Fatal case of Reye's syndrome associated with H3N2 influenza virus infection and salicylate intake in a 12-year-old patient

We describe a fatal case of Reye's syndrome in a 12-year-old male patient during an influenza A (H3N2) infection for which he received salicylates. In the current situation of the novel A/H1N1 virus pandemic, we believe that it is of high importance to emphasize the risks associated with salicylate intake to avoid the reappearance of Reye's syndrome.

[Respiratory complications of accidental drownings in children]

Accidental drownings are severe and sometimes mortal events in children. Our study aims to better clarify the epidemiology and the respiratory complications of these accidents in our hospital. We led a retrospective study over 10 years concerning the children hospitalized for accidental drowning in our hospital centre. Age at the moment of the accident, sex, history of accident, hospitable care, thoracic imaging and neurological outcome of the children were studied. In total, 83 children were hospitalized (5 years on average, 70% being boys). The drowning especially took place in fresh water (71%), particularly in swimming pools (51.8%). Stages III and IV of drowning concerned 40.9% of the population. The coverage was the following one: admittance in ICU 57.8%, mechanical ventilation 34.9%, oxygen therapy 16.9%, antibiotics 87.9%. A normal chest x-ray was present in 45.7% of the cases. Drowning in fresh water, especially in contaminated fresh water (canal, WC, etc.), induced atelectasis (10.8%), whereas drowning in sea water induced diffuse infiltrates (8.4%). Aspiration pneumonia (33.7%) was present in both cases and a pulmonary oedema (6%) was only noticed during stage IV drowning. The secondary infections were rare (1 case was suspected and another probable). A child presented a secondary acute respiratory distress syndrome (1.2 %). Finally, 7 deaths (8.4%) and 1 case with severe neurological sequelae (1.2%) were noted. Accidental drowning causes important consequences in children. The long-term respiratory outcomes have not been properly studied. Prevention of such accidents is based on parental vigilance during their child's bathe.

Oxcarbazépine et syndrome DRESS : un cas pédiatrique révélé par une hépatite fulminante

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome, also called hypersensitivity reaction, is a severe idiosyncratic reaction to drugs, especially to anti-epileptic drugs. Clinical features associate cutaneous eruption, fever, multiple peripheral ganglions, and potentially life-threatening damage of one or more organs. DRESS syndrome is well described in adults treated with aromatic anti-epileptic drugs, such as phenytoin, phenobarbital, and carbamazepine, but also with other drugs. The new anti-epileptic drugs, such as oxcarbazepine also induce various cutaneous eruptions, but with less report of DRESS syndrome. In children, DRESS syndrome is rare and probably underdiagnosed. We report on the case of a 11-year-old girl hospitalised with an acute severe hepatitis revealing an oxcarbazepine-induced DRESS syndrome.

[Central alveolar hypoventilation syndrome and cerebral venous thrombosis: fortuitous association?]

Central hypoventilation syndrome is defined as the failure of automatic control of breathing. Secondary central hypoventilation syndrome should distinguish from congenital central hypoventilation syndrome by brainstem abnormalities, place of respiratory control.

CASE REPORTS

We report two clinical cases characterized by late onset central hypoventilation syndrome (three years--six months, and five years old): in the first case the diagnosis was made after general anesthesia and the second one presented with acute nocturnal comatose state. Neuroradiologic investigations showed bilateral cerebral sinus veinous thrombosis without any brainstem lesions. Moreover these children had severe behavior disorders: psychomotor instability, alterations of social relations, language dysfunction, and neurocognitive deficit. This symptomatology seems independent from central hypoventilation syndrome and cerebral venous thrombosis.

CONCLUSION

Late onset central hypoventilation syndrome may be associated with cerebral venous thrombosis. Ischemia of central chemoreceptors or integration of their informations could be one of mechanism.

Evaluating the prognosis of multiple, severely traumatized children in the intensive care unit

OBJECTIVE

To assess the Pediatric Risk of Mortality (PRISM) score and to identify other prognosis factors in severe, multiple trauma in children.

DESIGN

Retrospective study over a 9-year period.

SETTING

A Pediatric Intensive Care Unit (PICU) in a University Hospital.

PATIENTS AND PARTICIPANTS

One hundred and thirty-three traumatized children, 8.6 years (8 months-16 years), were reviewed.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Pediatric Trauma Score (PTS), Injury Severity Score (ISS), New ISS (NISS), Glasgow Coma Scale (GCS) score, and PRISM were calculated. The areas under the Receiver Operating Characteristic (ROC Az) curves, were compared. Univariate and multivariate analyses were performed. The mortality rate was 25.6%. PRISM performed well for discrimination between survivors and non-survivors. Az PRISM 0.9387 (0.029) was not different from Az GCS score 0.9451 (0.027) (P=0.568), but was significantly different from Az ISS 0.756 (0.052) (P<0.001), Az NISS 0.7606 (0.051) (P<0.001), and Az PTS 0.8244 (0.047) (P=0.016). Death was significantly associated with head trauma (P=0.014), PRISM >35, PTS <5, GCS <7, and ISS or NISS >32 (P<0.00001). PRISM >35 (P=0.001) and GCS <7 (P=0.003) were independent risk factors of death.

CONCLUSIONS

PRISM is a reliable tool for evaluating the prognosis of multiple, severely traumatized children. Its relative simplicity and the fact that it is extremely widespread as a general prognosis score in PICUs represent other arguments for its use. Due to the leading influence of head trauma on mortality, GCS, a score even simpler than PRISM, showed identical accuracy regarding survival prediction.

Pharmacokinetics of transdermal fentanyl in the peri-operative period in young children

The pharmacokinetics of transdermal fentanyl were assessed in eight children aged 18-60 months, weighing 11-20 kg and monitored postoperatively in the intensive care unit. A patch, delivering 25 microg.h-1 of fentanyl, was applied for 72 h from the induction of anaesthesia. Plasma fentanyl concentrations were measured over 144 h. Mean (SD) peak concentration of fentanyl was 1.7 (0.66) ng.ml-1 and time to reach maximal plasma concentration was 18 (11) h. The elimination half-life was 14.5 (6.2) h, and the area under the curve for plasma fentanyl concentration (0-144 h) was 86.8 (27) ng.h.ml-1. Maximal fentanyl concentration was negatively correlated with patient age (r = - 0.71; p = 0.049) but not with body weight. These results suggest that the pharmacokinetics of transdermal fentanyl in children are similar to those in adults.

Kidney function in cyclosporine-treated paediatric pulmonary transplant recipients

BACKGROUND

Lung or heart-lung transplantation is a useful therapy in life-threatening pulmonary disorders during childhood. Cyclosporine A is a major immunosuppressive treatment but has a number of adverse effects including nephrotoxicity. There have been no reports on the long-term evolution of renal function in a large series of paediatric pulmonary transplantation recipients.

METHODS

We examined 19 patients followed up for at least 3 years after pulmonary transplantation. The mean time of follow-up was 5.36 years. Kidney function was evaluated by calculation of glomerular filtration rate (GFR) according the Schwartz formula.

RESULTS

The GFR was normal before transplantation in all patients. The short-term evolution of GFR was marked by a significant drop during the first and until the 6th month. Then, regardless of the level reached at the end of the 6th month, the GFR remained stable in all patients except one until the end of follow-up. At the end of follow-up, 31% had normal GFR, 57% had mild chronic renal failure, and 5% had advanced renal failure. Hypertension was frequent and associated with renal failure.

CONCLUSIONS

Paediatric pulmonary recipients showed evidence of long-term cyclosporine A-associated nephrotoxicity. Most of this toxicity occurred during the first 6 months.

Lung infections in pediatric lung transplantation: experience in 49 cases

OBJECTIVES

Pulmonary infections, and particularly cytomegalovirus (CMV) infections, are a major cause of morbidity after lung transplantation. We report here our results in 49 pediatric lung transplantations.

METHODS

Between may 1988 and 1997, we have done 49 lung transplantations in 42 children (en bloc double lung transplantation (DLT):10, HLTx:7, sequential bilateral sequential-lung transplantation (BSLT):31, single-lung transplantation (SLT): 1). In seven, it was a retransplantation. Among these, 34 were cystic fibrosis (CF) patients, all with multiresistant organisms (Pseudomonas aeruginosa, Burkholderia cepacia, Achromobacter xylososydans, Staphylococcus aureus). All patients were treated with multiantibiotic prophylaxy adapted to the preoperative cultures. Donor-recipient CMV matching was possible in only 31 cases. CMV prophylaxy and immunosuppression protocols have evolved with time, with a current protocol of IV Gancyclovir prophylaxy for 3 months and triple drug immunosuppression without post-operative rabbit anti-thymocyte globulin (RATG) induction. There was no perioperative mortality in the primary transplantations and three early deaths in the whole group (6.1%).

RESULTS

Only five patients had no pulmonary infection. The patients presented 3.2 infection episodes per year, 75% localized on the lungs, 41% during the first 3 months. Among the 13 deaths in the 1st year, 10 were directly related to infection, 60% due to CMV. After the 1st year, in all patients dying of pulmonary dysfunction or obliterative bronchiolitis (OB), bacterial infections were associated. There was no serious fungal infection. Actuarial survival at 3 months, 1, 3, 5 years were 85, 65.7, 47.5 and 28.5%, respectively. There was a significant difference in 3 year survival between patients receiving CMV negative organs (40%) and CMV positive organs (17%).

CONCLUSION

In our experience, as in other's, pulmonary infection risk is important in lung transplantation. Bacterial infections were mainly an aggravating factor of secondary pulmonary dysfunction or OB, and were not the primary cause of death. CMV infections have been very severe and lead us, despite the scarcity of donors, to avoid positive donors in negative recipients, this leads to disastrous mid-term results in our experience, despite prophylaxis.

[Severe lactic acidosis and thiamine deficiency during parenteral nutrition in a child]

We report the case of a leukemic child treated with chemotherapy and parenteral nutrition for three weeks, who developed a severe lactic acidosis. Clinical features included both digestive and neurological disorders associated with a moderate cardiovascular collapse. After elimination of a toxic, a neoplastic or a septic cause, a thiamin (or vitamin B1) deficiency was suspected because of the lack of vitamin supply to parenteral nutrition. Intravenous administration of thiamin rapidly controlled lactic and clinical features. The diagnosis was confirmed by a low plasmatic concentration of thiamin. Thiamin deficiency must be suspected in case of severe lactic acidosis during parenteral nutrition and systematically prevented by supply of vitamins.

[Recent developments in the treatment of pediatric acute respiratory distress syndrome]

Acute respiratory distress syndrome (ARDS) is a severe condition with a high mortality rate, despite conventional treatment using mechanical ventilation. Better understanding of the pathophysiology and awareness of important iatrogenic lung injury secondary to mechanical ventilation has led to new therapeutic principles. Mechanical ventilation strategy during ARDS is characterized by positive end-expiratory pressure, increase in the inspiratory time, high inspiratory oxygen concentration and, more recently, use of permissive hypercapnia. High frequency ventilation allows optimal lung recruitment under small tidal volume. The effectiveness of extracorporeal oxygenation techniques is demonstrated, but because of their cost and morbidity these therapies are rational only in patients who seem likely to die. Partial liquid ventilation and inhaled nitric oxide have great potential but require further studies. Intratracheal exogenous surfactant might be beneficial but controlled trials are needed to confirm the usefulness of this expensive therapy. Finally, a number of adjuncts to mechanical ventilation are currently available to minimize iatrogenic lung injury and improve the outcome. The role of these new treatments must be defined with randomized and controlled clinical trials using homogenous inclusion criteria.

[Value of surfactant in the treatment of acute respiratory distress syndrome in a child]

BACKGROUND

Adult respiratory distress syndrome has a high mortality rate, despite treatment including mechanical ventilation with positive end-expiratory pressure, increase of the inspiratory time and high inspiratory oxygen concentration. Exogenous surfactant, a well established treatment in premature newborns with neonatal respiratory distress syndrome has only been occasionally evaluated in adult respiratory distress syndrome.

CASE REPORT

A 3 year-old child suffered from adult respiratory distress secondary to respiratory syncytial virus infection. Both mechanical ventilation and inhaled nitric oxide failed to improve the respiratory distress. Two doses of intratracheal surfactant application immediately improved pulmonary functions, transiently after the first instillation on day 13 and definitely after the second one, on day 16.

CONCLUSION

Exogenous surfactant appeared to be useful for the survival of our patient but prospective evaluation of this treatment in adult respiratory distress syndrome is needed.

Acute presentation of congenital diaphragmatic hernia past the neonatal period: a life threatening emergency

PURPOSE

Major gastric distension in the left hemithorax can threaten life in patients with congenital diaphragmatic hernia (CDH) presenting after the neonatal period. After presentation of two pediatric cases, guidelines for the optimal care of these patients are given.

CLINICAL FEATURES

Both children had respiratory and cardio-circulatory compromise on arrival. The diagnosis of late presenting CDH was made and the severity of symptoms was related to a voluminous distension of an intrathoracic stomach. Successful placement of an naso-gastric tube in the first patient, lead to a rapid clinical improvement, allowing surgical repair. In the second patient, oro- or naso-gastric decompression was not possible, and while the lungs were mechanically ventilated and the patient was prepared for surgery, a sudden cardiocirculatory arrest was managed by external chest compressions and rescuscitation drugs. Transthoracic percutaneous decompression of the stomach was the sole treatment allowing spontaneous cardiac activity to reappear, and haemodynamic condition to normalize. However, the child died from brain death after this episode.

CONCLUSION

Gastric decompression is the key for the treatment of patients with CDH who present respiratory and/or cardiocirculatory distress due to the intrathoracic distension of the stomach. If an oro- or naso-gastric decompression is not possible, then radiologically directed percutaneous decompression under local anesthesia is required. After decompression, the patient is prepared for surgery, with particular emphasis on fluids infusion, in order to correct the frequently associated hypovolaemia.

Balance between alveolar macrophage IL-6 and TGF-beta in lung-transplant recipients. Marseille and Montréal Lung Transplantation Group

Acute inflammation in the lung is characterized by a phase of tissue injury followed by a phase of tissue repair. When the latter is excessive, fibrosis occurs. Alveolar macrophages (AM) can produce cytokines involved in both phases of acute lung inflammation, notably interleukin-6 (IL-6), involved in injury and transforming growth factor-beta (TGF-beta), mediating repair. We hypothesized that AM were activated in both phases, and studied IL-6 and TGF-beta production by AM during complications of lung transplantation, acute rejection (AR), and cytomegalovirus pneumonitis (CMVP). In addition, we analyzed these cytokines in bronchiolitis obliterans (BO), a fibrotic complication of lung transplantation linked to previous AR and CMVP. At the onset of AR and CMVP, IL-6 secretion increased, whereas AM TGF-beta content was increased, but not its secretion. In contrast, with time, IL-6 reached control value whereas TGF-beta secretion rose significantly. In BO, IL-6 was not oversecreted, but TGF-beta increased, notably before functional abnormalities occurred. These results show that during acute complications of lung transplantation, AM display an early activation with oversecretion of IL-6, which is involved in tissue injury, counterbalanced by a late activation in which TGF-beta predominates, mediating tissue repair. The results provide new insights into the pathogenesis of BO, which is linked to acute complications of lung transplantation through this biphasic AM activation.

Bilateral single-lung transplantation in children

BACKGROUND

This study examined our experience with bilateral single-lung transplantation in pediatric patients.

METHODS

Between 1988 and 1995, we have performed 32 double-lung transplantations in children. The first 10 were performed en bloc, the following 22 by bilateral single-lung transplantation. Indications for bilateral single-lung transplantation were cystic fibrosis in 16 patients, primitive obliterative bronchiolitis in 1, pulmonary artery hypertension in 1, and retransplantation in 4. Patients' ages ranged from 7 to 16 years (mean, 12 years). Four patients underwent a parenchymal reduction (lobectomy or bilobectomy). Bilateral single-lung transplantation was performed with a "clam-shell" incision, normothermic cardiopulmonary bypass, and a beating heart.

RESULTS

There was one postoperative death (heart failure in a retransplantation patient). Bleeding was moderate, and 4 patients had a bloodless procedure. Bronchial healing was satisfactory, with 3 patients receiving temporary left main bronchus stenting. There were two hospital deaths (recurrent cytomegalovirus infection in a retransplantation patient and multiorgan failure at 2 months) and seven late deaths, caused by infection (mostly cytomegalovirus), obliterative bronchiolitis, or both. Actuarial survival was 75% at 1 year, 56% at 2 years, and 36% at 3 years.

CONCLUSIONS

We conclude that bilateral single-lung transplantation appears to be an acceptable technique, even in small children. Bronchial healing is satisfactory, and no revascularization procedure appears necessary. Midterm and long-term results are comparable with those of heart-lung transplants, and in view of the current problems with organ donation, we think it is an adequate strategy in pediatric lung parenchymal disease.

Monitoring of alveolar macrophage production of tumor necrosis factor-alpha and interleukin-6 in lung transplant recipients. Marseille and Montreal Lung Transplantation Group

Bronchiolitis obliterans (BO), a common complication in lung transplant recipients, is a fibrotic process probably related to acute rejection (AR) and cytomegalovirus pneumonitis (CMVP). Because the pathogenesis of pulmonary fibrotic diseases involves activation of alveolar macrophages (AM), the present study was carried out to determine if AM were activated during AR, CMVP, and BO. Interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) were measured in 157 AM supernatants obtained from 29 transplant recipients by immunoradiometric assay. Five groups were analyzed: AR (n = 21), CMVP (n = 12), BO (n = 15), bacterial pneumonia (BP) (n = 8), and control subjects (n = 70). Cytokines were also assayed 15 d (n = 15) and 30 d (n = 9) after AR and 30 d (n = 9) after CMVP. Cytokine secretion was elevated during AR (TNF-alpha = 3,709 +/- 1,409 pg/10(6) cells, IL-6 = 5,482 +/- 2,058 pg/10(6) cells, p < 0.005), and they returned to control values within 15 d. A similar pattern was observed during CMVP (TNF-alpha = 5,000 +/- 2,773 pg/10(6) cells, IL-6 = 12,280 +/- 3,939 pg/10(6) cells, p < 0.005), and values returned to control levels within 30 d. During BP, cytokine production values were higher than control values, but to a lesser extent than in AR and CMVP (TNF-alpha = 2,502 +/- 1,072, p < 0.05; IL-6 = 3,734 +/- 1,440, p < 0.005). In contrast, cytokine secretion during BO was not statistically different from that of control subjects.(ABSTRACT TRUNCATED AT 250 WORDS)

[Tracheobronchial healing after lung and heart-lung transplantations. Apropos of 64 anastomoses]

The authors report an analysis concerning the healing of tracheo-bronchial anastomoses after lung- and heart-lung transplantation. The present study includes 64 anastomoses selected from a total of 80 cases. Sixteen had to be excluded because of early post-operative death; none of these deaths was related to an air-way complication. Bronchial healing was assessed by bronchoscopic follow-up; the appearance of the suture-line was classified according to Couraud's grades. The initial reference was the examination at 2 weeks, which was compared to subsequent follow-up. At the initial assessment, 42 anastomoses were grade 1, 4 were grade II, and 18 were grade III. The subsequent anatomic result was satisfactory for 52 sutures (81%). The complications were malacia in 2 cases, stenoses treated with a stenting device in 4 cases, dehiscence in 6 cases. The duration of ischemia and postoperative mechanical respiratory support, as well as the proximal or distal site of the anastomosis appeared to be of significant prognostic value.

[Left ventricular involvement in mucoviscidosis after 2 years of age]

BACKGROUND

The cardiac involvement in cystic fibrosis includes the rare cardiomyopathy seen in infants and changes in left ventricular performance in older children.

POPULATION AND METHODS

67 patients, 6 to 34 months-old (mean: 16.7), 37 male and 30 female, with cystic fibrosis, were studied. Their Shwachman score was < 70. None showed any clinical manifestations of left ventricular insufficiency, but 6 patients had right ventricular insufficiency. Echocardiography was performed on 58 patients; it showed dilation of the right ventricle in 32 of them. Left ventricular perfusion was studied with thallium 201 tomoscintigraphy and left ventricular ejection fraction with 99mTc ventriculography.

RESULTS

The left ventricular ejection fraction was < 45% in 17 patients and scintigraphy showed hypofixation in 6 of them. In contrast, only 4 of the 50 patients with left ventricular ejection fraction > 45% had thallium hypofixation.

CONCLUSIONS

Resting perfusion abnormalities are more frequent in patients with a low left ventricular ejection fraction. These perfusion abnormalities suggest that myocardial fibrosis complicates the advanced stages of cystic fibrosis.

Double-lung transplantation in mechanically ventilated patients with cystic fibrosis

Many lung transplant programs consider ventilator dependence as a contraindication for transplantation. Among 54 patients in whom bilateral lung transplantations for cystic fibrosis were performed by the Joint Marseille-Montreal Lung Transplant Program, 10 were ventilator dependent. Three of them died in the early postoperative period (30%): 2 as a result of cerebral anoxia and sepsis, 1 of Pseudomonas cepacia pneumonia. Two patients died at 15 and 19 months after transplantation of obliterative bronchiolitis and secondary bacterial pneumonitis. Another 2 patients in whom obliterative bronchiolitis developed underwent retransplantation with a heart-lung block; 1 of those was operated on at 12 months and is well at 29 months after his initial transplantation; the second was operated on at 34 months and died of primary graft failure. Three other patients are alive and well at 3, 11, and 14 months after transplantation. Actuarial survival at 1 year was 70%. The postoperative course and the infectious and rejection complications were no different from those in patients who underwent transplantation while spontaneously breathing. Obliterative bronchiolitis developed in 66% of patients at risk (2 of 6 patients surviving more than 6 months). We conclude that transplantation in mechanically ventilated patients with cystic fibrosis is not associated with an increase in morbidity or mortality after bilateral lung transplantation. Long-term survival, as in patients who undergo transplantation while spontaneously breathing, is limited by the development of obliterative bronchiolitis.

Double-lung transplantation in children: a report of 20 cases. The Joint Marseille-Montréal Lung Transplant Program

In the last 3 1/2 years, we have performed 20 double-lung transplantations in children between 7 and 16 years old (mean age, 13 years). One patient had primitive bronchiolitis obliterans and the other 19, cystic fibrosis. Eight patients were operated on in an emergency situation, 7 of them requiring ventilator support before transplantation. The procedures were en bloc double-lung transplantation in the first 11 patients with separate bronchial anastomoses in 10, and sequential bilateral lung transplantation in the later 9 patients. There were no operative deaths. Two patients died in the hospital on postoperative days 37 and 73, and there were four late deaths, which were due to infection, rejection, and bronchiolitis obliterans. The acceptable incidence of airway complications, the improvement in lung function of survivors, and the acceptable midterm survival make double-lung transplantation an acceptable alternative to heart-lung transplantation in children. However, in very small children, heart-lung transplantation may be preferable because of the size of the airway anastomoses at risk.

Successful treatment of fungal right atrial thrombosis complicating central venous catheterization in a critically ill child

A 9-year-old boy was admitted to our pediatric intensive care unit after multiple trauma. On the 17th day post trauma, he developed catheter-related sepsis with candidemia. After removal of the catheter and 6 days of unsuccessful intravenous antifungal therapy, conventional and transesophageal two-dimensional echocardiography was performed revealing a large right atrial thrombus. Surgical thrombectomy under cardiopulmonary bypass was performed and the patient recovered within a few days. Fungal right atrial thrombus is a rare, life-threatening complication of central venous catheterization. Two-dimensional echocardiography is a simple and effective diagnostic technique that should be performed when candidemia is detected. The proper therapeutic response depends on the findings of this examination. For a symptomatic patient with a large, mobile thrombus, we strongly recommend thrombectomy. Surgery not only allows removal of the mass and thus elimination of the mechanical complication but is also a key to management of infection.

[Duodenal atresia with bifid termination of the common bile duct]

A new case of duodenal atresia with gas below the obstruction is reported. This apparently contradictory feature is due to a bifid termination of the common bile duct in the duodenum, air by-passing the atretic area. The anomaly was proven by operative cholangiography.

[Disseminated intravascular coagulation masking neonatal hemophilia]

Most infants with hemophilia have no bleeding in the neonatal period even if birth trauma occurs. The explanation for this lack of bleeding in the first few days of life in most hemophiliacs is unknown. Maternal factors VIII and IX fail to cross the placenta and cannot, therefore, protect the neonate. There have, however, been an increasing number of reports of severe neonatal bleeding in hemophiliac neonates. Herein, a case of severe neonatal bleeding responsible for hypovolemic shock and disseminated intravascular coagulation masking the hemophilia and delaying its diagnosis is reported. Transfusion of twice the total globular mass and exchange-transfusion were required. Hemorrhagic gastric necrosis occurred, requiring subtotal gastrectomy. The diagnosis of severe hemophilia A (factor VIII = 1%) was established only at 17 days of age. At the age of five months, the child developed a dumping syndrome which improved under appropriate dietary therapy and finally resolved. Outcome was favorable and at the evaluation at two years of age the child was leading a normal life. This case underlines the difficulty of the diagnosis of hemophilia at birth. When there is no family history of bleeding, the diagnosis of hemophilia is usually missed in the neonatal period and established only later or retrospectively. Factors VIII and IX should consequently be measured in male neonates with unusual bleeding and an increased activated partial thromboplastin time, even if disseminated intravascular coagulation is present. Prompt diagnosis and initiation of specific therapy may lessen acute morbidity and prevent long-term sequelae in affected infants.

[Purpuras fulminans: development over a 15-year period]

Eighty one children were admitted in ICU between 1969 and 1983. 35% of them died. There happened in the meantime an improvement in the results (12 deaths out of 30 children admitted in hospital from 1969 to 1974, 15 deaths out of 51 children from 1975 to 1983). The improvement was obvious in the tiniest children and the less severe cases; this is mostly owing to technical progress (hemodynamic control, sedation, artificial ventilation). Corticoids and heparin were not used, or exceptionally used since 1975. Mortality in severe cases did not change. It is important to point out the fact that the four children presenting a purpura fulminans secondary to an infection with Hemophilus Influenzae died.

[Digitalized angiography of the thorax in children]

Technical aspects and indications for the use of digital subtraction angiography of thorax in 109 children are discussed, and the interest of this exploratory method emphasized in chronic respiratory disease in children. Results obtained are compared with other investigations for screening of bronchopulmonary dysplasia. Although generally reliable for exploration of thoracic aorta anomalies (coarctation and abnormal vascular arch) it is considered to be incompletely effective for investigation of congenital heart disease.

[Tamponade due to pericardial perfusion. A peranesthetic complication in a child]

This report describes a case of fatal peroperative cardiac tamponade in a 5-year-old boy. It was the consequence of myocardial perforation by a polyethylene central venous catheter and intrapericardial infusion. In case of peroperative unexplained cardiovascular collapse, repeat check of the position of the central venous catheter is mandatory.