An Autoimmune Basis for Raynaud's Phenomenon: Murine Model and Human Disease

OBJECTIVE

Raynaud's phenomenon (RP) is common in anti-RNP-positive patients with rheumatic diseases but is not itself known to be caused by autoimmunity. The aim of this study was to assess autoantibodies that could mediate this process.

METHODS

Antibodies derived from patient sera and from murine models of anti-RNP autoimmunity were screened for the ability to induce RP-like tissue ischemia and endothelial cell apoptosis in murine models and in vitro systems.

RESULTS

RNP-positive sera from RP patients and murine sera from RNP-positive B cell adoptive transfer recipients induced RP-like tissue ischemia and endothelial cell apoptosis. Proteomic analysis identified cytokeratin 10 (K10) as a candidate autoantigen in RP. Monoclonal anti-K10 antibodies reproduced patterns of ischemic tissue loss and endothelial cell apoptosis; K10 knockout or depletion of anti-K10 activity in serum was protective. Cold exposure enhanced K10 expression and in vivo tissue loss.

CONCLUSION

Anti-K10 antibodies are sufficient to mediate RP-like ischemia in murine models and are implicated in the pathogenesis of RP in patients with anti-RNP autoimmunity.

B-cell antigen receptor activates transcription factors NFAT (nuclear factor of activated T-cells) and NF-κB (nuclear factor κB) via a mechanism that involves diacylglycerol

Engagement of the B-cell antigen receptor (BCR) induces the activation of various transcription factors, including NFAT (nuclear factor of activated T-cells) and NF-κB (nuclear factor κB), which participate in long-term biological responses such as proliferation, survival and differentiation of B-lymphocytes. We addressed the biochemical basis of this process using the DT40 chicken B-cell lymphoma. We discovered that Bruton's tyrosine kinase (BTK) and phospholipase C-γ2 (PLC-γ2) are required to activate NFAT and NF-κB, and to produce the lipid second messenger diacylglycerol in response to BCR cross-linking. Therefore the functional integrity of the BTK/PLC-γ2/diacylglycerol signalling axis is crucial for BCR-directed activation of both transcription factors NFAT and NF-κB.

Regulation of B lymphocyte development and activation by Bruton's tyrosine kinase

The generation and maintenance of B lymphocytes is controlled by biochemical signals transmitted by the B cell antigen receptor(BCR) complex. These signals are transduced by multiple cytoplasmic protein tyrosine kinases (PTKs) including Lyn, Syk, and Bruton's tyrosine kinase (BTK). Upon BCR engagement, these PTKs activate downstream effectors, including transcription factors that modulate gene expression. In turn, activation of downstream effectors is critical for B cell survival, cell cycle progression, and antibody production. Our studies focus on the role of BTK in these biological responses. We have discovered that BTK is required for activation of the BCR-responsive transcription factor, NF-kappaB. Furthermore, BTK-dependent activation of NF-kappaB is essential for reprogramming the expression of genes that control B cell survival and proliferation. The biochemical mechanisms by which BTK regulates signaling components that activate NF-kappaB, and the identification of BTK-responsive genes are under investigation. Elucidation of these regulatory mechanisms is expected to reveal new therapeutic targets for B cell pathologies involving defects in BTK, including X-linked agammaglobulinemia (XLA).

Phospholipase C-gamma 2 couples Bruton's tyrosine kinase to the NF-kappaB signaling pathway in B lymphocytes

Mutations in the gene encoding Bruton's tyrosine kinase (BTK) interfere with B cell proliferation and lead to an X-linked immunodeficiency in mice characterized by reduced B cell numbers. Recent studies have established that BTK transmits signals from the B cell antigen receptor (BCR) to transcription factor NF-kappaB, which in turn reprograms a set of genes required for normal B cell growth. We now demonstrate that induction of NF-kappaB via this pathway requires the intermediate action of the -gamma2 isoform of phospholipase C (PLC-gamma2), a potential phosphorylation substrate of BTK. Specifically, pharmacologic agents that block the action of either PLC-gamma2 or its second messengers prevent BCR-induced activation of IkappaB kinase. Moreover, activation of NF-kappaB in response to BCR signaling is completely abolished in B cells deficient for PLC-gamma2. Taken together, these findings strongly suggest that PLC-gamma2 functions as an integral component of the BTK/NF-kappaB axis following BCR ligation. Interference with this NF-kappaB cascade may account for some of the B cell defects reported for plc-gamma2(-/-) mice, which develop an X-linked immunodeficiency-like phenotype.

Cloning and functional characterization of the early-lymphocyte-specific Pb99 gene

The Pb99 gene is specifically expressed in pre-B cells and thymocytes and not in mature B and T cells or nonlymphoid tissues, implying that it may function in early lymphoid development. We have previously described the cloning of an incomplete cDNA for Pb99. Here we report the isolation of full-length cDNAs and genomic clones for the murine Pb99 gene and the mapping of its location to mouse chromosome 8. Sequence analyses of different Pb99 cDNA clones suggest that there may be at least three forms of the Pb99 protein generated by differential processing of the Pb99 transcript. The cDNA with the longest open reading frame encodes a putative protein that has seven hydrophobic domains similar to those of seven membrane-spanning proteins, such as the classical G protein-coupled receptors. To directly address the role of the Pb99 protein in lymphoid development, Pb99-deficient mice were generated by gene targeting, and lymphocyte development in these mice was analyzed.

Prospective, randomized, investigator-blinded study of the efficacy and safety of meropenem vs. cefotaxime therapy in bacterial meningitis in children. Meropenem Meningitis Study Group

OBJECTIVES

To compare the efficacy and safety of meropenem with cefotaxime for the treatment of infants and children with bacterial meningitis.

METHODS

Infants and children with strongly suspected or documented bacterial meningitis were randomly assigned in a prospective multicenter study to receive either meropenem or cefotaxime. Patients were assessed at the end of therapy and at 5 to 7 weeks and 5 to 7 months after the end of treatment for the presence of neurologic and sensory neural sequelae.

RESULTS

A total of 258 children were randomized to either treatment group. A further 8 patients with suspected pneumococcal meningitis were treated with meropenem without randomization. Of the randomized patients 154 were fully evaluable, 79 in the meropenem group and 75 in the cefotaxime group. At the end of treatment there were no significant differences in clinical outcome between the two treatment groups. Clinical cure with or without sequelae was achieved in 97 and 96% of the meropenem- and cefotaxime-treated patients, respectively. At the end of treatment and at 5 to 7 weeks, 46 and 54% of meropenem patients were cured with no sequelae, respectively. Corresponding results for cefotaxime patients were 56 and 58%. All pathogens were eradicated. In total 37 patients had seizures during treatment, 15 (12%) in the meropenem and 22 (17%) in the cefotaxime group. None of the seizures was considered to be drug-related.

CONCLUSIONS

This trial shows that meropenem is suitable therapy for bacterial meningitis in infants and children and that it offers an efficacy and safety profile similar to that of cefotaxime.

Independent and opposing roles for Btk and lyn in B and myeloid signaling pathways

Transphosphorylation by Src family kinases is required for the activation of Bruton's tyrosine kinase (Btk). Differences in the phenotypes of Btk-/- and lyn-/- mice suggest that these kinases may also have independent or opposing functions. B cell development and function were examined in Btk-/-lyn-/- mice to better understand the functional interaction of Btk and Lyn in vivo. The antigen-independent phase of B lymphopoiesis was normal in Btk-/-lyn-/- mice. However, Btk-/-lyn-/- animals had a more severe immunodeficiency than Btk-/- mice. B cell numbers and response to T cell-dependent antigens were reduced. Btk and Lyn therefore play independent or partially redundant roles in the maintenance and function of peripheral B cells. Autoimmunity, hypersensitivity to B cell receptor (BCR) cross-linking, and splenomegaly caused by myeloerythroid hyperplasia were alleviated by Btk deficiency in lyn-/- mice. A transgene expressing Btk at approximately 25% of endogenous levels (Btklo) was crossed onto Btk-/- and Btk-/-lyn-/- backgrounds to demonstrate that Btk is limiting for BCR signaling in the presence but not in the absence of Lyn. These observations indicate that the net outcome of Lyn function in vivo is to inhibit Btk-dependent pathways in B and myeloid cells, and that Btklo mice are a useful sensitized system to identify regulatory components of Btk signaling pathways.

Involvement of Bruton's tyrosine kinase in FcepsilonRI-dependent mast cell degranulation and cytokine production

We investigated the role of Bruton's tyrosine kinase (Btk) in FcepsilonRI-dependent activation of mouse mast cells, using xid and btk null mutant mice. Unlike B cell development, mast cell development is apparently normal in these btk mutant mice. However, mast cells derived from these mice exhibited significant abnormalities in FcepsilonRI-dependent function. xid mice primed with anti-dinitrophenyl monoclonal IgE antibody exhibited mildly diminished early-phase and severely blunted late-phase anaphylactic reactions in response to antigen challenge in vivo. Consistent with this finding, cultured mast cells derived from the bone marrow cells of xid or btk null mice exhibited mild impairments in degranulation, and more profound defects in the production of several cytokines, upon FcepsilonRI cross-linking. Moreover, the transcriptional activities of these cytokine genes were severely reduced in FcepsilonRI-stimulated btk mutant mast cells. The specificity of these effects of btk mutations was confirmed by the improvement in the ability of btk mutant mast cells to degranulate and to secrete cytokines after the retroviral transfer of wild-type btk cDNA, but not of vector or kinase-dead btk cDNA. Retroviral transfer of Emt (= Itk/Tsk), Btk's closest relative, also partially improved the ability of btk mutant mast cells to secrete mediators. Taken together, these results demonstrate an important role for Btk in the full expression of FcepsilonRI signal transduction in mast cells.

Btk dosage determines sensitivity to B cell antigen receptor cross-linking

Mutations in Btk result in the B cell immunodeficiencies X-linked agammaglobulinemia (XLA) in humans and X-linked immunodeficiency (xid) in mice. Btk is a critical component of signaling pathways regulating B cell development and function. We used a genetic approach to determine whether Btk is also limiting for these processes. One allele of a murine Btk transgene expressed a dosage of Btk (25% of endogenous levels in splenic B cells) sufficient to restore normal numbers of phenotypically mature conventional B cells in xid mice. 2,4,6-trinitrophenyl-Ficoll response, anti-IgM-induced proliferation, B1 cell development, and serum IgM and IgG3 levels remained significantly impaired in these animals. B cells from Btk -/- transgenic mice also responded poorly to anti-IgM, indicating that the xid mutation does not create a dominant negative form of Btk. Response to 2,4,6-trinitrophenyl-Ficoll and B cell receptor cross-linking were increased 3- to 4-fold in xid mice homozygous for the transgene. These results demonstrate that Btk is a limiting component of B cell antigen receptor signaling pathways and suggest that B cell development and response to antigen may require different levels of Btk activity.

Bruton's tyrosine kinase regulates apoptosis and JNK/SAPK kinase activity

Mast cells derived from Bruton's tyrosine kinase (Btk)-defective xid or btk null mice showed greater expansion in culture containing interleukin-3 (IL-3) than those from wild-type (wt) mice. Although the proliferative response to IL-3 was not significantly different between the wt and xid mast cells, xid and btk null mast cells died by apoptosis more slowly than their wt counterparts upon IL-3 deprivation. Consistent with these findings, the apoptosis-linked c-Jun N-terminal kinase/stress-activated protein kinase (JNK) activity was compromised in these btk-mutated cells upon Fc(epsilon)RI crosslinking or upon stimulation with IL-3 or with stem cell factor. p38 activity was less severely, but significantly, affected by btk mutation, whereas extracellular signal-regulated kinases were not affected by the same mutation. Btk-mediated regulation of apoptosis and JNK activity was confirmed by reconstitution of btk null mutant mast cells with the wt btk cDNA. Furthermore, growth factor withdrawal induced the activation and sustained activity of JNK in wt mast cells, while JNK activity was consistently lower in btk-mutated mast cells. These results support the notion that Btk regulates apoptosis through the JNK activation.

Impaired B cell maturation in mice lacking Bruton's tyrosine kinase (Btk) and CD40

Mutations in Bruton's tyrosine kinase (Btk) gene, in mice, result in reduced numbers and responses of peripheral B cells. Surface Ig-mediated signaling is defective in Btk mutant B cells as they do not proliferate upon slg cross-linking and lack thymus-independent (TI) type II responses. Signals through sIg and CD40 play a critical role in B cell maturation. To investigate the consequences of the lack of both Btk and CD40 on B cell development and function, mice were generated that were homozygous for targeted mutations in the Btk and the CD40 genes (BtkMCD40M). The CD40 mutation (CD40M) had a synergistic effect on the BtkM defects. In BtkMCD40M mice the number of B cells was reduced 3- to 4-fold compared to BtkM mice and mature B cells (IgMlow/IgDhigh) were virtually absent; serum levels of all Ig isotypes were diminished; and antibody responses to TI-I TI-II and thymus-dependent antigens were impaired. Furthermore, although wild-type BtkM and CD40M mice produced germinal centers in response to TI-I antigen, the BtkMCD40M mice did not. Maturational and functional B cell defects in BtkMCD40M mice may result from a combination of intrinsic B cell defects, lack of CD40L-dependent T cell help and microenvironmental defects. These data suggest that signals through Btk and CD40 are necessary for the production and maintenance of the mature B cell.

Defective B cell development and function in Btk-deficient mice

Mutations in the Bruton's tyrosine kinase (Btk) gene have been linked to severe early B cell developmental blocks in human X-linked agammaglobulinemia (XLA), and to milder B cell activation deficiencies in murine X-linked immune deficiency (Xid). To elucidate unequivocally potential Btk functions in mice, we generated mutations in embryonic stem cells, which eliminated the ability to encode Btk pleckstrin homology or kinase domains, and assayed their effects by RAG2-deficient blastocyst complementation or introduction into the germline. Both mutations block expression of Btk protein and lead to reduced numbers of mature conventional B cells, severe B1 cell deficiency, serum IgM and IgG3 deficiency, and defective responses in vitro to various B cell activators and in vivo to immunization with thymus-independent type II antigens. These results prove that lack of Btk function results in an Xid phenotype and further suggest a differential requirement for Btk during the early stages of murine versus human B lymphocyte development.

Streptococcus pneumoniae resistant to penicillin: incidence and potential therapeutic options

Streptococcus pneumoniae was recovered from 12 (50%) samples of middle ear fluid of 24 consecutive patients with AOME and in mixed culture of middle ear pathogens from one (4%) additional specimen. Two (15.3%) isolates had intermediate resistance to penicillin (minimal inhibitory concentration (MIC) 0.125 and 1.0 micrograms/mL). The antimicrobial susceptibility to various antimicrobials of 30 S pneumoniae strains recovered from patients seen in the last 12 months was also determined. One of the patients with AOME developed bacteremia that resolved uneventfully, whereas the other developed meningitis. MIC90 was determined from penicillin (2 micrograms/mL), erythromycin (> 32 micrograms/mL), cefaclor (32 micrograms/mL), loracarbef (> or = 64 micrograms/mL), cefixime (16 micrograms/mL), ceftibuten (> 64 micrograms/mL), chloramphenicol (16 micrograms/mL), cefpodoxime (4 micrograms/mL), ciprofloxacin (2 micrograms/mL), cephalexin (> or = micrograms/mL), augmentin (2 micrograms/mL), cefprozil (8 micrograms/mL), clindamycin (64 micrograms/mL), TMP-SXT (> 64 micrograms/mL), clarithromycin (32 micrograms/mL), rifampin (0.06 micrograms/mL), cefuroxime (2 micrograms/mL), cefotaxime (0.25 micrograms/mL), vancomycin (0.25 micrograms/mL), and imipenem (0.5 micrograms/mL). Cefprozil, vancomycin, and rifampin inhibited all strains, whereas cefpodoxime, cefuroxime, clindamycin, and clarithromycin exhibited very good activity.

Genomic organization of mouse and human Bruton's agammaglobulinemia tyrosine kinase (Btk) loci

Btk is a cytoplasmic protein tyrosine kinase (PTK) that has been directly implicated in the pathogenesis of X-linked agammaglobulinaemia (XLA) in humans and X-linked immunodeficiency (Xid) in mice. We have isolated phage and cosmid clones that allowed us to deduce the genomic structure of mouse and human Btk loci. The mouse and human genes are contained within genomic regions that span approximately 43.5 kb and 37.5 kb, respectively. Both loci contain 18 coding exons ranging between 55 and 560 bp in size with introns ranging in size from 164 bp to approximately 9 kb. The 5'-untranslated regions are encoded by single exons located approximately 9 kb upstream of the first coding exon. Exon 18 encodes for the last 23 carboxyl-terminal amino acids and the entire 3'-untranslated region. The location of intron/exon boundaries in the catalytic domains of the mouse and human Btk loci differs from that found in other described sub-families of intracellular PTKs, namely that of Src, Fes/Fer, Csk, and Abl/Arg. This observation is consistent with the classification of Btk together with the recently characterized kinases, Tec and Itk, into a separate sub-family of cytoplasmic PTKs. Putative transcription initiation sites in the mouse and human Btk loci have been determined by using the rapid amplification of cDNA ends assay. Similar to many other PTK specific genes, the putative Btk promoters lack obvious TATAA and CAAAT motifs. Putative initiator elements and potential binding sites for Ets (PEA-3), zeste, and PuF transcription factors are located within the 300 bp which are located upstream of the major transcription start site in both species. These sequences can mediate promoter activity when placed upstream of a promotorless chloramphenicol acetyl transferase reporter gene in an orientation-dependent manner. The present analysis will significantly facilitate the mutational analyses of patients with XLA and the further characterization of the function and regulation of the Btk molecule.

Genomic organization of mouse and human Bruton's agammaglobulinemia tyrosine kinase (Btk) loci

Btk is a cytoplasmic protein tyrosine kinase (PTK) that has been directly implicated in the pathogenesis of X-linked agammaglobulinaemia (XLA) in humans and X-linked immunodeficiency (Xid) in mice. We have isolated phage and cosmid clones that allowed us to deduce the genomic structure of mouse and human Btk loci. The mouse and human genes are contained within genomic regions that span approximately 43.5 kb and 37.5 kb, respectively. Both loci contain 18 coding exons ranging between 55 and 560 bp in size with introns ranging in size from 164 bp to approximately 9 kb. The 5'-untranslated regions are encoded by single exons located approximately 9 kb upstream of the first coding exon. Exon 18 encodes for the last 23 carboxyl-terminal amino acids and the entire 3'-untranslated region. The location of intron/exon boundaries in the catalytic domains of the mouse and human Btk loci differs from that found in other described sub-families of intracellular PTKs, namely that of Src, Fes/Fer, Csk, and Abl/Arg. This observation is consistent with the classification of Btk together with the recently characterized kinases, Tec and Itk, into a separate sub-family of cytoplasmic PTKs. Putative transcription initiation sites in the mouse and human Btk loci have been determined by using the rapid amplification of cDNA ends assay. Similar to many other PTK specific genes, the putative Btk promoters lack obvious TATAA and CAAAT motifs. Putative initiator elements and potential binding sites for Ets (PEA-3), zeste, and PuF transcription factors are located within the 300 bp which are located upstream of the major transcription start site in both species. These sequences can mediate promoter activity when placed upstream of a promotorless chloramphenicol acetyl transferase reporter gene in an orientation-dependent manner. The present analysis will significantly facilitate the mutational analyses of patients with XLA and the further characterization of the function and regulation of the Btk molecule.

The pregnancy-specific glycoprotein (PSG) gene cluster on human chromosome 19: fine structure of the 11 PSG genes and identification of 6 new genes forming a third subgroup within the carcinoembryonic antigen (CEA) family

The human pregnancy-specific glycoprotein (PSG) genes belong to the carcinoembryonic antigen (CEA) family, which in turn is a member of the immunoglobulin superfamily. We have analyzed a 700-kb cosmid contig spanning the PSG region on chromosome 19q13.2. The region contains 11 closely related PSG genes organized in tandem with a highly conserved structure and organization. Seven novel genes (CGM12 to CGM18) were found in the PSG region. CGM12 belongs to the CEA subgroup and appears to be a pseudogene. CGM13 to CGM18 forms a third new subgroup within the CEA gene family. The members of this new subgroup show 94-99% identity to each other but only 70-80% to other members of either the CEA or the PSG subgroups. They are composed of exons encoding two IgC-like domains and short hydrophilic carboxyl terminals similar to those of the PSGs. Unlike any of the known CEA family genes, however, they seem to lack the exon for an IgV-like N-terminal domain.

Penetration of cefprozil into middle ear fluid of patients with otitis media

Penetration of cefprozil into the middle ear fluid was investigated in patients with chronic otitis media. A total of 89 patients ranging from 7 months to 11 years old participated in the study. The middle ear fluid was removed by ventilation tubes inserted through the tympanic membrane at times ranging from 0.38 to 5.97 h after oral administration of a single dose of 15 or 20 mg/kg of body weight. A blood sample was also collected as soon as the middle ear fluid was removed. Plasma samples were analyzed for the concentration of cefprozil by a high-performance liquid chromatographic assay. Middle ear fluid samples were analyzed for the concentration of cefprozil by a microbiological assay. The concentrations of cefprozil in plasma ranged from 0.38 to 15.97 micrograms/ml at the 15-mg/kg dose level and from 1.28 to 21.47 micrograms/ml at the 20-mg/kg dose level. The corresponding middle ear fluid concentrations of cefprozil ranged from 0.06 to 4.44 micrograms/ml and from 0.17 to 8.67 micrograms/ml, respectively. Cefprozil penetrates well into middle ear fluid in patients with chronic otitis media.

Expression of antigens of the carcinoembryonic antigen family on B cell lymphomas and Epstein-Barr virus immortalized B cell lines

Expression of antigens of the carcinoembryonic (CEA) family on B cell lymphomas and Epstein-Barr virus (EBV) immortalized B cell lines was studied using two CEA reactive mAbs. Results from experiments where five B cell lymphomas and two immortalized B cell lines, one from fetal liver and one from normal blood, were analyzed by flow cytometry, showed that all cell lines were strongly reactive with both mAbs. Glycoproteins of 66-90 kDa were identified in cell lysates and spent medium of metabolically labelled cells, immunoprecipitated with the two anti-CEA mAbs and analyzed by SDS-PAGE autoradiography. In cell lysates, a polyclonal anti-CEA antibody reacted with two molecules of 78 and 90 kDa. EBV negative lymphomas, converted, in vitro, with EBV, expressed significantly higher glycoprotein levels, as compared with the parent cell lines. Furthermore, two additional glycoproteins of 45 and 33 kDa were found in lysates from these cells. Northern analysis of mRNA from four of the lymphoma and one of the EBV immortalized B cell lines, using a probe which hybridizes with all CEA family members, showed two CEA related transcripts of 3.9 and 2.2 kb. Based on the sizes of the transcripts and of the glycoproteins, it was concluded that some of the CEA antigens expressed on B cells were, most likely, alternatively spliced forms of biliary glycoprotein.

Identification of three new genes and estimation of the size of the carcinoembryonic antigen family

Using carcinoembryonic antigen (CEA) subgroup-specific degenerate PCR primers, we have identified three new CEA gene family member L/N exons (CGM9, CGM10, and CGM11) and all previously reported L/N exons of the CEA subgroup (CEA, BGP, NCA, CGM1, CGM2, CGM6, CGM7, and CGM8). This suggests that the CEA subgroup contains 11 genes. CGM9, CGM10, and CGM11 seem to be pseudogenes. A deletion of an asparagine in CGM9 results in loss of a glycosylation site, which is conserved throughout the CEA gene family. We have previously suggested the number of genes in the pregnancy-specific glycoprotein (PSG) subgroup to be 11, which together with this study indicates that the CEA gene family contains 22 genes in all. Parsimony analysis of the CEA subgroup interrelationships suggests that CGM7 occupies the most primitive position within the CEA subgroup, being a sister group to the rest. CEA, BGP, NCA, and CGM1 form a fairly well-supported group within the CEA subgroup.

Circulating endotoxin and tumor necrosis factor during pediatric cardiac surgery

OBJECTIVES

To study the hypothesis that endotoxin and tumor necrosis factor-alpha (TNF) are released into the circulation during the perioperative period in children undergoing open-heart surgery, and to assess the possible role of these factors in postoperative morbidity.

DESIGN

Prospective study.

SETTING

Operating room and ICU of a children's hospital.

PATIENTS

Twenty-four consecutive patients undergoing open-heart surgery for repair of congenital heart disease.

METHODS

Endotoxin and TNF concentrations were measured in blood samples withdrawn from patients at predetermined time points in the perioperative period. These concentrations were also measured in samples from all fluids and drugs administered to patients. Clinical variables were measured throughout the perioperative period, and the Pediatric Risk of Mortality score was calculated daily.

RESULTS

All of the preoperative control samples were negative for endotoxin and TNF. Endotoxin or TNF was detected in the blood of 21 (88%) of 24 patients during or after surgery. Endotoxin (ranging in concentrations from 0.32 to 438 pg/mL) was detected in the blood of 16 (67%) of the 24 patients. The majority of the samples positive for endotoxin were withdrawn during cardiopulmonary bypass and were associated with positive samples from the pump, from cardiotomy suction specimens, and from autotransfused blood. Blood cultures of all patients, except one, were negative for bacterial growth. TNF (ranging in concentrations from 3 to 132 U/mL) was detected in the blood of nine (37%) of the 24 patients. Patients positive for TNF had significantly (p less than .05) lower mean central venous pressures at 20 hrs after surgery and higher mean heart rates postoperatively compared with patients negative for TNF. No differences in other indicators of perioperative morbidity and intraoperative conditions were found, when the groups positive for endotoxin or TNF were compared with the groups negative for endotoxin or TNF, respectively.

CONCLUSIONS

Endotoxin and TNF are released into the circulation during and after pediatric open-heart surgery. TNF release may be related to some of the hemodynamic changes observed after open-heart surgery.

The pregnancy-specific glycoprotein family of the immunoglobulin superfamily: identification of new members and estimation of family size

The members of the carcinoembryonic antigen (CEA)/pregnancy-specific glycoprotein (PSG) gene family have a characteristic N-terminal domain that is homologous to the immunoglobulin variable region. We have estimated the size of the PSG subfamily by identification of N-domain exons from isolated genomic clones and from total genomic DNA through PCR amplification and DNA sequence determination. The PSG subfamily contains at least 11 different genes. For 7 of these, two DNA sequences differing from each other in 1 to 4 nucleotides were detected. Most likely, they represent different alleles. They are PSG1, PSG2, PSG3, PSG4, PSG5, PSG6, PSG7, PSG8, PSG11, PSG12, and PSG13. Six of the N-domain sequences described here are new. All of the PSGs except PSG1, PSG4, and PSG8 contained the arginine-glycine-aspartic acid sequence at position 93-95 corresponding to the complementarity determining region 3 of immunoglobulin. Parsimony analysis of 24 CEA and PSG sequences using 12 members of the immunoglobulin gene superfamily as outgroups to root the family tree shows that the N-domain of the CEA group genes evolved in one major branch and the PSG group genes in the other.

Biosynthesis of carcinoembryonic antigen (CEA) gene family members expressed in human tumor cell lines: evidence for cleavage of the glycosyl phosphatidyl inositol (GPI) anchor by GPI-PLC and GPI-PLD

Three Carcinoembryonic Antigen (CEA) gene family members: CEA, Non-specific cross-reactive antigen 50/90 (NCA) and biliary glycoprotein (BGP) were expressed in the colon carcinoma cell lines LS174T and HT29. The CEA, NCA50/90 and four alternatively spliced BGP transcripts (BGP a-d) were identified. The molecular weights of the mature glycoproteins were: CEA, 180kD; NCA50/90, 70-100 kD; BGP, 85, 120 and 140 kD. Pulse chase experiments demonstrated that CEA first appears as a 165 kD high mannose precursor which is trimmed to a 160 kD intermediate and finally transformed into the mature 180 kD glycoprotein. The precursor form of NCA had a molecular weight of 50 kD. CEA and NCA50/90, but not BGP, were linked to the cell membrane via glycosyl phosphatidyl inositol and could be released from the intact tumor cells by glycosyl phosphatidyl inositol-specific phospholipase C. CEA on isolated membranes and in cell lysates, but not on intact cells, was also cleaved by fresh human serum or purified glycosyl phosphatidyl inositol-specific phospholipase D.

Carcinoembryonic antigen gene family members in submandibular salivary gland: demonstration of pregnancy-specific glycoproteins by cDNA cloning

We have recently shown that human submandibular salivary gland and saliva contain a number of glycoproteins belonging to the carcinoembryonic antigen (CEA) gene family. The members of the CEA family can be divided into the CEA subgroup and the pregnancy specific beta 1 glycoprotein (PSG) subgroup. The latter glycoproteins are abundant in placenta and fetal liver. Here we report that PSG's are expressed in normal adult submandibular salivary gland. Thus, cDNA cloning and sequencing gave two clones (SG5 and SG9) which coded for glycoproteins with a domain arrangement of N-A1-A2-B2-C and a third clone (SG8) which coded for a glycoprotein with a domain arrangement of N-A1-B2-C. SG5 is identical to PSG3, and SG9 to PSG1d, while SG8 most probably corresponds to PSG2. The 3' untranslated regions of the different members of the PSG subgroup contain highly homologous segments, suggesting a common evolutionary origin.

Identification of a new carcinoembryonic antigen (CEA) family member in human fetal liver--cloning and sequence determination of pregnancy-specific glycoprotein 7

The carcinoembryonic antigen gene family consists of the CEA- and the Pregnancy-Specific Glycoprotein- (PSG) subfamilies. Human fetal liver express several PSGs. Here we report cloning and sequencing of a new PSG subfamily member, PSG7. It is the fifth type of PSG found in fetal liver. PSG7 has the N-A1-A2-B2-C domain arrangement. Unlike other PSGs the N-terminal of PSG7 is unblocked. PSG7 has a cysteine in the C-terminal domain, which may allow dimerization. Variability analysis according to Wu and Kabat reveals that the region in the N-domain corresponding to complementarity determining region 3 of immunoglobulin is different between PSG subfamily members. Many members, including PSG7, contain the RGD sequence in this region. The CD2 region as well as two other short sequences (in N and A1 domains respectively) also show some variability. The function of PSGs is probably linked to the N-domain and the CDR2- and CD3-like regions are most likely responsible for ligand binding.

Treatment of Pseudomonas meningitis with ceftazidime with or without concurrent therapy

In ongoing studies in Europe and the United States, 10 pediatric patients with bacterial meningitis caused by Pseudomonas species were treated with ceftazidime. Pseudomonas aeruginosa was isolated from the CSF of 7 patients and other Pseudomonas species from the remaining 3. Eight of the 10 patients had received previous antimicrobial treatment which included aminoglycosides in 6, along with ticarcillin and ureidopenicillins in 3. Ceftazidime was administered 10 to 42 days in dosages ranging from 109 to 300 mg/kg/day. Seven of the 10 patients received ceftazidime only for 10 to 42 days. The other 3 patients received amikacin in 2 and gentamicin and tobramycin in the other. Seven patients were cured clinically and 3 died; 9 were cured bacteriologically and one who was presumed cured on the basis of clinical response subsequently died. Sterilization of the cerebrospinal fluid occurred at 48 hours to 12 days. Ceftazidime appears useful in treating bacterial meningitis caused by Pseudomonas species.

Carcinoembryonic antigen gene family: molecular cloning of cDNA for a PS beta G/FL-NCA glycoprotein with a novel domain arrangement

Human fetal liver contains a family of carcinoembryonic antigen related glycoproteins called the pregnancy specific beta 1 glycoprotein/fetal liver non specific cross-reactive antigen (PS beta G/FL-NCA) glycoprotein family. The sequence for the major FL-NCA species has been reported [Khan et al., Proc. Natl. Acad. Sci. USA 1989, 86 in press]. Two additional CEA-related fetal liver glycoproteins FL-NCA-2 and 3 were cloned, sequenced and expressed. FL-NCA-3 is a new gene family member. It has a unique domain arrangement (N-A2-B2-T) and contains a hydrophobic tail. FL-NCA-3 has a molecular weight of approximately 54 kD and is released from the transfected cells. Like three other members of the family, FL-NCA-3 contains the Arg-Gly-Asp sequence in a position in the N-domain corresponding to complementarity determining region 3 of immunoglobulin. FL-NCA-2 is identical in structure to PS beta G-D previously found in placenta. The PS beta G/FL-NCA glycoprotein family may be involved in processes related to cell adhesion and cell differentiation.

Molecular cloning and expression of cDNA for a carcinoembryonic antigen-related fetal liver glycoprotein

Carcinoembryonic antigen (CEA) is considered to be an embryonic antigen that is reexpressed in carcinomas. However, at the molecular level little is known about fetal forms of CEA. We have studied fetal liver, which was originally considered to contain CEA. A first-trimester cDNA library from fetal liver was screened with CEA-specific probes, and a dominant cDNA clone was identified and sequenced. This 1.7-kilobase cDNA codes for a complete protein of 426 amino acids, of which 34 constitute a leader peptide. Structurally, it can be divided into four immunoglobulin-like domains homologous to CEA (N-A1-A2-B2) and a hydrophobic tail (12 residues). The A and B domains each contain two cysteines; the N domain has none. The protein has seven potential sites for asparagine-linked glycosylation. It is a form of pregnancy-specific beta 1-glycoprotein (PS beta G) but differs from other PS beta G species at the C terminus. The N and A1 domains show 45% and 51% amino acid sequence identity with the corresponding domains of the three CEA family members whose sequences have been determined. Expression studies showed that the cDNA codes for a 72-kDa glycoprotein that reacts immunologically with antisera to CEA, biliary glycoprotein I, and PS beta G. The 72-kDa glycoprotein was released from the transfected cells. At least six mRNA species were identified in human tissues by using this cDNA as a probe. Genomic DNA analysis with an N-domain-specific probe indicated that the number of genes is relatively small.

Aztreonam in the treatment of gram-negative meningitis and other gram-negative infections

Ninety patients (41 males, 49 females) with a diagnosis of meningitis, urinary tract infection (UTI), gastroenteritis or other miscellaneous gram-negative infections were enrolled. Their ages ranged from 7 days to 10 years, with a mean age of 4 months. 58 (63%) patients had an etiology confirmed by either positive culture (52; 89%) or latex agglutination (6; 10%). 41 of these patients had meningitis diagnosed by positive CSE culture (38) or by positive CSF latex agglutination (3); 27/41 patients also had positive blood cultures. Aztreonam MIC100 for 27 isolates of Haemophilus influenzae, all ampicillin-sensitive, was 0.19 micrograms/ml; 4 Salmonella sp., 1 Neisseria meningitidis and 1 Serratia marcescens isolates were inhibited by 0.19 micrograms/ml, and the MIC100 for 2 Klebsiella pneumoniae, 1 Proteus vulgaris and 2 Pseudomonas aeruginosa isolates were 0.045 and 0.19, 0.022 and 12.5 micrograms/ml, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Penetration of sulbactam and ampicillin into cerebrospinal fluid of infants and young children with meningitis

Infusions of 50 mg of sulbactam per kg per day and 400 mg of ampicillin per kg per day in divided doses to infants and children with bacterial meningitis produced levels in cerebrospinal fluid approximately one-third those in serum. Concentrations in cerebrospinal fluid of 5.5 micrograms of sulbactam per ml and 16.0 micrograms of ampicillin per ml declined within a few days of therapy to 1.9 microgram of sulbactam per ml and 5.2 micrograms of ampicillin per ml.

Effect of spectinomycin use on the prevalence of spectinomycin-resistant and of penicillinase-producing Neisseria gonorrhoeae

Because of the high prevalence of penicillinase-producing Neisseria gonorrhoeae in the Republic of Korea, spectinomycin has been used there in the primary treatment of gonococcal infections in U.S. military personnel since 1981, but there have been increasingly frequent reports of treatment failures with spectinomycin. We conducted a clinical study to determine the efficacy of spectinomycin treatment in 124 U.S. servicemen in the Republic of Korea who had urethral gonococcal infections. Ninety-seven patients were treated with spectinomycin alone and evaluated in a follow-up visit. In eight patients (8.2 percent), this treatment was unsuccessful. Antibiotic-sensitivity testing on isolates from seven of the patients with treatment failure demonstrated that six isolates were highly resistant to spectinomycin (minimal inhibitory concentration, greater than or equal to 100 micrograms per milliliter). None of the spectinomycin-resistant strains had become resistant to penicillin, either through the production of penicillinase or through a chromosomal mutation. Although the mechanism of spectinomycin resistance appears to be a chromosomal mutation, these isolates were generally sensitive to other antibiotics. The prevalence of resistance to spectinomycin resulted in the substitution of ceftriaxone for the primary treatment of gonorrhea acquired by U.S. military personnel in the Republic of Korea. We believe that the rapid emergence of spectinomycin resistance in this population mandates a cautious approach to widescale use of the drug and indicates a need to broaden current surveillance programs.

Sulbactam/ampicillin vs. chloramphenicol/ampicillin for the treatment of meningitis in infants and children

Eighty-one patients ages one month to 14 years with meningitis were randomized to receive either sulbactam (50 mg/kg per day) and ampicillin (400 mg/kg per day; 41 patients) or chloramphenicol and ampicillin (40 patients). The groups were comparable in terms of sex and degree of illness; however, more patients treated with chloramphenicol/ampicillin than patients treated with sulbactam/ampicillin were younger than 12 months of age (78% vs. 56%). Pathogens were isolated from the cerebrospinal fluid (CSF) of 65 (80%) of the 81 patients. In the sulbactam/ampicillin group, there were 18 Haemophilus influenzae isolates (one resistant to ampicillin), five Streptococcus pneumoniae, five Neisseria meningitidis, one Klebsiella pneumoniae, one Pseudomonas aeruginosa, and one Listeria. In the chloramphenicol/ampicillin group, there were 19 H. influenzae isolates, 10 S. pneumoniae, three N. meningitidis, one Haemophilus parainfluenzae, and one Citrobacter. Of 63 patients with assessable CSF pathogens, one (3%) of 29 treated with sulbactam/ampicillin died (S. pneumoniae) and six (18%) of 34 treated with chloramphenicol/ampicillin died (two, H. influenzae; three, S. pneumoniae; and one, Citrobacter). Twelve percent in the sulbactam/ampicillin group and 18% in the chloramphenicol/ampicillin group had neurologic sequelae. No clinically significant reactions or toxicities were noted. Sulbactam/ampicillin was as effective as chloramphenicol/ampicillin in the treatment of meningitis.

Ceftazidime vs. standard therapy for pediatric meningitis: therapeutic, pharmacologic and epidemiologic observations

One hundred patients ages 1 month to 15 years received either ceftazidime (CZ) at a dose of 150 mg/kg/day divided every 8 hours or conventional treatment with chloramphenicol and ampicillin (CA). Seventy-eight had isolates recovered from the cerebrospinal fluid: 40 (51%) were Haemophilus influenzae (all ampicillin-susceptible); 16 (21%) were Streptococcus pneumoniae; 14 (18%) were Neisseria meningitidis; 3 (4%) were salmonellae; 1 (2%) was Pseudomonas; and 1 (2%) was Group B Streptococcus. Six patients with negative cerebrospinal fluid culture had positive latex agglutination (two H. influenzae, three N. meningitidis, one S. pneumoniae). Sixty-one patients had positive blood cultures. CZ inhibited 100% of H. influenzae at 0.78 micrograms/ml, S. pneumoniae at 0.39, N. meningitidis at 0.04 and salmonellae at 0.39 micrograms/ml. The mean peak serum concentration of CZ was 36.4 micrograms/ml with a mean cerebrospinal fluid level of 7.4 micrograms/ml. If one eliminates from the statistics those patients who died less than or equal to 24 hours after admission, five (10%) of 49 patients treated with CZ died, one (2%) improved and 43 (88%) were cured. Overall 29 patients died, 12 receiving CZ (20%) and 8 receiving CA (21%). There were no significant CZ-related toxicities. Gross neurologic sequelae were noted in 5% of 38 CZ patients and 4% of 28 CA patients. CZ compared favorably to CA for treatment of meningitis.

Ceftazidime in the treatment of meningitis in infants and children over one month of age

Ceftazidime, a new beta-lactamase-resistant cephalosporin, was compared with a combination of ampicillin and chloramphenicol for the treatment of meningitis in 100 infants and children aged one month to 15 years. In this open, randomized trial conducted in the Dominican Republic, 61 patients received 50 mg/kg of ceftazidime intravenously every eight hours; 39 received ampicillin plus chloramphenicol in conventional dosages. Seventy-eight of the patients had discernible isolates in samples from cerebrospinal fluid, six had a positive diagnostic Directogen result, and the remainder either had miscellaneous pathogens evident in samples of cerebrospinal fluid, bacteriologic growth in cultures of blood samples only, or no bacteriologic growth in cultures of either cerebrospinal fluid or blood. Among patients with discernible etiologic agents in samples of cerebrospinal fluid, 11 of 57 (19 percent) ceftazidime-treated patients died, and five of 27 (19 percent) patients treated with the combination died. Mortality by pathogen was as follows for patients who received ceftazidime or ampicillin plus chloramphenicol, respectively: Hemophilus influenzae, two of 27 (7 percent) and one of 15 (6 percent); Streptococcus pneumoniae, six of 12 (50 percent) and two of five (40 percent); Neisseria meningitidis, none of 11 (0 percent) and one of six (17 percent); and Salmonella, neither of two (0 percent) and one of one (100 percent). Overall mortality in the ceftazidime group was 20 percent versus 21 percent in the combination group. No significant toxicities were noted in the patients treated with ceftazidime.

Erythromycin-sulfisoxazole vs amoxicillin in the treatment of acute otitis media in children. A double-blind, multiple-dose comparative study

A fixed combination of erythromycin ethylsuccinate and sulfisoxazole acetyl (erythromycin-sulfa) was compared with amoxicillin for the treatment of acute otitis media (AOM) in children. Of 145 patients studied, 76 boys and 69 girls were compliant and were evaluated for drug efficacy (72 amoxicillin, 73 erythromycin-sulfa). Based on otoscopic and tympanometric results, cure rates at ten to 14 days for AOM due to all organisms were 83% (63/72) for amoxicillin and 89% (65/73) for erythromycin-sulfa; for Haemophilus species (including mixed infections), they were 84% for amoxicillin (26/31) and 83% for erythromycin-sulfa (20/14). Cure rates for ampicillin-resistant Haemophilus were 1/1 for amoxicillin and 7/8 (88%) for erythromycin-sulfa; one patient (12%) had persistent AOM at day 10. Of the patients with AOM due to Streptococcus pneumoniae, 82% (29/35) in the amoxicillin-treated group and 98% (39/40) in the erythromycin-sulfa-treated group were cured. Patients with S pneumoniae as the initial infecting organism who were treated with amoxicillin had significantly more clinical recurrences then their erythromycin-sulfa-treated counterparts, 66% (8/12) vs 33% (3/9). There was no difference between treatment groups in recurrence rates for patients with Haemophilus as the initial infecting organism. On the treatment day indicated, the following number of patients had middle ear effusion: by days 10 to 14, 38% (27/72) amoxicillin-treated patients and 48% (35/73) erythromycin-sulfa-treated patients; by day 28, 10% (7/71) amoxicillin-treated patients and 16% (11/70) erythromycin-sulfa-treated patients. There were no significant differences in adverse reactions. The erythromycin-sulfa combination is safe and effective treatment for AOM, including ampicillin-resistant Haemophilus.

Erythromycin-sulfisoxazole for persistent acute otitis media due to ampicillin-resistant Haemophilus influenzae

In patients with acute otitis media who had failed to improve with ampicillin therapy, 35% of Haemophilus strains isolated from the middle ear were ampicillin-resistant. Twenty-nine children (24 of whom had failed to respond to ampicillin) were treated with 40 mg erythromycin ethylsuccinate per kg per day and 100 to 150 mg sulfisoxazole per kg per day. Middle ear exudate was cultured on chocolate and 5% sheep blood agar. Twenty-three of 29 Haemophilus isolates were nontypable, 10% (3 children) were type b, 2 were Haemophilus parainfluenzae and one was not typed. All strains were resistant to ampicillin by disc susceptibility testing, and 28 of 29 strains produced beta-lactamase. The minimal inhibitory concentration of ampicillin for 15 strains ranged from 3.12 to 100 micrograms/ml (median, 6.25 micrograms/ml). The erythromycin ethylsuccinate and acetyl sulfisoxazole combination was effective in treatment of acute otitis media secondary to ampicillin-resistant Haemophilus influenzae. After 10 days of erythromycin ethylsuccinate-sulfisoxazole therapy, 18 patients had normal tympanic membranes. Of 11 with middle ear effusion, 7 cleared, 3 had recurrent otitis media within 1 month and 1 had persistent otitis media with effusion. Our experience suggests the efficacy of this combination in otitis media caused by ampicillin-resistant H. influenzae.

Evaluation of cefaclor in acute otitis media caused by ampicillin-resistant H. influenzae

Cefaclor was used to treat 13 children with acute otitis media caused by ampicillin-resistant strains of Hemophilus influenzae. The children were re-examined on days 4, 10, and 28. Pharmacologic compliance was assessed by means of a bioinhibition assay on a urine specimen obtained on days 4, 7, and 10. Nine of the 13 children had evidence by tympanogram of residual otitis media with effusion (secretory otitis media). Of these, three were noted to have a bulging, yellow or grey eardrum, which suggested an ongoing acute process. A second middle ear culture was obtained from two of the 3 children, but no pathogens were recovered. Two others had recurrence of otitis shortly after cessation of therapy. Cefaclor is an acceptable antibiotic for the treatment of ampicillin-resistant acute otitis media; but, after cefaclor therapy, some children continued to have a bulging eardrum and sterile pus in the middle ear or had recurrences of otitis soon after cessation of therapy.

Otitis media secondary to ampicillin-resistant Hemophilus influenzae. An update

During a 2-year period ending December 1978, we encountered 27 cases of otitis media secondary to ampicillin-resistant Hemophilus influenzae. This represents 19% of the 139 Hemophilus isolates obtained by tympanocentesis. In agreement with data from Huntsville, Alabama, Boston, and Pittsburgh, we estimate that as of 1978, approximately 4% of all cases of acute otitis media are caused by this pathogen.

Trimethoprim-sulfamethoxazole in the treatment of otitis media caused by ampicillin-resistant strains of Haemophilus influenzae

Trimethoprim-sulfamethoxazole (TMP-SMZ) was successful treatment for 93% of cases of acute otitis media caused by ampicillin-resistant Haemophilus influenzae studied. All 15 children in this study had symptoms of otitis media that were unrelieved by a course of ampicillin therapy, but 14 of them responded promptly to a 10-day course of TMP-SMZ. Potentially invasive type b strains of H. influenzae were isolated in cultures of the middle ear exudate of three children, all of whom responded well to TMP-SMZ therapy. The middle ear isolates of H. influenzae were sensitive in vitro to TMP-SMZ. It is concluded that TMP-SMZ is effective and convenient for the treatment of otitis media caused by ampicillin-resistant H. influenzae.

Persistent purulent otitis media

Of 429 children with acute otitis media who returned for follow-up evaluation, 49 (11%) were unresponsive to a 10- to 14-day course of ampicillin, amoxicillin, or erythromycin/sulfisoxazole. Patients with persistent purulent otitis media were noted to have immobile, bulging, yellow or grey, abscessed tympanic membranes at the follow-up visit. A myringotomy was performed on 45 children. Cultures of middle-ear exudate yielded ampicillin-resistant Haemophilus influenzae in 14 (31%), ampicillin-susceptible pathogens (H. influenzae or Streptococcus pneumoniae) in 23 (51%), and no growth in 8 (18%).

Yersinia enterocolitica enteritis in children

Five patients were admitted to Children's Hospital National Medical Center with manifestations of Yersinia enterocolitica infections. Four of five had primarily enteric illness, while the fifth had associated ocular and joint involvements. In three of five cases, the disease was self-limiting. Two of the patients (No. 1 and 2) may have had their disease improved by antibiotic therapy. Increased alertness to the potential of Y enterocolitica to cause a variety of syndromes is necessary to make an accurate bacteriologic diagnosis and to expedite medical treatment.

Clinical and laboratory evaluation of cefamandole in infants and children

Fifty-three infants and children, aged three months to 15 years, were treated with an average daily dose of 100 mg of cefamandole/kg intravenously. Of these patients, 47 had soft tissue cellulitis and six had pneumonia. Primary pathogens, including Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae, and Haemophilus influenzae, were isolated from 43 of the 53 patients. Bacteremia was documented in six of the 53 patients. A satisfactory clinical and bacteriologic response to cefamandole was achieved in all cases except on (98%). The only treatment failure occurred in an infant with both periorbital cellulitis and bacteremia due to H. influenzae who developed meningitis while receiving cefamandole; no extravasation of the drug across the blood-brain barrier could be detected in spite of inflamed meninges. In general, the only aberrant effects of cefamandole were the appearance of eosinophilia in 28% of patients and a positive indirect Cooms' test without hemolysis in one patient. Cefamandole showed excellent in vitro activity against 87 ampicillin-resistant strains of H. influenzae. Because it has greater activity than any of the other cephalosporins against this important pediatric pathogen, cefamandole may have particular pertinence in the treatment of infections in infants and young children.

Acute purulent otitis media in children older than 5 years. Incidence of Haemophilus as a causative organism

It is generally believed that Haemophilus influenzae is not commonly a causative agent of otitis media in children older than 5 years of age. We recently studied cases of 58 children, aged from 5 to 9 years, who had acute otitis media. Haemophilus species were the causative agents in 36% of cases. This high incidence of Haemophilus isolation from the middle ear exudate of these children has important therapeutic implications; antibiotics effective against H influenzae should be employed when dealing with otitis media in this older age group.