[Perinatal Presentation and Complicated Course of a Multifocal Atrial Tachycardia]

We report a male newborn who became symptomatic with supraventricular tachycardia on the first day of life. Neither adenosine nor electric cardioversion could terminate the tachycardia, therefore intravenous esmolol (β-receptor blocker) was initiated. Inspite of subsequent administration of various antiarrhythmic medications in increasingly higher doses, repeated supraventricular tachycardic episodes occurred. The electrocardiogram showed typical findings of a multifocal atrial tachycardia as the underlying cause. When tachycardic episodes occurred, they also presented as atrial flutter at 460 bpm and a 2:1 block. Finally, high dosage of amiodarone (10 mg/kgbw/d) led to continuous control of the heart rate without tachycardic episodes. To date our patient is mostly in sinus rhythm but without tachycardic episodes and doing well.

Outbreak of multidrug-resistant Escherichia coli sequence type 131 in a neonatal intensive care unit: efficient active surveillance prevented fatal outcome

BACKGROUND

Outbreaks of infections with multidrug-resistant bacteria in neonatal intensive care units (NICUs) pose a major threat, especially to extremely preterm infants. This study describes a 35-day outbreak of multidrug-resistant Escherichia coli (E. coli) in a tertiary-level NICU in Germany.

AIM

To underline the importance of surveillance policies in the particularly vulnerable cohort of preterm infants and to describe the efficacy of outbreak control strategies.

METHODS

Data were collected retrospectively from medical reports. Infants and environment were tested for E. coli.

FINDINGS

The outbreak affected a total of 13 infants between 25(+1) and 35(+0) weeks of gestation with seven infants showing signs of infection. The outbreak strain was identified as E. coli sequence type 131. Environmental screening provided no evidence for an environmental source. Through colonization surveillance and immediate and adequate treatment of potentially infected preterm infants, no fatalities occurred. Outbreak control was achieved by strict contact precautions, enhanced screening and temporary relocation of the NICU. Relocation and reconstruction improved the NICU's structural layout, focusing on isolation capacities. Follow-up indicated carriage for several months in some infants.

CONCLUSION

Routine surveillance allowed early detection of the outbreak. The identification of carriers of the outbreak strain was successfully used to direct antibiotic treatment in case of infection. Enhanced hygienic measures and ward relocation were instrumental in controlling the outbreak.

[Staphylococcal Scalded Skin Syndrome in a Very Low Birth Weight Premature Infant]

INTRODUCTION

Staphylococcal scalded skin syndrome (SSSS) was often endemic in the past but is nowadays rare. The hematogeneous spread of exfoliative toxins A (ETA) or B (ETB) produced by specific Staphylococcus aureus strains causes a scald-like eruption with disseminated bullous lesions.

CASE REPORT

A perioral impetigo lesion occurred on day 14 of life in a preterm male infant (1,065 g, 30 weeks of gestational age). Empiric antibiotic therapy with cefotaxime and vancomycin was given for 6 days and led to complete resolution. A Staphylococcus aureus strain was isolated. After a symptom-free interval a relapse was noted on day 26 of life. Despite restarting the antibiotic therapy immediately the initial lesion expanded, and disseminated flaccid blisters on an erythematous base appeared within a few hours. On histological examination the cleavage was in the level of the granular layer. There was no mucosal involvement, and the Nikolsky I sign was positive. The antibiotic therapy was changed to a combination of cefotaxime, flucloxacillin and clindamycin which rapidly stopped progression of the exfoliation. Supportive therapy included adequate analgesia, parenteral rehydration, and application of local antiseptics. The preterm infant completely recovered. In the primary lesion an ETA-producing Staphylococcus aureus strain was isolated. Nasal microtrauma by a nasogastric tube was assumed to have caused the fulminant disease. At the same time, no other Staphylococcus aureus infections were seen in our Department of Neonatology.

DISCUSSION

According to the literature, the incidence of SSSS is higher in premature infants and newborns than in older children. Possible causes include lower antibody levels against exfoliative toxins and renal immaturity. Rapid diagnosis and immediate appropriate antibiotic therapy are essential to prevent secondary infection, dehydration with electrolyte disturbance, death, and endemic spread.

Late Vitamin K Deficient Bleeding in 2 Young Infants--Renaissance of a Preventable Disease

INTRODUCTION

Late vitamin K deficiency bleeding in young infants is a rare disorder which occurs almost exclusively in breast-fed infants who did not receive proper vitamin K prophylaxis at birth and who might additionally suffer from cholestasis. Its impact on morbidity is high since in 50% of the cases it presents with intracranial hemorrhage with a mortality rate of 20% and life-long neurologic sequelae in 30% of the affected infants.

CASE REPORTS

2 male infants were both admitted to our unit at the age of 5 weeks with subdural hematoma with midline shift due to late vitamin K deficiency bleeding. Both infants did not receive the recommended Vitamin K prophylaxis in Germany. One patient presented with cholestatic jaundice on admission as an additional risk factor.

DISCUSSION

Parents who in the apparent best interest for their children refuse the recommended and well established vitamin K prophylaxis at birth leading to the reappearance of late vitamin K deficiency bleeding. These parents also tend to refuse routine immunizations of childhood in later life, which not only have an impact on their own child but might bear a risk for the whole community.

CONCLUSION

It is the responsibility of health-care takers to show increased awareness to the growing number of parents refusing vitamin K prophylaxis at birth and educate them properly about the devastating consequences of late vitamin K deficiency bleeding.

[Umbilical Absent and Reverse End-Diastolic Flow Velocity Waveforms Already Present Prior to Viability do not Exclude Long-Term Foetal Surveillance: A Report of Two Cases]

The finding of absent or reverse end-diastolic flow velocities (AREDV) in the umbilical artery already prior to viability corresponds to the most severe end of the clinical spectrum of placental insufficiency. However, there is little or no experience or published literature with regard to perinatal outcome. We report 2 cases in which structurally and chromosomally normal foetuses showed severe early onset retardation but were continuing to grow. These gestations could be prolonged by 62 and 64 days, respectively. Perinatal outcome was good in both following Caesarean section at 32+3 and 31+5 gestational weeks respectively.

[Anesthesia and analgesia in the lactation period. Criteria for drug selection]

There is no sound information concerning the safe and correct use of analgesics and anesthetics during the lactation period based on studies with a large sample size. Available information is limited to case studies and small sample observations. As a result, information given by the drug manufacturers about the use of drugs during the lactation period is often restrictive or contains contraindications for the lactation period. Although some drugs are not officially licensed for use during lactation they need to be administered in daily (off-label) use. This review gives an overview about the recent knowledge and clinical experience concerning the perioperative use of anesthetics and analgesics during breast feeding.

A Boy with an LCR3/4-Flanked 10q22.3q23.2 Microdeletion and Uncommon Phenotypic Features

The recurrent 10q22.3q23.2 deletion with breakpoints within low copy repeats 3 and 4 is a rare genomic disorder, reported in only 13 patients to date. The phenotype is rather uncharacteristic, which makes a clinical diagnosis difficult. A phenotypic feature described in almost all patients is a delay in speech development, albeit systematic studies are still pending. In this study, we report on a boy with an LCR3/4-flanked 10q22.3q23.2 deletion exhibiting an age-appropriate language development evaluated by a standardized test at an age of 2 years and 3 months. The boy was born with a cleft palate - a feature not present in any of the patients described before. Previously reported cases are reviewed, and the role of the BMPR1A gene is discussed. The phenotype of patients with an LCR3/4-flanked 10q22.3q23.2 deletion can be rather variable, so counseling the families regarding the prognosis of an affected child should be done with caution. Long-term studies of affected children are needed to delineate the natural history of this rare disorder.

[Unexpected respiratory distress in the delivery room--a rare differential diagnosis for the obstetrician and neonatologist]

We present the case of a female infant born prematurely at 34 weeks of gestation. Prenatally a midsized ventricular septal defect was diagnosed. Due to marked respiratory distress intubation was attempted but failed, since the tube could not be placed beyond the glottis. Oxygenation could be improved by nasopharyngeal bag ventilation. The clinical course as well as radiographic imaging was suggestive for a complete tracheal agenesis with broncho-oesophageal fistula which was confirmed at autopsy. Tracheal agenesis (TA) is a rare differential diagnosis of postnatal respiratory distress and the obstetrician or neonatologist will regularly be surprised by this malformation. Partial or complete absence of the trachea without associated malformations will be rarely diagnosed antenatally. In the case of the absence of an oesophageal fistula to the remaining airway a congenital high airway obstruction syndrome (CHAOS) ensues, leading to enlarged hyperechogenic lungs, dilated and fluid-filled trachea and bronchi and an absent tracheal flow during foetal breathing. Aetiology of TA is unknown, therapeutic options are limited thus making TA a usually fatal disorder.

Compound heterozygosity of two functional null mutations in the ALPL gene associated with deleterious neurological outcome in an infant with hypophosphatasia

Hypophosphatasia (HPP) is a heterogeneous rare, inherited disorder of bone and mineral metabolism caused by different mutations in the ALPL gene encoding the isoenzyme, tissue-nonspecific alkaline phosphatase (TNAP). Prognosis is very poor in severe perinatal forms with most patients dying from pulmonary complications of their skeletal disease. TNAP deficiency, however, may also result in neurological symptoms such as neonatal seizures. The exact biological role of TNAP in the human brain is still not known and the pathophysiology of neurological symptoms due to TNAP deficiency in HPP is not understood in detail. In this report, we describe the clinical features and functional studies of a patient with severe perinatal HPP which presented with rapidly progressive encephalopathy caused by new compound heterozygous mutations in the ALPL gene which result in a functional ALPL "knock out", demonstrated in vitro. In contrast, an in vitro simulation of the genetic status of his currently asymptomatic parents who are both heterozygous for one mutation, showed a residual in vitro AP activity of above 50%. Interestingly, in our patient, the fatal outcome was due to progressive encephalopathy which was refractory to antiepileptic therapy including pyridoxine, rather than hypomineralization and respiratory insufficiency often seen in HPP patients. The patient's cranial MRI showed progressive cystic degradation of the cortex and peripheral white matter with nearly complete destruction of the cerebrum. To our knowledge, this is the first MRI-based report of a deleterious neurological clinical outcome due to a progressive encephalopathy in an infant harboring a functional human ALPL "knock out". This clinical course of disease suggests that TNAP is involved in development and may be responsible for multiple functions of the human brain. According to our data, a certain amount of residual TNAP activity might be mandatory for normal CNS function in newborns and early childhood.

Live-born trisomy 22: patient report and review

Trisomy 22 is a common trisomy in spontaneous abortions. In contrast, live-born trisomy 22 is rarely seen due to severe organ malformations associated with this condition. Here, we report on a male infant with complete, non-mosaic trisomy 22 born at 35 + 5 weeks via caesarean section. Peripheral blood lymphocytes and fibroblasts showed an additional chromosome 22 in all metaphases analyzed (47,XY,+22). In addition, array CGH confirmed complete trisomy 22. The patient's clinical features included dolichocephalus, hypertelorism, flattened nasal bridge, dysplastic ears with preauricular sinuses and tags, medial cleft palate, anal atresia, and coronary hypospadias with scrotum bipartitum. Essential treatment was implemented in close coordination with the parents. The child died 29 days after birth due to respiratory insufficiency and deterioration of renal function. Our patient's history complements other reports illustrating that children with complete trisomy 22 may survive until birth and beyond.

[Patient-controlled intravenous analgesia with remifentanil as an alternative to epidural analgesia during labor: case series and discussion of medicolegal aspects]

BACKGROUND

Epidural analgesia is considered as the standard method for labor analgesia by inducing a minimal negative impact on labor while providing effective analgesia. Labor analgesia in the absence of epidural analgesia is difficult to achieve with the commonly used analgesic interventions. If epidural analgesia is not feasible due to coagulation disorders, anticoagulation, inability to insert an epidural catheter or due to the mother''s refusal to accept neuraxial analgesia, there is a need for interventions to cope with labor pain. So far, pethidine, diamorphine, meptazinol and spasmolytics remain the most widely used substances for IM and IV use. Unfortunately, in addition to not being very effective, these interventions may be associated with undesirable side effects for the parturient and the newborn. For a decade, anaesthesiologists have experienced the unique properties of remifentanil in the settings of surgical anaesthesia and conscious sedation since it was introduced for labor analgesia. Unfortunately, remifentanil is not licensed for administration to the pregnant patient, and it is unlikely that the manufacturers would consider the cost justified.

METHODS

Therefore, relevant concerns, legal issues and precautions are discussed based on the presentation of case series and a protocol is presented on how the use of remifentanil can be safely implemented for labor analgesia in selected situations.

RESULTS AND CONCLUSIONS

Proper informed consent, appropriate monitoring for the mother and the newborn, one-to-one nursing or midwifery care as well as the availability of an attending physician experienced in neonatal resuscitation and an anaesthesiologist with experience regarding the use of remifentanil are important to ensure that this method retains its good reputation for obstetric analgesia.

[Hypertensive crisis in infancy and childhood]

The extended physical examination of a patient includes measurement of blood pressure. In infancy and childhood the blood pressure measurement may be difficult due to an uncooperative and restless patient. In a 16-month-old girl apparently unmeasurable blood pressure was a hypertensive crisis with systolic blood pressure of more than 200 mmHg. The cause of the hypertension was found to be a nephroblastoma. In the case of rapidly progressive arterial hypertension in another 16-month-old girl with left ventricular dilatation and reduced function was a consequence of kidney dysplasia. Headache attacks lead to diagnosis of a subtotal coarctation of the aortic isthmus in a 17-year-old boy. Hypertensive crisis in infancy, childhood and adolescence is discussed based on these case reports. Special features of blood pressure measurement in the pediatric age group, pathogenesis of hypertensive crisis and the potential therapies are discussed incorporating a brief review of the literature.

[Severe foetal growth retardation in a patient with uterus bicornis, velamentous insertion and partial placental abruption in the 26th week of gestation--a case report]

Foetal growth retardation (IUGR) occurs in approximately 3-10 % of all pregnancies and may result from foetal, maternal or placenta-related conditions. In IUGR, the placental weight is often reduced and the placental capacity, reflected by the organ's weight, is impaired. Uterine malformations have an incidence of 3-4 % and may be the cause of placental abruptions occurring in 0.4-1.3 % of all pregnancies. We report on a patient in the 26 (th) week of pregnancy who was admitted with vaginal bleeding. A uterus bicornis had been found previously. Sonography showed severe foetal growth retardation and a pathological foetal Doppler signal. A haematoma located cranial of the os uteri was sonographically diagnosed, and a partial placental abruption was suspected. Due to a pathological cardiotocography, a primary Caesarean section was performed. Intraoperative evaluation confirmed the presence of a uterus bicornis. In addition, the placenta showed an insertio velamentosa. The growth retarded foetus - 490 g birth weight - was anaemic. Respiratory therapy and surfactant substitution were performed because of a respiratory distress syndrome. At a corrected age of 8 weeks the boy was sent home without neurological sequelae. In the case reported, a malformation of the uterus was the cause of a pathologically altered placenta. The multiple factors responsible for the described severe intrauterine growth retardation were a low placental weight and thus a reduced placental capacity, an impaired foetal circulation caused by the velamentous insertion, as well as a partial placental abruption. In normotensive pregnancies with IUGR, macroscopic and histopathological examinations of the placenta are therefore strongly recommended. Prior to getting pregnant, the therapeutic options should be explained to women with uterine malformations.

MR-Bildgebung und MR-Spektroskopie zur Charakterisierung von Kardiomyopathien bei Jugendlichen - erste Ergebnisse

PURPOSE

Cardiomyopathy is a rare but life-threatening disease in children and adolescents. Recent studies reported morphological, functional or metabolic alterations of the heart. We discuss a combined MR imaging and (31)P MR spectroscopy (MRS) protocol allowing the analysis of interdependencies between these parameters. Since normal values of cardiac MR parameters in this age group are not available, we included studies of age-matched healthy adolescents.

MATERIALS AND METHODS

2D-CINE was used to assess left ventricular (LV) parameters. Additional 3D-Chemical Shift Imaging (3D-CSI) and Spectral Localization with Optimal Pointspread Function (SLOOP) reconstruction allowed quantification of the cardiac energy metabolism. Patients (n = 4; all male; age 16.8 +/- 2.9 years) were included on the basis of an echocardiographic diagnosis of possible cardiomyopathy. The same protocol was applied to healthy young volunteers (n = 4; 1 female, 3 male; age 15.5 +/- 0.6 years).

RESULTS

The patients had a significantly higher LV mass index compared to the control group (147 +/- 41 g/m (2) versus 97 +/- 16 g/m2; p = 0.04). The other LV parameters (including LV EF with 59 +/- 22 % versus 67 +/- 10 %) showed no significant differences. The phosphocreatine to adenosine triphosphate ratio (PCr/ATP-ratio) of the patients was reduced to 1.71 +/- 0.40 versus 2.44 +/- 0.30 (p = 0.01), combined with a tendency towards decreased PCr concentrations of 9.1 +/- 2.5 versus 7.9 +/- 1.0 mmol/kg.

CONCLUSION

The combination of (31)P MR spectroscopy and MR imaging allows quantitative determination of morphologic, functional and metabolic alterations in adolescents with suspected cardiomyopathy in one examination procedure. The reduction of energy metabolism combined with unaltered global function may indicate a primary role of metabolism in the pathogenesis of cardiomyopathies in adolescents.

Differenzialdiagnose einer papulösen Hauterkrankung des Neugeborenen: Pemphigoid gestationis

The clinical relevance of bullous skin diseases in newborns varies widely. We present the case of a preterm, 35 weeks of gestation, infant who was admitted to our hospital with skin lesions on face, thorax and plantae. There were no other pathological findings on clinical and neurological examinations. During another pregnancy the mother of the child had already suffered from pemphigoid gestationis. In the blood of the newborn complement-fixing auto-antibodies against BP180, the common antigen of pemphigoid gestationis and bullous pemphigoid, were detected. The skin lesions disappeared after a few days of local antiseptic therapy. Pemphigoid gestations is a rare autoimmune dermatosis in pregnancy. The frequency of skin lesions in newborns of mothers with pemphigoid gestationis is estimated to about 5 -- 10 %.

Schwere arzneimittelinduzierte Hautreaktion: toxische epidermale Nekrolyse durch Carbamazepin

BACKGROUND

Drug-related skin reactions often present as macular, maculopapular or urticarial rashes. Severe drug eruptions are rare, with life-threatening events occurring in about 4 per one million persons a year. In pediatric patients the estimated incidence of Stevens-Johnsons-syndrome (SJS) and toxic epidermal necrolysis (TEN) is even lower. They are often caused by antiepileptic drugs like carbamazepine.

CASE REPORT

A 10 (5)/ (12) year old boy of dark complexion suddenly developed a severe bullous skin disease six weeks after starting carbamazepine therapy due to focal epilepsy. Within few hours a life-threatening systemic inflammatory reaction occurred with subsequent respiratory failure. The clinical course was complicated by bacterial sepsis, bilateral thrombosis of the external iliacal veins and bilateral ocular symblephara. The skin healed with considerable pigmentary disturbance. We report the differential diagnostic and therapeutical features of toxic epidermal necrolysis and give a review of the literature.

[Inhaled nitric oxide in neonatology: state of the art]

In the late 1970 s it was demonstrated that nitric oxide (NO) was involved in the regulation of vasomotor tone. In Europe inhaled NO (iNO) was approved as a therapy option for the treatment of pulmonary hypertension in term and slightly preterm (> 34 weeks of gestation) neonates. Therapy by iNO mainly reduces the necessity for treatment by extracorporeal membrane oxygenation. However, the mortality of the underlying disease is not affected. According to our current knowledge iNO therapy for term and slightly preterm (> 34 weeks of gestation) neonates does not represent an additional risk factor for the neurological development. Today, iNO therapy constitutes the gold standard for pulmonary hypertension in new-born babies. However, the 30 % non-responders warrant a continued search for alternative treatment concepts. Prophylactic therapy according to a risk profile has not yet proved to be meaningful. An indication for the treatment of preterm neonates of less than 34 weeks of gestation has not yet been confirmed.

[Aseptic meningitis after intrathecal infusion of a parenteral nutrition solution: examples of rare malpositions of central venous catheters in preterm neonates]

BACKGROUND

Central venous catheters are an indispensable part of intensive care. In the management of preterm neonates, these are introduced after puncture of a peripheral subcutaneous vein. The catheters are supposed to be pushed forward with the venous flow. A chest X-ray is usually performed for verification of the position of the catheter. Localization of the tip of the catheter is often very difficult because of its extremely small diameter.

METHODS

A malposition of a central venous catheter resulting in intrathecal infusion of parenteral nutrition and subsequent aseptic meningitis in a preterm neonate is presented. Further cases of catheter malpositions leading to arthrography, arteriography and incorrect position in various parts of the venous system are discussed.

DISCUSSION AND CONCLUSION

The case reports demonstrate that wire-guided central venous catheters are not only advanced by the forward blood flow but can also inadvertently end up in undesired sites and may thus induce serious side effects.