatory laboratory data are available, clues to the bacteriologic etiology must be sought. Knowledge of the patient's age, the clinical circumstances of the infection, and the associated physical findings may provide a presumptive bacteriologic diagnosis. Gram-staining of the surgical aspirate or tissue may provide immediate information about the nature of the pathogen. Definitive culture results and antibiotic sensitivities may be useful in modifying therapy, if necessary. It is advocated that antibiotics be given parenterally for the full course of therapy because of the seriousness of the infection and the importance of high blood and tissue levels. To determine a response to therapy, frequent careful physical examinations along with periodic roentgenograms and sedimentation rate determinations are indicated. Because long-term, high-dose antibiotic-therapy can produce side effects, it is essential that studies be done to monitor any potentially harmful effects on organ systems.
The present review of disk space infection in children agrees with that carried out in 1962.12 The physician who encounters a child with back or hip pain, irritability, and a change in walking pattern should always suspect an infection of the vertebral column, particularly in the presence of limited spine motion, spasm, and an elevated sedimentation rate. S. aureus still is the usual primary infecting agent. Treatment consisting of rigid immobilization of the spinal column during the acutely painful phase appears to be adequate therapy. The use of antibiotics is not generally recommended. Because of this, hospitalization is usually not prolonged unneccessarily. The rationable for the use of antibiotics in one atypical case included recurrence of clinical signs and symptoms despite immobilization. These included persistent pain and spasm associated with a high sedimentation rate. Disk space aspiration probably is no longer necessary or desirable in the usual patient in whom immobilization is generally effective. The prognosis for most patients is good. Occasionally spinal fusion should be considered in this young age group if mechanical backache persists after the infection has been cured. The findings and recommendations regarding management of this disease in children should not be applied to the adult.