Safety of intradermal Bacillus Calmette-Guerin vaccine for neonates in Eastern Saudi Arabia

To evaluate the safety of Bacillus Calmette-Guerin [BCG] in Saudi infants and outline our management for BCG related lymphadenitis. The records of infants who developed BCG related complications were retrospectively reviewed from March 2008 to March 2011 at the Maternity and Children Hospital, Dammam, Saudi Arabia for age, gender, birth weight, presentation, and outcome. All our patients were immunized with the BCG vaccine within 48 hours after birth, and the total number of vaccinated newborns was obtained from the vaccination registry. During a 3-year period [March 2008 to March 2011], 26,000 newborns received BCG and 81 [51 males and 30 females] developed complications. This gives an incidence of 3.12 complications/1000 newborns. Their presentations were: left axillary lymphadenitis [n=62], supraclavicular lymphadenitis [n=9], collection at immunization site [n-6], and one each [left cervical lymphadenitis, bilateral axillary lymphadenitis, left arm abscess, left axillary lymphadenitis and collection at immunization site]. Two were immunocompromized and 6 with local collection were aspirated. The arm abscess had drainage. Simple lymphadenitis [n=6] were treated expectantly, while those with suppurative lymphadenitis [n=68] had excision [n=65] or incision and drainage [n=3] without anti-tuberculous treatment. Bacillus Calmette-Guerin is safe but is associated with a relatively high incidence of suppurative lymphadenitis. Non-suppurative lymphadenitis can be treated conservatively, while suppurative lymphadenitis should be treated with excision. This is safe, avoids rupture, and shortens the recovery period without anti-tuberculous treatment. Although, the use of BCG vaccine may be associated with side effects, the potential morbidity and mortality from tuberculosis outweighs that from BCG related complications

Esophageal atresia with or without tracheoesophageal fistula: success and failure in 94 cases

The management of newborns with esophageal atresia [EA] with or without tracheoesophageal fistula [TEF] has evolved considerably over the years. Currently an overall survival of 85% to 90% has been reported from developed countries. In developing Countries, several factors contribute to higher mortality rates. We describe our experience with 94 consecutive cases of EA with or without TEF. We retrospectively studied 94 patients with EA with or without TEF treated at our hospital over a period of 15 years. Medical records were reviewed for age at diagnosis, sex, birth weight, associated anomalies, aspiration pneumonia, method of diagnosis, treatment, postoperative complications and outcome. Ninety-four newborns [55 males and 39 females] with EA/TEF were treated at our hospital. Their mean birth weight was 22 kg [700 g to 3800 g]. Age at diagnosis ranged from birth to 7 day. At the time of admission 37 [39.4%] had aspiration pneumonia. Associated anomalies were seen in 46[49%] patients. Thirteen patients had major associated anomalies that contributed to mortality Postoperative complications were similar to those from developed countries but overall operative mortality [30.8%] was high. The overall mortality was high but excluding major congenital malformations, sepsis was the most frequent cause of death. Factors contributing to mortality included prematurity, delay in diagnosis with an increased incidence of aspiration pneumonia and a shortage of qualified nurses. To improve overall outcome, factors contributing to sepsis should be evaluated and efforts should be made to overcome them

Hypertrophic pyloric stenosis in a newborn with propionic acidaemia

Hypertrophic pyloric stenosis is exceedingly rare in the first week of life. This report describes a rare case of congenital pyloric stenosis in a newborn with propionic acidaemia. Although newborns with propionic acidaemia may present with feeding problems in the form of vomiting, associated congenital pyloric stenosis should be considered in the differential diagnosis. These patients should be investigated with abdominal ultrasound and or barium meal and once diagnosed they should undergo pyloromyotomy

Hypertrophic pyloric stenosis in a newborn with propionic acidaemia

Hypertrophic pyloric stenosis is exceedingly rare in the first week of life. This report describes a rare case of congenital pyloric stenosis in a newborn with propionic acidaemia. Although newborns with propionic acidaemia may present with feeding problems in the form of vomiting, associated congenital pyloric stenosis should be considered in the differential diagnosis. These patients should be investigated with abdominal ultrasound and or barium meal and once diagnosed, they should undergo pyloromyotomy

Predictors of gangrenous necrotizing enterocolitis and extent of disease. Early laparotomy versus peritoneal drainage

Evaluation of known predictors of gangrene in neonates with necrotizing enterocolitis [NEC] and identification of those suggestive of severe disease, requiring expeditious laparotomy rather than primary peritoneal drainage as a definitive treatment. This is a retrospective review of data collected from the medical records of newborns with confirmed NEC, treated at the Maternity and Children's Hospital, Dammam, Kingdom of Saudi Arabia, from May 1993 to May 2004. Fifty-five cases were selected for the study, 23 had successful medical management and 32 underwent laparotomy. Of this group, 15 had peritoneal drainage prior to laparotomy. Nine known clinical, radiological and laboratory features suspicious of bowel perforation or gangrene were evaluated. The operated group was classified according to the extent of disease into isolated, multifocal or pan intestinal and the distribution of these 9 criteria was calculated for each of the 3 groups. Comparison was then carried out between the group with isolated NEC and those with extensive disease. Isolated NEC was present in 8 [25%], multifocal NEC in 19 [59%] and pan intestinal NEC in 5 [16%] of the operated cases. Pneumoperitoneum and palpable abdominal mass were the most specific and predictive signs of perforated or gangrenous bowel in NEC. Severe pneumatosis intestinalis and gasless abdomen were also highly specific and predictive of the same but had a low prevalence. Abdominal wall erythema, persistent metabolic acidosis, portal vein air, gasless abdomen and severe pneumatosis intestinalis were found to be associated with severe or extensive gangrene. Palpable abdominal mass and fixed dilated loops were increased in cases of isolated NEC. Portal vein air was associated with the highest mortality. Pneumoperitoneum, though the only absolute evidence of bowel perforation, cannot predict the extent of disease. Peritoneal drainage is a useful stabilizing procedure but the presence of any of the above mentioned criteria which are associated with severe disease necessitate a quick decision in favor of laparotomy. The absence of these signs, however, cannot rule out extensive or progressive NEC and failure to improve after peritoneal drainage also requires an emergency laparotomy, regardless of birth weight or gestational age

Choledochal cyst.

Choledochal cyst, which is characterized by dilatation of the biliary ducts, is common in Asian countries, mainly Japan, but relatively rare worldwide. This report describes 2 Saudi female children with choledochal cysts, with emphasis on long term follow-up

Lymphangiomas in infancy and childhood

Lymphangiomas are rare congenital malformations, commonly seen in the head and neck. This is a review of our experience in the management of 22 children with lymphangiomas. The medical records of children with lymphangioma admitted to Qatif Central Hospital, Qatif, Kingdom of Saudi Arabia over a period of 10 years from August 1989 to July 2000 were retrospectively reviewed for age at diagnosis, gender, mode of presentation, site of lymphangioma, method of treatment and outcome. We treated 22 children [12 females and 10 males] with lymphangioma. Their ages ranged from birth to 12 years, but majority [73%] were 4 years of age or younger. In 10 [45.5%], the lymphangioma involved the neck, 5 of them presented with sudden neck swelling as a result of hemorrhage into a lymphangioma, which caused diagnostic confusion. One patient had extensive lymphangioma involving the floor of the mouth, tongue, and left parotid gland. The remaining 11 patients had lymphangioma involving the parotid gland in 2, floor of the mouth in 3, and one each in the abdominal wall, above the right knee, mediastinum, breast, scrotum, and mesentery. All were treated surgically except 3 who were treated with intralesional bleomycin and showed complete disappearance of their lesions. There was recurrence in the child with mediastinal lymphangioma and a small recurrence in the child with bilateral lesions in the floor of the mouth. Lymphangiomas are relatively rare, involving mainly the head and neck, but they can be rarely seen at other sites. An important observation is the sudden appearance of cervical lymphangioma as a result of hemorrhage, which should be kept in mind. Our experience in the treatment of lymphangiomas using bleomycin is limited to draw any conclusions. We therefore considered surgery as treatment of choice for lymphangiomas. However, sclerotherapy can be used when there is a risk of damaging surrounding structures, and also to obviate the poor cosmetic results

Acute appendicitis in patients with sickle cell disease

Patients with sickle cell disease [SCD] often present with abdominal pain, usually attributed to vaso-occlusive crisis, but not rarely, it may be caused by other surgical conditions. Acute appendicitis although common in patients with SCD, it is rare and has a rapid course with a high incidence of perforation. Over a period of 7 years from 1995 to 2001, only 8 patients with SCD out of 1563 [0.5%] patients with acute appendicitis underwent operation at Qatif Central Hospital, Qatif, Kingdom of Saudi Arabia. Their histological slides were reviewed and the findings were compared to those with sickle cell trait [9 patients] and control group [28 patients]. All patients with SCD and in spite of a short duration of symptoms had a moderate to severe inflammation and the vessels were packed with sickle red blood cells [RBCs] except one who had an intact mucosa, extensive transmural hemorrhage and congested blood vessels with sickled RBCs without inflammatory cell infiltrate. The mucosa was intact in only one patient with SCD when compared to 5 [55.6%] in those with sickle cell trait and 6 [21.4%] in the control group and in the majority [87.5%] of those with SCD there were moderate to severe mucosal ulcerations when compared to those with sickle cell trait [44.4%] or controls [64.3%]. In patients with SCD, acute appendicitis is rare, and these appendicular changes were a sequelae of blockage of appendiceal vessels by sickled RBCs leading to congestion, edema, and ischemia with subsequent mucosal ulceration and marked inflammatory cell infiltrate

Neuroblastoma - the Tawam Hospital experience

Over the past two decades, there have been significant improvements in the survival of children with different types of cancer. Neuroblastoma is the exception, as in spite of many different kinds of chemotherapeutic regimens, the prognosis of advanced neuroblastoma remains unsatisfactory. This study is an analysis of our experience in the management of 53 children [25 males and 28 females] with neuroblastoma in this part of the world. Their ages at presentation ranged from birth to 10 years [mean 2.9 years]. The majority of our patients [83%] had intra-abdominal neuroblastoma. Five had intrathoracic neuroblastoma, 2 had intracranial neuroblastoma, 1 had oropharyngeal neuroblastoma, and one had metastatic neuroblastoma without a known primary. The distribution of our patients according to stage was as follows: 3 stage I, 5 stage II, 9 stage III, 33 stage IV and 3 stage IV-S. All our patients with stage I, II, III, and IV-S survived. A large number of our patients [62.3%] presented with advanced stage IV neuroblastoma, and this contributed to the high mortality rate [34%] in our series. The exact incidence of neuroblastoma in the United Arab Emirates [UAE] is not known, but it accounted for 7.5% of the total number of malignancies in the paediatric age group. The recently established cancer registry in the UAE should prove useful regarding the incidence and prevalence of cancer in the future

Traumatic Diaphragmatic Rupture in Children

Traumatic Diaphragmatic Rupture [TDR] is rare. This is even so in pediatric age gimp. This is a report of 5 children with TDR, outlining aspects of diagnosis and management