Sixth Nerve Palsy in Children Etiology, Long-Term Course, and a Diagnostic Algorithm

BACKGROUND

Acute onset strabismus is worrisome for parents and physicians. This condition is sometimes attributed to sixth cranial nerve palsy, which may be secondary to various etiologies. Debate still exists about the appropriate diagnostic approach.

OBJECTIVE

The objective of this study was to describe the common etiologies of sixth nerve palsy in our pediatric population and to suggest a clear, implementable diagnostic algorithm.

METHODS

The authors conducted an electronic medical review of files of patients admitted to the pediatric department at Emek Medical Center between January 2014 and April 2020. They reviewed the medical records from the study period of patients with the following diagnoses according to the International Classification of Diseases 9: sixth nerve palsy, acute infective polyneuritis, Guillain-Barré syndrome, benign intracranial hypertension, malignant neoplasm of the brain, strabismus, myasthenia gravis, and multiple sclerosis. The authors extracted information regarding clinical presentation, previous history, and diagnostic work-up, including serological testing, cerebrospinal fluid testing, and neuroimaging. Final diagnosis and clinical follow-up were assessed.

RESULTS

Seventeen patients with sixth nerve palsy were identified. The most common etiologies were increased intracranial hypertension and anti-GQ1B syndrome (3 patients each).

CONCLUSIONS

This is a retrospective study of patients diagnosed in one medical center. The suggested algorithm was not validated on a prospective study. The etiologies of sixth nerve palsy in children are variable. The authors suggest performing neuroimaging in all patients and considering serum and cerebrospinal fluid testing in selected patients. Initial neuroimaging combined with laboratory testing is useful and provides rational tools for proper diagnosis.

The utility of next generation sequencing in the correct diagnosis of congenital hypochloremic hypokalemic metabolic alkalosis

Persistent hypokalemic hypochloremic metabolic alkalosis represents a heterogeneous group of genetic disorders of which the most common is Bartter syndrome (BS). BS is an inherited renal tubulopathy caused by defective salt reabsorption in the thick ascending loop of Henle, which results in persistent hypokalemic hypochloremic metabolic alkalosis. Here we report a 10-year-old girl of a consanguineous family. She presented prenatally with severe polyhydramnios and distended bowel loops. Thereafter, she displayed failure to thrive and had recurrent admissions due to dehydration episodes associated with diarrhea, and characterized by hypokalemia, hypochloremia and metabolic alkalosis. BS was considered her working diagnosis for several years despite negative genetic analysis of the known genes associated with BS. Whole exome sequencing identified a novel homozygous c.1652delT deleterious frameshift mutation in the SLC26A3 gene, which confirmed the diagnosis of congenital chloride diarrhea (CCD), a rare autosomal recessive disease that mimics biochemically BS. A review of twelve additional reported cases of CCD that were initially misdiagnosed as BS, emphasizes CCD in the differential diagnosis of BS, and highlights the clinical discrepancies between these two entities. Taken together, our report further emphasizes the typical clinical features of CCD, and the importance of next generation sequencing in the diagnosis of syndromes with genetic heterogeneity. We suggest including SLC26A3 in the extended BS targeted gene panels.

Growth hormone deficiency in children with antenatal Bartter syndrome

Background Bartter syndrome is a group of rare autosomal-recessive renal disorders characterized by hypokalemic hypochloremic metabolic alkalosis associated with severe growth failure; the exact causes for growth retardation are unclear. GH deficiency (GHD) has been reported in a few cases of Bartter syndrome. The aim of our study was to determine the prevalence of GHD in children with antenatal Bartter syndrome and to assess their response to GH therapy. Methods Ten patients aged 1.5-14.5 years and diagnosed with antenatal Bartter syndrome were enrolled. Seven children with short stature underwent GH stimulation tests. Results Common presenting symptoms were failure to thrive and polyuria. The mean patient height at study entry was -2.7 standard deviation (SD) (range 0.89 to -5.95) and mean weight (SD) was -1.7 (range 1.89 to -4.11). A decline in height and weight (SD) was observed over the years. GHD was diagnosed in four children and GH therapy was started in all of them. Two patients responded very well and gained >1 SD in height, one patient stopped therapy due to non-adherence and one had a poor response. Conclusions In addition to other important causes for poor growth in antenatal Bartter syndrome, our findings suggest that GHD should also be considered as a cause of growth retardation and therefore, clinical assessment of the GH axis is recommended. GH therapy has a role in the treatment of growth failure in some individuals with Bartter syndrome.

Brucellosis Outbreak in Children and Adults in Two Areas in Israel

Two parallel outbreaks of Brucella melitensis infection occurred in 2014 in two geographical areas in Israel. In two medical centers in northern Israel and one medical center in Jerusalem, 102 patients (58 children, 47 adults) were diagnosed with brucellosis. Most patients (N = 76, 72%) were Muslim Arabs, 28 (27%) were Druze, and one was Jewish. The source of infection was often traced to cheese from the Palestinian Authority. Biovar-1 was evident in 98% in northern Israel but only in 42% in Jerusalem. Most common manifestations were fever (82%) and osteoarticular symptoms (49%). The major differences between the geographic areas were ethnicity and duration until diagnosis. Compared with adults, children had higher rates of hospitalization (93% versus 64%, P = 0.001), osteoarticular symptoms (60% versus 36%, P = 0.05), elevated alanine aminotransferase (12% versus 0%, P = 0.01), and lower C-reactive protein (2.28 ± 2.08 versus 5.57 ± 6.3l mg/dL, P = 0.001). Two unrelated brucellosis outbreaks occurred in 2014 in two different geographic areas of Israel and were limited to sections of the Arab and Druze populations. Most of the demographic and clinical aspects of patients were not affected by geographic variability. Clinical and laboratory differences were found between children and adults emphasizing the nonuniformity of the disease in different age groups. Effective control of unpasteurized dairy foods, health education programs, and improved regional cooperation are required to control brucellosis in Israel.

Community-acquired urinary tract infection in hospitalized children: etiology and antimicrobial resistance. A comparison between first episode and recurrent infection

Urinary tract infection (UTI) is common in infants and children, and Escherichia coli is the leading pathogen. The aims of this study were to compare first episode of UTI with recurrent infection, reveal organisms that cause UTI, uropathogen resistance, and presence of bacteria producing extended-spectrum β-lactamase (ESBL). The first-UTI group included 456 children. E coli was the leading pathogen (80.5%), and Pseudomonas aeruginosa was found in 1.5%. The uropathogens were resistant to gentamicin (3.41%) and cefuroxime (5.71%), and highly resistant to cefamezin (37.39%). The recurrent-infection group included 106 children. E coli was also the leading pathogen, but 7.5% of the isolates were P aeruginosa (P = .002 compared with first-episode group); 6.6% were ESBL-producing bacteria compared with 1.1% in the first-episode group (P = .002). E coli is the leading pathogen in both groups. P aeruginosa and ESBL-producing bacteria were more common in the recurrent infection group.

Renal function in children with beta-thalassemia major and thalassemia intermedia

In beta-thalassemia, profound anemia and severe hemosiderosis cause functional and physiological abnormalities in various organ systems. In recent years, there have been few published studies demonstrating proteinuria, aminoaciduria, low urine osmolality, and excess secretion of the tubular damage markers, such as urinary N-acetyl-D-glucosaminidase (U(NAG)) and beta2 microglobulin, in patients with thalassemia. The object of this study was to analyze renal tubular and glomerular function in pediatric patients with beta-thalassemia and to correlate the renal findings to iron overload. Thirty-seven patients with beta-thalassemia major and 11 with thalassemia intermedia were studied. Twelve children without iron metabolism disorders or renal diseases served as a control group. No difference in blood urea nitrogen (BUN), serum creatinine, creatinine clearance, electrolytes, fractional excretion of sodium and potassium, and tubular phosphorus reabsorption was found. Serum uric acid was equal in the two groups, but its urine excretion was significantly higher in the thalassemic group. U(NAG) and U(NAG) to creatinine ratio (U(NAG/CR)) were elevated in all patients with thalassemia compared with the control group (p < 0.001) and were directly correlated to the amount of transfused iron but not to actual ferritin level. We found that renal tubular function is impaired in children with beta- thalassemia major and intermedia. It is not known whether these functional abnormalities would have any long-term effects on the patients. Further studies are needed, and means of preventing these disturbances should be sought.

Is omitting post urinary-tract-infection renal ultrasound safe after normal antenatal ultrasound? An observational study

BACKGROUND

Guidelines recommend obtaining a renal ultrasonogram (RUS) for young children after a first urinary tract infection (UTI).

OBJECTIVE

The aim of the current study was to assess the concordance of prenatal and post-UTI RUS findings in children with a first simple UTI.

METHODS

This was a prospective study and included all children aged 5 years or younger who were hospitalised with a first simple UTI (determined as clinical response and normalisation of temperature within 48 h on initiation of antibacterial therapy with no complications). Data were collected from each child regarding the results of prenatal and post-UTI RUS.

RESULTS

Overall, 250 children were included in the study and the results of late-pregnancy and post-UTI RUS were available for 84% (n = 209). Complete concordance between the two RUS was demonstrated in 96% (n = 201). The predictive value of normal antenatal to normal post-UTI RUS was 96% (95% CI: 93% to 99%). These results include four children with mild transient pelvic dilatation. In eight children in whom renal anomalies were demonstrated only in post-UTI RUS, the influence of these anomalies on the children's management was negligible.

CONCLUSIONS

Prenatal-RUS have been performed in most children <5 years old hospitalised with a first simple UTI. Concordance with post-infection tests is very high. Findings which appear only in post-infectious RUS usually have negligible effects on children's management. Thus, in such children with normal antenatal RUS omitting post-UTI RUS could be considered.

Antibiotic consumption successfully reduced by a community intervention program

BACKGROUND

The association between antibiotic use in the community and antimicrobial resistance is known. Attention has recently focused on the type of agents being prescribed.

OBJECTIVES

To implement, evaluate and compare the efficacy of two community intervention programs--continuous versus seasonal medical education--oriented to primary care physicians with emphasis on the appropriate use of antimicrobial drugs.

METHODS

From October 2000 to April 2003 we conducted two interventions: a) a monthly educational campaign in selected clinics promoting appropriate diagnosis of common infectious diseases and prudent antibiotic use (continuous intervention group); and b) a massive educational campaign, conducted before two consecutive winters, promoting the judicious use of antibiotics for treating respiratory infections (continuous intervention group and seasonal intervention group). Sixteen similar clinics were randomized (8 to each group). The total antibiotic use was measured as defined daily dose/1000 patients/day, and compared between the groups.

RESULTS

The total use of antibiotics decreased between 1999-2000 and 2002-2003 in both groups, but slightly more significantly in the continuous intervention group. The DDD/1000 patients/day for the seasonal group in 1999-2000 was 27.8 vs. 23.2 in 2002-2003; and for the continuous group 28.7 in 1999-2000 vs. 22.9 in 2002-2003, a reduction of 16.5% and 20.0% respectively (P < 0.0001). The main change in antibiotic use was noted for broad-spectrum antibiotics.

CONCLUSIONS

We present a successful community intervention program aimed to reduce unnecessary antibiotic use. Amplification of this type of intervention is imperative to stop the increase in antimicrobial resistance.

Quick identification of febrile neonates with low risk for serious bacterial infection: an observational study

OBJECTIVE

To examine the possible usefulness of simple and quick criteria for identifying febrile neonates with low risk for serious bacterial infection (SBI).

DESIGN

All febrile neonates who were admitted between August 1998 and August 2003 to the Pediatric Emergency Department, HaEmek Medical Center, Afula, Israel, and to the Poriya Hospital, Tiberias, Israel, were included in the study. The recommended evaluation of each neonate included details of medical history and a complete physical examination, including blood culture, erythrocyte sedimentation rate (ESR), white cell count (WBC), and analysis and culture of urine and cerebrospinal fluid. Other tests were carried out as necessary. Patients who met all the following criteria were considered to have low risk for SBI: (1) unremarkable medical history; (2) good appearance; (3) no focal physical signs of infection; (4) ESR <30 mm at the end of the first hour; (5) WBC 5000-15 000/mm(3); (6) a normal urine analysis by the dipstick method.

RESULTS

Complete data were available for 386 neonates. SBI was documented in 108 (28%) neonates, of whom 14% had a urinary tract infection, 9.3% had acute otitis media, 2.3% had pneumonia, 1.3% had cellulitis, 0.5% had bacterial meningitis and 0.5% had bacterial gastroenteritis. The overall incidence of SBI was 1 in 166 (0.6%) neonates who fulfilled the criteria compared with 107 in 220 (48.6%) in the neonates who did not fulfil the criteria (p<0.001). The negative predictive value for SBI of the combination of the low-risk criteria was 99.4% (95% confidence interval 99.35% to 99.45%).

CONCLUSIONS

Fulfillment of the criteria for low risk might be a reliable and useful tool for excluding SBI in febrile neonates.

[Brucellosis: clinical presentation, diagnosis, complications and therapeutic options]

Brucellosis is a zoonotic disease that causes systemic symptoms and can involve many organs and tissues. The major sources of infection are consumption of unpasteurized diary products and occupational contact. Brucella is a small, gram-negative coccobacillus that grows slowly in vitro. There are four species of brucella that are pathogenic for humans; in Israel Brucella melitensis is still the most frequent organism. There are several methods to identified the organism and make the diagnosis (1) isolation of brucella from blood, tissue specimens, body fluids and bone marrow; (2) agglutination test and (3) polymerase chain reaction (PCR) that has recently been shown to be a promising tool for the diagnosis of acute disease. Involvement of the musculoskeletal system is the most common complication of brucellosis, while meningitis and endocarditis are life-threatening complications. The standard treatment for acute and chronic brucellosis is a combination of doxycycline with a second drug such as rifampicin or gentamicin, in order to cure, prevent complications and relapse. Although the rate of occurrence is ever-decreasing due to vaccination of animals, nonetheless, the disease has not been eradicated in Israel. This review focuses on the clinical presentation, diagnosis, and mainly on complications of brucellosis and the available therapeutic options.

Acute otitis media in infants less than three months of age: clinical presentation, etiology and concomitant diseases

OBJECTIVE

Acute otitis media (AOM) in the neonatal period can be difficult to diagnose. This infection can be isolated and localized, or it may be associated with serious bacterial infections or other illnesses. The objectives of this study were to determine the clinical presentation, etiology, susceptibility pattern, and frequency of bacteremia, meningitis and other serious bacterial infections associated with the first episode of AOM in young infants.

METHODS

From July 2002 to August 2004, infants less than 12 weeks of age with confirmed AOM underwent tympanocentesis with culture of the middle ear fluid. Sepsis work-up was performed in all infants, and they were admitted to the pediatric department. Parenteral antibiotic therapy with a combination of ampicillin and gentamicin was initiated.

RESULTS

Sixty-eight infants were diagnosed with AOM. The median age was 43+/-17 days, 17 infants (25%) were less than 4 weeks of age. Fever was present in 45 (66%) of the patients. Meningitis or bacteremia was not diagnosed in any of the cases. Concomitant urinary tract infection was diagnosed in six (8.8%) cases and broncholitis in seven (10.4%). Forty-seven bacterial pathogens were isolated from the middle-ear fluid. Streptococcus pneumoniae was the leading pathogen with 18 isolates (38%), followed by non-typable Haemophilus influenzae with nine (19%). Fourteen of the S. pneumoniae (78%) isolates were susceptible to penicillin and the other four (22%) were intermediately resistant. Three (33%) of the nine H. influenzae isolates were beta-lactamase producers.

CONCLUSIONS

In our study, AOM in infants less than 3 months of age is a localized infection and it is not associated with severe bacterial infections. S. pneumoniae and H. influenzae are the leading pathogens. In our region, most of S. pneumoniae strains are still susceptible to penicillin. Although only small number of patients were under 4 weeks of age, the results of the present study raise the question of whether the current policy of a full sepsis work-up in neonates with AOM is relevant.

Procalcitonin as a diagnostic aid in osteomyelitis and septic arthritis

OBJECTIVES

Plasma procalcitonin (PCT) increases rapidly during bacterial infections but remains low in viral infections and other inflammatory processes. High plasma PCT typically occurs in children with bacterial meningitis, severe bacterial infections, particularly in cases of septic shock or bacteremia, and in renal parenchymal damage. The aim of this study was to test the usefulness of plasma PCT analysis in the diagnosis of osteomyelitis, septic arthritis, and other skeletal inflammatory diseases in pediatric patients admitted because of fever and limping.

METHODS

White blood cell count, erythrocyte sedimentation rate, C-reactive protein, and PCT levels were measured in children admitted to the pediatric department with fever, limping, and suspected osteomyelitis or septic arthritis. PCT levels were measured by an immunochromatography assay, based on monoclonal and polyclonal antibodies against katacalcin.

RESULTS

Forty-four children were evaluated: 12 (27.3%) were diagnosed with osteomyelitis, 11 (25%) had septic arthritis, 5 children (11.4%) were diagnosed as a soft tissue infection, and transient synovitis or reactive arthritis was diagnosed in another 6 children (13.6%). Four children (9.1%) were diagnosed as having juvenile rheumatoid arthritis, and 6 (13.6%) with different diseases. PCT value was elevated in 7 patients (58.3%) with osteomyelitis, and only 3 children (27.2%) with the diagnosis of septic arthritis had a mildly elevated value. Among the children with other diagnosis, there were no positive PCT values (P < 0.001 between skeletal infection and all other diagnosis).

CONCLUSIONS

In this study, PCT was found to be a useful marker in the diagnosis of osteomyelitis and not in septic arthritis. A larger group of patients needed to be studied to confirm our findings.

Unusual presentation of McKusick-Kaufman syndrome in a female Bedouin Arab baby

McKusick-Kaufman syndrome is a rare, autosomal, recessive disorder characterized by hydrometrocolpos, post-axial polydactyly, and congenital heart disease. Less than one hundred cases have been reported in the English literature to date, mainly in the Amish population; sporadic cases have also been described. We present a case of an Arab Bedouin girl who presented with features resembling this syndrome.

Solitary liver abscess in a healthy child presenting with fever of unknown origin

Pyogenic liver abscess is rarely encountered in normal children. We report a case of solitary pyogenic liver abscess in a healthy child aged 8 months. He presented with fever of unknown origin and mild hepatomegaly. Full recovery was achieved by surgical intervention and prolonged antibiotic treatment. Management and recommended treatment in children with liver abscess are presented.

Identification of the emerging pathogen Vibrio vulnificus biotype 3 by commercially available phenotypic methods

Identification of the emerging pathogen Vibrio vulnificus biotype 3 has become a challenge for clinical laboratories in the last few years. In this study, the abilities of five commercial systems to identify this new species have been evaluated for the first time, using a unique collection of strains. Fifty-one well-documented wild strains of V. vulnificus biotype 3 were processed using API 20 NE, GNI+ Vitek 1 cards, ID-GNB Vitek 2 cards, Neg Combo 20 Microscan panels, and NMIC/ID-5 BD Phoenix panels. The numbers of strains identified as V. vulnificus by ID-GNB, NMIC/ID-5, and GNI+ were 50 (98.0%), 46 (90.2%), and 7 (13.7%), respectively. Neg Combo 20 Microscan panels and API 20 NE were unable to identify any of the strains of this emerging pathogen to the species level and mostly misidentifies them as other species of the Vibrionaceae family. Data on the phenotypic pattern of V. vulnificus biotype 3 when processed in all five systems as presented here could help clinical laboratories in identifying this new pathogen.

Streptococcal necrotizing fasciitis with toxic shock syndrome following cervical adenitis

In the recent years an increase of serious invasive infections due to Group A Streptococcus have been reported. Necrotizing fasciitis is a rapidly progressive soft tissue infection characterized by necrosis of the subcutaneous tissues and superficial fascia. We report a case of necrotizing fasciitis and toxic shock syndrome following cervical adenitis in a previously healthy 11-month-old boy. Cultures from blood and the necrotic lymph node grew Group A Streptococcus. Group A Streptococcus belonging to M1 serotype and producing streptococcal pyrogenic exotoxin, SPE A was identified. Full recovery was achieved by aggressive treatment, which included intensive care support, extensive surgical debridement of necrotic lesions and antibiotic treatment with the combination of penicillin and clindamycin.

Power Doppler ultrasonography in the diagnosis of acute childhood pyelonephritis

In the absence of specific symptomatology in children, the early diagnosis of acute pyelonephritis (APN) is a challenge, particularly during infancy. In an attempt to differentiate APN from lower urinary tract infection (UTI), we evaluated the ability of power Doppler ultrasonography (PDU) to predict renal parenchymal involvement, as assessed by dimercaptosuccinic acid ((99m )Tc-DMSA) scintigraphy. The study comprised 62 patients, 46 girls and 16 boys, aged 2 weeks to 5 years, admitted to the pediatric department with febrile UTI. All children were examined by PDU and DMSA scintigraphy within the first 3 days of admission. In the group of 31 patients with one or more DMSA scan abnormalities, the PDU showed a matching perfusion defect in 27 (87%). Of 26 children with normal DMSA scintigraphy, the PDU evaluation was also normal in 24. The sensitivity and specificity of PDU for the detection of affected kidneys were 87% and 92.3%, and the positive predictive value and negative predictive value were 93.1% and 85.7%, respectively. These data indicate the PDU has a high sensitivity and specificity for differentiating APN from lower UTI and may be a useful and practical tool for the diagnosis of APN in infants and children.

Improved antimicrobial susceptibility of community-acquired uropathogens in northern Israel (1995–1999–2002)

Since antimicrobial therapy for the treatment of community-acquired urinary tract infection is given empirically, knowledge of local antimicrobial sensitivity patterns is essential for clinicians. This study compares the susceptibility to antimicrobial drugs, of all urinary isolates from outpatients processed at the Ha'Emek Medical Center during 1995, 1999 and 2002. No significant changes in the susceptibility to ceftriaxone and ciprofloxacin were seen over this period of time. There was a significant increase in susceptibility to amoxycillin-clavulanate, TMP-SXZ, cefuroxime and nitrofurantoin. MIC(90) values of all drugs except amoxicillin-clavulanate remained stable. In contrast to a worldwide increase in resistance, we observed not only a halt in this trend, but also an improvement in antimicrobial susceptibility of uropathogens in northern-Israel.

Susceptibility of Streptococcus pyogenes to two macrolides in northern Israel

In the present study, the minimal inhibitory concentration (MIC) of azithromycin and roxithromycin for 200 Streptococcus pyogenes isolates from outpatients with tonsillopharyngitis were determined using Etest. All but one (99.5%) of the isolates were sensitive to both antibiotics; the MIC of the resistant isolate being 12 mg/l to azithromycin and 32 mg/l to roxithromycin. In this region, macrolides remain the drug of choice for the treatment of patients with S. pyogenes tonsillitis who present allergy to penicillin. The routine testing of susceptibility of S. pyogenes to macrolides in northern Israel is not justified.

Urinary tract infection: is there a need for routine renal ultrasonography?

AIMS

To assess the yield of routine renal ultrasound (RUS) in the management of young children hospitalised with first uncomplicated febrile urinary tract infection (UTI).

METHODS

All children aged 0-5 years who had been hospitalised over a two year period with first uncomplicated febrile UTI in a medium size institutional regional medical centre were included. Children with known urinary abnormalities and/or who had been treated with antibacterial agents within seven days before admission were excluded. All included children underwent renal ultrasonography during hospitalisation and voiding cystouretrography (VCUG) within 2-6 months. The yield of RUS was measured by its ability to detect renal abnormalities, its sensitivity, specificity, and positive and negative predictive values for detecting vesicoureteral reflux (VUR), and by its impact on UTI management.

RESULTS

Of 255 children that were included in the study, 33 children had mild to moderate renal pelvis dilatation on RUS suggesting VUR, of whom only nine had VUR on VCUG. On the other hand, in 36 children with VUR on VCUG the RUS was normal. The sensitivity, specificity, positive predictive value, and negative predictive value of abnormal RUS for detecting VUR were 17.7%, 87.6%, 23.5%, and 83.2% respectively. In none of the patients with abnormal RUS was a change in the management at or following hospitalisation needed.

CONCLUSION

Results show that the yield of RUS to the management of children with first uncomplicated UTI is questionable.

Risk factors for the development of extended-spectrum beta-lactamase-producing bacteria in nonhospitalized patients

Although the risk factors for acquiring infection by extended-spectrum beta-lactamase (ESBL)-producing bacteria have been investigated in hospitalized patients, such risk factors have not been defined in the community setting. In this study, clinical data from a total of 311 nonhospitalized patients with community-acquired urinary tract infection (128 with ESBL-positive strains and 183 with ESBL-negative strains) were obtained. According to a multivariate analysis, the following were identified as independent risk factors: previous hospitalization in the past 3 months (OR=8.95, 95%CI, 3.77-21.25), antibiotic treatment in the past 3 months (OR=3.23, 95%CI, 1.76-5.91), age over 60 years (OR=2.65, 95%CI, 1.45-4.83), diabetes (OR=2.57, 95%CI, 1.20-5.51), male gender (OR=2.47, 95%CI, 1.22-5.01), Klebsiella pneumoniae infection (OR=2.31, 95%CI, 1.17-4.54), previous use of third-generation cephalosporins (P=0.014, OR=15.8, 95%CI, 1.7-143), previous use of second-generation cephalosporins (P<0.0001, OR=10.1, 95%CI, 4.2-24), previous use of quinolones (P=0.001, OR=4.1, 95%CI, 1.8-9.0), and previous use of penicillin (P=0.003, OR=4.0, 95%CI, 1.6-9.0).

Acute neonatal suppurative parotitis: case reports and review

We describe two cases of neonatal suppurative parotitis caused by Staphylococcus aureus. Only 32 cases of neonatal suppurative parotitis (72% male) have been described in the English literature in the last 35 years. Thirty-eight percent were premature babies, only 41% were febrile and the causative agent in most cases was S. aureus. Recovery was achieved in 78% of the patients with antibiotic therapy without drainage.

Long-term follow-up of women hospitalized for acute pyelonephritis

Long-term outcome of acute pyelonephritis (AP) in adults is unknown. We evaluated the frequency of renal damage 10-20 years after hospitalization for AP in adult women and the utility of technetium Tc 99m-labeled dimercaptosuccinic acid (Tc 99m-DMSA) scanning for detection of renal scars; 63 of 203 women hospitalized with AP during 1982-1992 were included in the study. Tc 99m-DMSA scanning detected renal scarring in 29 women (46%). Multivariate analysis showed that pregnancy and hypoalbuminemia (albumin level, <3.2 g/dL) at hospitalization were independent risk factors for subsequent development of renal scars. At follow-up, hypertension was observed in approximately one-fifth of patients, regardless of renal scarring status. Four women with scars had a glomerular filtration rate of < or =75 mL/min; none of them developed severe renal impairment. In conclusion, the risk of developing renal scarring after AP in adult women is high. However, clinically relevant renal damage is rare 10-20 years after AP. Tc 99m-DMSA scanning is useful for detecting renal scars in adults but is not routinely needed in practice.

Listeria monocytogenes cross-contamination in a nursery [corrected]

Molecular evidence of Listeria monocytogenes cross-contamination in a nursery is presented. Listeria monocytogenes serotype 4b was isolated from the blood and the conjunctiva of a baby with neonatal sepsis who was born after septic amnionitis and premature rupture of membrane. Nine days later, the same bacterium was isolated from the cerebrospinal fluid of a second baby presenting with meningitis. Cervical cultures from the second baby's healthy mother were negative for Listeria sp. An in-depth epidemiologic investigation revealed that the same nurse administered routine treatments to both babies in the nursery during a 1-hour interval of time [corrected]. Pulse-field gel electrophoresis analysis of both strains with 2 different restriction enzymes demonstrated that they were identical and differ from other wild strains of L monocytogenes serotype 4b isolated in Israel. This fact strongly suggests that the second baby was infected during admittance to the nursery as a result of a hospital cross-contamination.

[Community acquired urinary tract infection among hospitalized children in northern Israel: pathogens, susceptibility patterns and urinary tract anomalies]

BACKGROUND

Urinary tract infection (UTI) is one of the most common diseases in children. Vesicoureteral reflux (VUR) has been demonstrated in a substantial number of young children with UTI. Empiric antibacterial therapy is recommended before results of the urine culture are available in order to shorten the duration of the disease and prevent renal complications.

OBJECTIVES

The aims of this study were to assess the prevalence and susceptibility patterns of UTI pathogens, and urinary anomalies in children admitted with UTI.

METHODS

The study population included 151 children younger than 14 years admitted with first UTI. Renal ultrasound was performed in all the patients and voiding cystourethrography (VCUG) in children younger than 5 years. Dimercaptosuccinic acid (DMSA) scan was performed in children with vesicoureteral reflux. The data included age, sex, symptoms and signs, urinalysis, the pathogen and its sensitivity and the results of the imaging studies.

RESULTS

A total of 119 patients (79%) were females. Gram negative rods caused 98% of the infections, of which Escherichia coli (87%) was the most prevalent pathogen, followed by Klebsiella pneumoniae (4%), and Proteus mirabilis (4%). The sensitivities to antibacterial agents were: Amikacin 100%, ceftazidime 97%, gentamicin 96%, ceftriaxone 96%, cefuroxime 95%, amoxicillin-clavulanate 84%, trimethoprim-sulfamethoxazole 63%, cephalexin 58%, and ampicillin 28%. Renal US showed minor abnormalities in 24/149 (16%) and VCUG demonstrated vesicoureteral reflux in 38/127 (30%) patients. DMSA revealed renal scars in 7/28 (25%) children with vesicoureteral reflux.

CONCLUSIONS

Overall Gram negative rods cause 98% of the UTI in hospitalized children in our area. E. coli is the leading pathogen and aminoglycosides and second or third generation cephalosporins are the most suitable agents for empiric therapy in UTI. A high incidence of renal scars in young children with vesicoureteral reflux was found.

Acute mastoiditis in children: Pseudomonas aeruginosa as a leading pathogen

OBJECTIVE

Acute mastoiditis is a serious bacterial infection of the temporal bone and is the most common complication of otitis media. The goal of this study is to assess the clinical features, pathogens, management, and outcome of acute mastoiditis in children in northern Israel.

METHODS

A systematic review of medical records of all children who were admitted with acute mastoiditis from January 1990 through December 2000.

RESULTS

Fifty-seven children were included. Median was age: 36 months. In 26 patients (45.6%) mastoiditis complicated the first episode of acute otitis media (AOM). Twenty-five children (44%) received antibiotic treatment prior to admission. Frequent symptoms included mastoid area erythema in 54 children (94.7%), proptosis of the auricle in 52 children (91.2%) and fever in 43 children (75.4%). Middle ear, and subperiostal culture yielded growth of pathogen in 30 children (75%), two cultures yielded more then one pathogen. The most frequent pathogens were: Pseudomonas aeruginosa in 10 children (25%), Streptococcus pneumoniae in eight children (20%), Group A streptococcus in six children (15%). The highest incidence of Streptococcus pneumoniae was found in children who did not suffer from AOM before admission (35 vs. 5%). Fifty-two (91.2%) children were cured with antibiotic treatment alone. Seventeen children underwent computed tomography (CT) of the mastoid. Mastoid bone destruction was demonstrated in six children and subperiostal abscess in eight. Mastoidectomy was performed in five children.

CONCLUSIONS

The diagnosis of acute mastoiditis can be made on clinical basis alone requiring CT only when complications are suspected. Half of the children admitted with acute mastoiditis had no previous history of recurrent AOM. In those children S. pneumoniae was the leading pathogen while P. aeruginosa was more prevalent in children with recurrent AOM. Most of the children recovered with medical therapy alone, without surgical intervention.

Procalcitonin as a marker of acute pyelonephritis in infants and children

In the absence of specific symptomatology in children, the early diagnosis of acute pyelonephritis is a challenge, particularly during infancy. In an attempt to differentiate acute pyelonephritis from lower urinary tract infection (UTI), we measured serum procalcitonin (PCT) levels and compared these with other commonly used inflammatory markers. We evaluated the ability of serum PCT levels to predict renal involvement, as assessed by dimercaptosuccinic acid (DMSA) scintigraphy. Serum C-reactive protein (CRP), leukocyte counts, and PCT levels were measured in 64 children admitted for suspected UTI. Renal parenchymal involvement was assessed by (99m)Tc-DMSA scintigraphy in the first 7 days after admission. In acute pyelonephritis, the median PCT level was significantly higher than in the lower UTI group (3.41, range 0.36-12.4 microg/l vs. 0.13, range 0.02-2.15 microg/l, P<0.0001). In these two groups, respectively, median CRP levels were 120 (range 62-249 mg/l) and 74.5 (range 14.5-235 mg/l, P=0.012) and leukocyte counts were 15,910/mm(3) (range 10,200-26,900) and 14,600/mm(3) (range 8,190-26,470, P=0.34). For the prediction of acute pyelonephritis, the sensitivity and specificity of PCT were 94.1% and 89.7%, respectively; CRP had a sensitivity of 100%, but a specificity of 18.5%. We conclude that serum PCT may be an accurate marker for early diagnosis of acute pyelonephritis.

Campylobacter bacteremia and pneumonia in two splenectomized patients

Two patients with beta thalassemia who had undergone splenectomy for hypersplenism were admitted to the hospital with high fever and lobar pneumonia. Neither patient had gastrointestinal symptoms. Campylobacter bacteremia was diagnosed in both patients. Campylobacter jejuni was identified in the first patient and Campylobacter fetus in the second. Both patients were treated with broad-spectrum antibiotics and recovered fully.

[Isolated susceptibility of Streptococcus pyogenes to 3 macrolides]

Erythromycin is considered the drug of choice in the treatment of streptococcal pharyngitis in patients allergic to penicillin. However, in recent years several publications, especially in Finland and Italy, showed high resistance rates of S. pyogenes isolates to erythromycin and other new macrolides. To evaluate the situation in Israel, we checked the MIC of isolates from patients with tonsillitis during 1996. E-test results showed an MIC-50 of 0.23, 0.13 and 0.47 mcg/ml for erythromycin, clarithromycin and roxithromycin, respectively and a MIC-90 of 0.37, 0.23 and 0.78 mcg/ml. Only 2 isolates (2.1%) were partially or completely resistant to all 3 antibiotics. We conclude that empiric therapy with macrolides in Israel is still a viable option and can be recommended in S. pyogenes tonsillitis for patients allergic to penicillin.

[Familial infantile myasthenia gravis]

The several forms of myasthenia gravis that occur in infancy include transient neonatal myasthenia, congenital myasthenia, and familial infantile myasthenia gravis. The latter is inherited in an autosomal recessive pattern. Severe episodes of respiratory distress are frequent in infancy, and are often provoked by mild respiratory infections. 2 sisters with congenital myasthenia gravis are described. Probably 2 other sisters died of the same disease, but no definite diagnosis was made in their cases.