Síndrome celulitis-adenitis, una forma infrecuente de presentación de la sepsis neonatal tardía: A propósito de dos casos / Adenitis-cellulitis syndrome, an infrequent form of presentation of the late-onset neonatal septicemia: Report of two cases

La sepsis es la principal causa de mortalidad neonatal. La forma precoz, habitualmente, está relacionada con la colonización recto-vaginal u otros factores de riesgo materno. En la forma tardía, es difícil establecer su origen; por lo general, es nosocomial o de la comunidad. El Streptococcus agalactiae (Streptococcus beta-hemolítico del grupo B) es el germen implicado con más frecuencia en la sepsis neonatal en países desarrollados. La forma tardía, generalmente, se presenta con septicemia y meningitis, y, en ocasiones, pueden detectarse infecciones osteoarticulares o de piel y tejidos blandos. El síndrome celulitis-adenitis en la región cervical, forma poco frecuente de presentación, es causado por Staphylococcus aureus y, ocasionalmente, por Streptococcus agalactiae. Se reportan 2 casos de sepsis neonatal tardía con clínica de celulitis-adenitis cervical causados por Streptococcus beta-hemolítico del grupo B, con una evolución satisfactoria con terapia antibiótica de amplio espectro.

Septicemia is the main cause of neonatal mortality. The early-onset neonatal sepsis is usually related to maternal factor risks including recto-vaginal colonization. In the late-onset neonatal septicemia it is more difficult to establish the etiology because the majority of the cases are nosocomial or community related. The Streptococcus agalactiae (beta-hemolytic Streptococcus) is the most frequent germ associated with neonatal sepsis in developed countries. The late-onset form usually occurs with septic symptoms and meningitis and, in a few cases, with osteoarticular, skin and soft tissue infection. Adenitis-cellulitis syndrome is rarely seen, and its main cause is Staphylococcus aureus, followed by Streptococcus agalactiae. We report two cases of group B Streptococcus late-onset neonatal septicemia, both of them with adenitis-cellulitis syndrome. Patients recovered uneventfully after an adequate antibiotic therapy.

De la escrófula a la linfoadenitis micobacteriana / From scrophula to mycobacterial lymphadenitis

Resumen En el siglo XIX se pensaba que la tuberculosis y la tumefacción ganglionar cervical llamada escrófula afectaban a individuos predispuestos por una "constitución diatésica" heredada. En 1882 Robert Koch demostró que lesiones tuberculosas y escrofulosas humanas eran causadas por el bacilo Mycobacterium tuberculosis. A principios del siglo XX se estableció que Mycobacterium bovis, bacilo de la tuberculosis del ganado, podía también causar linfoadenitis cervical en humanos, especialmente en niños, por la ingestión de leche de vacas enfermas. La condición disminuyó después que se controló la infección en el ganado y se introdujo la pasteurización de la leche. En 1956 se describió la linfoadenitis cervicofacial granulomatosa necrosante y supurada causada por micobacterias no tuberculosas. Afecta principalmente a niños bajo los cinco años, especialmente en países sin endemia de tuberculosis. Las linfoadenitis cervicales tuberculosas predominan en adultos jóvenes en países con tuberculosis endémica y en individuos infectados por VIH.

In the 19th century it was widely believed that both tuberculosis and cervical lymph node swelling, known as scrophula, affected individuals predisposed to an inherited "diathetic constitution". In 1882 Robert Koch proved that human tuberculosis and scrophulous lesions were caused by the bacillus Mycobacterium tuberculosis. In the early twentieth century it was stated that Mycobacterium bovis, the bacillus of cattle tuberculosis, could also cause cervical lymphoadenitis in humans, especially in children, by the intake of milk from sick cows. The incidence of this condition decreased after the infection was controlled in cattle and pasteurization of the milk was introduced. A type of granulomatous necrotizing and suppurative cervico-facial lymphadenitis associated to non-tuberculous mycobacteria was described in 1956. It mainly affects children younger than 5 years old, particularly those born in countries with non-endemic tuberculosis. Tuberculous cervical lymphadenitis is prevalent in young adults from tuberculosis-endemic countries and in HIV-infected subjects. Infectious etiology displaced the importance of a personal disposition in the development of scrophula. Nevertheless, mutations that confer susceptibility to mycobacterial infection are currently investigated.

Linfadenitis cervical por Salmonella no Typhi en una paciente diabética / Cervical lymphadenitis caused by no typhoid Salmonella in a diabetic patient

Resumen La infección por Salmonella no Typhi es una de las enfermedades transmitidas por alimentos más común y ampliamente extendida en el mundo. Aunque la mayoría de los casos se limitan al tracto gastrointestinal, el compromiso extraintestinal no es infrecuente. Sin embargo, la adenitis como manifestación aislada, es una forma inusual de presentación de la enfermedad. Comunicamos el caso clínico de una mujer de 67 años de edad con diagnóstico de diabetes mellitus y una linfadenitis cervical por Salmonella no Typhi tratada con ciprofloxacina y y que requirió resección quirúrgica.

No Typhoid Salmonella infection is one of the most common and widely spread foodborne diseases worldwide. Although most cases are limited to the gastrointestinal tract, extraintestinal involvement is not uncommon. However, adenitis as an isolated manifestation, is an unusual form of the disease. We report a case of Salmonella no Typhoid cervical lymphadenitis in a 67-year-old female with a recent diagnosis of diabetes mellitus, who was treated with surgery and ciprofloxacin.

Linfadenitis por Mycobacterium lentiflavum: Reporte de dos casos / Mycobacterium lentiflavum lymphadenitis: Two case reports

La linfadenitis es la manifestación clínica más frecuente de la infección por micobacterias no tuberculosas en niños inmunocompetentes. Se presentan dos casos de linfadenitis por M. lentiflavum diagnosticados en un hospital de tercer nivel en los últimos 10 años. Se realizaron pruebas complementarias de rutina ante adenopatía persistente y se obtuvo una muestra mediante drenaje para el cultivo, que resultó positivo para este germen. Ambos pacientes recibieron tratamiento antibiótico oral durante varias semanas. El caso 1 precisó exéresis completa al quinto mes de evolución, mientras que el caso 2 presentó resolución completa de la lesión a los 4 meses. M. lentiflavum es considerado, de entre las nuevas especies de micobacterias no tuberculosas recientemente descritas, un germen emergente en nuestro medio. Posee unas características microbiológicas y clínicas especiales, diferentes del resto de las micobacterias no tuberculosas. Son pocos los casos publicados hasta la fecha desde que se describió por primera vez la infección en 1997.

Lymphadenitis is the most common clinical feature in nontuberculous mycobacterium infection in immunocompetent children. We present two case reports of M. lentiflavum lymphadenitis diagnosed in a tertiary hospital in the last 10 years. Routine tests were performed after persistent adenopathy, and a sample for culture was obtained, being positive for this microorganism. Both patients received oral antibiotics during several weeks. Case 1 needed complete excision after five months of treatment, whilst Case 2 was cured by medical therapy. M. lentiflavum is considered, among the newly described nontuberculous mycobacterial species, an emergent pathogen in our environment. It has its own microbiological and clinical characteristics, different from the rest of nontuberculous mycobacteria. Case reports are limited in the literature since the infection was described for the first time in 1997.

Neutropenia grave secundaria al tratamiento médico de una adenitis por micobacterias no tuberculosas / Severe neutropenia as side effect of medical treatment in nontuberculous mycobacterial adenitis

Non-tuberculous mycobacterial adenitis is getting more common in our environment. Epidemiologic studies and clinical trials published nowadays are limited. We present a 2-years-old boy diagnosed of Mycobacterium intracellulare adenitis and severe neutropenia as side effect of combined treatment with oral azythromycin and rifabutin, which recovers after suspending the second one. Liver metabolism of macrolide seems to increase other drugs toxicity, in this case, rifabutin. The patient eventually needed surgery due to persistence of the adenitis despite treatment with antibiotics.

Las adenopatías por micobacterias no tuberculosas (AMNT) son cada vez más frecuentes en nuestro medio. Los estudios epidemiológicos y ensayos clínicos controlados publicados hasta la fecha son escasos. Presentamos el caso de un niño de 2 años con el diagnóstico de una adenitis por Mycobacterium intracellulare que desarrolló una neutropenia grave secundaria a la terapia combinada de azitromicina y rifabutina oral. La metabolización hepática de los macrólidos parece aumentar la toxicidad de otros fármacos, en este caso, la rifabutina. Finalmente, al paciente se le realizó una exéresis quirúrgica por persistencia de la adenitis a pesar de la antibioterapia.

Bartonella henselae en niños con adenitis regional atendidos en un hospital nacional del Perú, 2012 / Bartonella henselae in children with regional adenitis treated in a Peruvian national hospital, 2012

Con el objetivo de determinar la frecuencia de casos seropositivos a Bartonella henselae en niños con adenitis regional atendidos en un hospital nacional del Perú, se realizó un estudio trasversal en 106 niños con adenitis regional mayor de 1 cm de diámetro, de aparición aguda, con tiempo de enfermedad mayor de cinco días, atendidos en el Instituto Nacional de Salud del Niño durante el año 2012. Se definió seropositividad para B. henselae mediante el examen de inmunofluorescencia indirecta, siendo positivos 86 niños (81,1%) con una mediana de edad de 7 años, rango de 5 a 11; en el análisis bivariado se encontraron como factores asociados, edad mayor de 5 años, antecedentes de fiebre, adenopatía mayor de 4 cm y reporte de contacto con gato. En conclusión, los niños con adenitis regional atendidos en este hospital de referencia nacional presentaron una frecuencia alta de serología positiva para B. henselae.

In order to determine the frequency of seropositive cases of Bartonella henselae in children with regional adenitis treated in a national hospital in Peru, a cross-sectional study was conducted in 106 children with regional adenitis greater than 1 cm in diameter. The sample was selected from patients aged 5-11 years seen at the National Institute of Child Health for acute onset of regional adentitis, with more than five days of symptoms. B. henselae seropositivity was defined by indirect immunofluorescence test. We found that 86 children (81.1%) were positive for B.henselae. The median age of the patients was 7 years. In the bivariate analysis, the following associated factors were found: aged 5 years, history of fever, lymphadenopathy greater than 4 cm and reported contact with cat. In conclusion, children with regional adenitis treated in this national referral hospital showed a high frequency of positive serology for B. henselae.

Lymphadenitis caused by infection with an isoniazid- and rifampin-resistant strain of Mycobacterium bovis BCG in an infant with IFN-γ/IL-12 pathway defect / Linfadenite por Mycobacterium bovis BCG resistente a isoniazida e rifampicina em lactente com defeito no eixo IFN-γ/IL-12

We report a rare case in a female infant (age, 3.5 months) with primary immunodeficiency (IFN-γ/IL-12 pathway defect) who presented with suppurative lymphadenitis after Mycobacterium bovis BCG vaccination. The strain of M. bovis BCG identified was found to be resistant to isoniazid and rifampin. The patient was treated with a special pharmacological regimen involving isoniazid (in a limited, strategic manner), ethambutol, streptomycin, and IFN-γ, after which there was complete resolution of the lesions.

Relatamos um caso raro em uma lactente com três meses e meio de idade, portadora de imunodeficiência primária (defeito no eixo IFN-γ/IL-12), que apresentou linfadenite supurativa após a vacinação por Mycobacterium bovis BCG, cepa essa resistente a isoniazida e rifampicina. Após o tratamento com um esquema medicamentoso especial com isoniazida (de forma estratégica e limitada), etambutol, estreptomicina e IFN-γ, houve a cura completa das lesões.

Mycobacterium fortuitum-related lymphadenitis associated with the varicella-zoster virus

Lymphadenitis caused by non-tuberculous mycobacteria is an uncommon manifestation in immunocompetent individuals. Here, we report a case of Mycobacterium fortuitum infection in a previously healthy 9-year-old patient who developed cervical lymphadenitis evolving to a suppurative ulcer associated with a varicella-zoster virus infection. We discuss the relationship between the varicella-zoster virus and the immune response of the host as an explanation for the unusual progression of the case.

Adenitis tuberculosa por Mycobacterium bovis: reporte de caso / Tuberculous adenitis from Mycobacterium bovis: a case report

Introducción. La linfadenitis tuberculosa, que en la actualidad es producida con mayor frecuencia por Mycobacterium tuberculosis, alguna vez fue causada esencialmente por Mycobacterium bovis. Objetivo. Describir un caso clínico con adenitis tuberculosa por Mycobacterium bovis que resulta infrecuente. Caso Clínico. Mujer con antecedentes de salud y costumbre de ingerir leche cruda y derivados de la leche caseros no supervisados desde el punto de vista sanitario con adenitis cervical de más de 5 meses de evolución sin otro síntoma. El diagnóstico de adenitis tuberculosa por Mycobacterium bovis se realizó por biopsia, ELISA, RCP y cultivo. Discusión. Aproximadamente del 11 al 25 por ciento de todos los casos de TB son exclusivamente extrapulmonares. La linfadenitis cervical es la presentación periférica más frecuente de esta enfermedad. El tratamiento es aconsejable con 4 fármacos. La cirugía queda reservada para los procedimientos diagnósticos y las complicaciones. Conclusiones. La infección por Mycobacterium bovis es infrecuente en nuestro medio, no obstante debe tenerse en cuenta en la valoración diagnóstica de todo paciente con un síndrome adénico de localización cervical y elementos epidemiológicos.

Introduction. Tuberculous lymphadenitis, which currently is most often caused by Mycobacterium tuberculosis, was once mainly caused by Mycobacterium bovis. Objective. To describe an unusual case of tuberculous adenitis from Mycobacterium bovis. Case report. A woman with a history of consuming raw milk and unsupervised dairy home-made products presents with cervical adenitis of 5 month course unassociated to other symptoms. A diagnosis of Mycobacterium bovis tuberculous adenitis was made by biopsy, ELISA, PCR and culture. Discussion. Approximately 11 to 25 percent of all TB cases are extrapulmonary exclusively. Cervical lymphadenitis is the most common presentation of peripheral disease. Treatment usually is based on four drugs. Surgery is indicated for diagnostic procedures and complications. Conclusion. Mycobacterium bovis infection is uncommon in our environment, but must be considered in the diagnostic evaluation of all patients with cervical adenitis and epidemiological correlations.

Bacillus Calmette-Guerin lymphadenitis: A 6-year experience in two Saudi hospitals.

Background : The World Health Organization (WHO) has recommended Bacillus Calmette-Guerin (BCG) vaccination as a part of the global expanded program for immunization. Although the BCG vaccine is usually a safe vaccine, a number of complications with lymphadenitis being the most common complication, can occur. Aim : We evaluated the frequency, the clinical presentation and treatment modalities of lymphadenitis after BCG vaccine in Saudi children. Results : A total of 145 patients with BCG lymphadenitis presented between January 2005 and December 2010. In the majority (103) of the cases, the lymphadenitis involved ipsilateral left axillary nodes. Other sites of involvement included the left supraclavicular lymph nodes in 26 (18%) patients, and both the left axillary and supraclavicular lymph nodes were involved in 7 cases (4.8%). A total of 75 patients (65%) were given antituberculous medication. Eight (27%) patients had positive acid-fast bacilli and positive cultures for Mycobacterium bovis. Conclusion : In light of the findings of this study, it would be advisable to administer the BCG vaccine in Saudi Arabia at a time later than at birth, as the younger children are commonly affected.

Desarrollo de una prueba de ELISA para detectar anticuerpos en carneros vacunados o infectados con Corynebacterium pseudotuberculosis / Development of an ELISA test to detect antibodies in vaccinated sheep or infected Corynebacterium pseudotuberculosis

El objetivo de este trabajo fue evaluar un ELISA indirecto desarrollado para medir la respuesta inmune humoral en carneros vacunados contra la linfoadenitis caseosa (LC) y/o desafiados con una cepa de Corynebacterium pseudotuberculosis homóloga. Se distribuyeron corderos de 4 meses clínicamente sanos en 4 grupos: grupo 1, corderos vacunados (G1, n = 5); grupo 2, corderos vacunados e inoculados (G2, n = 8); grupo 3, corderos inoculados (G3, n = 2); y grupo 4, control (G4, n = 2). Los animales del G1 y del G2 recibieron dos dosis de una bacterina experimental; los del G2 y del G3 fueron desafiados con una cepa de C. pseudotuberculosis cuatro semanas posvacunación. Se estudiaron por ELISA los títulos serológicos durante 7 meses y se efectuaron las necropsias en los grupos G2, G3 y G4. Se tomaron muestras de pulmón y linfonódulos para efectuar estudios bacteriológicos e histopatológicos. La cepa inoculada en los animales del G2 y del G3 reprodujo las lesiones macroscópicas y microscópicas típicas de la LC; ésta fue aislada del sitio de inoculación, de linfonódulos o de pulmón en 7/8 animales del G2 y en 2/2 animales del G3. La prueba de ELISA, con una sensibilidad del 98% y una especificidad del 100%, detectó diferencias significativas entre los serorreactores de los diferentes grupos experimentales y permitió establecer una relación con el tipo de tratamiento aplicado. Se concluye que el ELISA desarrollado puede ser una herramienta útil para identificar animales infectados y con clínica positiva a la LC.

The aim of this study was to evaluate an indirect specific ELISA developed for the detection of humoral immune response in vaccinated sheep and/or challenged with a Corynebacterium pseudotuberculosis strain. Healthy 4 month-old lambs were distributed into 4 groups: Group 1 immunized (G1, n = 5), Group 2 vaccinated/inoculated (G2, n = 8), Group 3 inoculated (G3, n = 2) and Group 4 control (G4, n = 2). Groups G1 and G2 received two doses of an experimental bacterin. Four weeks postvaccination, G2 and G3 groups were challenged with a C. pseudotuberculosis strain. Serological titers were studied by ELISA for 7 months and pathological studies were performed in groups G2, G3 and G4 by taking lung and lymph node samples for bacteriology and histopathology. The inoculated strain in G2 and G3 animals reproduced the macroscopic and microscopic lesions typical of caseous lymphadenitis (CL) and was isolated from the inoculation site, lymph nodes and/or lung in 7/8 animals from G2, and 2/2 animals of G3. The developed ELISA test had sensitivity and specificity of 98% and 100% respectively, detected significant differences between serological reactors of different experimental groups and allowed to establish a relationship with the type of treatment. We conclude that the developed ELISA may be a useful tool to identify infected animals with positive clinical CL.

clinicomorphological study of lymphadenopathy

A total 238 lymph nod specimen were studied at various Hospitals of Lahore. The ages of these patients ranged from 2 years to 80 years. Maximum number of patients with lymphadenopathy [90 out of 238] 37.8% cases were in 10-19 years age group. Females [51.7%] presenting with lymph node enlargement were more affected than males [48.3%]. The commonest presenting complaint was fever [56.3%]. Cervical lymph nodes [80.3%] were the commonest site of involvement. On histopathological examination, seven morphological groups were highlighted; tuberculous lymphadenitis [42.5%], chronic nonspecific lymhadenitis [36.6%], viral lymphadenitis [3.4%] acute bacterial lymphadenitis [0.8%]. Fungal lymphadenitis [0.8%], Metastatic carcinoma [11.3%] and lymphomas [4.6%]

Bacille Calmette-Guérin lymphadenitis and immune reconstitution syndrome in HIV-infected children on antiretroviral therapy in Jamaica / Linfadenitis por Calmette-Guérin y síndrome de reconstitución inmune en niños infectados con el VIH bajo terapia antiretroviral en Jamaica

The immune reconstitution inflammatory syndrome (IRIS) is a recognized complication associated with opportunistic infections occurring in HIV-infected individuals after the initiation of highly active antiretroviral therapy (HAART). We report on three HIV-infected infants with rapid progressor HIV disease who present with IRIS due to the BCG vaccine and occurring 3-6 weeks after initiation of HAART.

El síndrome inflamatorio de la reconstitución inmune (SIRI) es una complicación reconocida asociada con infecciones oportunistas que ocurren en individuos infectados por el VIH, luego de su iniciación en la terapia antiretroviral altamente activa (TARAA). Se reporta el caso de tres infantes infectados por VIH con enfermedad VIH de progresión rápida, que se presentan con SIRI debido a la vacuna BCG, 3-6 semanas después de la iniciación de TARAA.

A study of mycobacterial species causing lymphadenitis.

This prospective study evaluated the non-tuberculous mycobacteria (NTM) cases of lymphadenitis. A total of 76 isolates of mycobacteria were obtained from 200 lymph node aspirates suspected of tuberculosis, 74 of which were Mycobacterium tuberculosis, one was Mycobacterium fortuitum and one Mycobacterium kansasii. These results highlight the importance of NTM in HIV-negative patients as a case of lymphadenitis, and indicates the re-emergence of NTM as potential lymph node pathogens in this part of the country. Further studies on a larger scale are needed to delineate the association between NTM infections in HIV positive and negative subjects.

Soft tissue abscess and lymphadenitis due to Mycobacterium avium Complex as an expression of immune reconstitution inflammatory syndrome after a second scheme of highly active antiretroviral therapy

Immune reconstitution inflammatory syndrome (IRIS) is an atypical and unexpected reaction related to highly active antiretroviral therapy (HAART) in human immunodeficiency virus (HIV) infected patients. IRIS includes an atypical response to an opportunistic pathogen (generally Mycobacterium tuberculosis, Mycobacterium avium complex, cytomegalovirus and herpes varicella-zoster), in patients responding to HAART with a reduction of plasma viral load and evidence of immune restoration based on increase of CD4+ T-cell count. We reported a case of a patient with AIDS which, after a first failure of HAART, developed a subcutaneous abscess and supraclavicular lymphadenitis as an expression of IRIS due to Mycobacterium avium complex after starting a second scheme of HAART.

El síndrome inflamatorio de reconstitución inmune (SIRI) es una reacción atípica e inesperada relacionada con el tratamiento antirretroviral de gran actividad (TARGA) en pacientes infectados por el virus de la inmunodeficiencia humana (VIH). El SIRI representa una respuesta inflamatoria frente a un patógeno oportunista (generalmente Mycobacterium tuberculosis, Complejo Mycobacterium avium, citomegalovirus y herpes varicela-zóster) en pacientes que responden a la TARGA con una marcada reducción de la carga viral en plasma y evidencia de una recuperación inmunológica expresada por el incremento de los niveles de linfocitos T CD4+. Presentamos el caso de un paciente con síndrome de inmunodeficiencia adquirida que desarrolló un absceso subcutáneo en muslo derecho y una adenitis supraclavicular izquierda como manifestación de SIRI por Complejo Mycobacterium avium luego del inicio de un segundo esquema de TARGA.

Mucormycosis isolated from perilymphatic tissue: an unusual presentation.

We present a rare case of a patient who presented with atypical cranial nerve palsies, with subsequent isolation of mucormycosis from an upper neck subcutaneous swelling. This is an unusual initial site of isolation of mucormycosis. We believe that this should be considered among the differentials when a diabetic or immunosupressed patient presents with cervical lymphadenopathy and cranial nerve palsies.

Adenoflegmón cervical por Streptococcus intermedius en una niña de 3 años: caso clínico / Cervical lymphadenitis due to Streptococcus intermedius in a 3 years-old girl: case report

Objetivo: Comunicar el caso de un adenoflegmón cervical por Streptococcus intermedius y caracterizar aspectos clínicos y microbiológicos de la infección por esta bacteria. Caso: Niña de 3 años, con historia de fiebre y aumento de volumen cervical anterior y supraclavicular izquierdo de 5 días de evolución, diagnosticándose adenoflegmón cervical; la punción revela Streptococcus intermedius. Se trató con cloxacilina y luego penicilina EV y completó tratamiento de 10 días con cotrimoxazol. Discusión: Streptococcus intermedius corresponde a una de las tres especies del grupo “anginosus” o “milleri”, integrante a su vez del grupo viridans. Forma parte de la flora bacteriana habitual orofaringea, de tubo digestivo y vagina. Tiene capacidad de migrar a otros parénquimas, produciendo infecciones abscedantes, a veces polimicrobianas y de difícil erradicación. Estudios nacionales de susceptibilidad antimicrobiana reportan sensibilidades cercanas al 100 por ciento a Penicilina y Cefotaxima. Diversos protocolos microbiológicos de identificación rápida permiten su diferenciación bacteriológica, ayudando a establecer alternativas terapéuticas más adecuadas.

Focal non-typhoidal Salmonella infections from a single center in Malaysia.

A retrospective review of patients with focal non-typhoidal Salmonella (NTS) infection was performed to determine its features and outcome. All patients with focal NTS infection admitted to the University of Malaya Medical Center, Malaysia, from 1993 to 2002 were studied. More than half (58%) of the 35 cases (54% male, median age 39 years, range 1.5 months to 79 years) were immunocompromized or had chronic medical conditions. One-third of the patients (34%) had superficial infections (lymphadenitis or subcutaneous tissue infection) and all recovered with antimicrobial therapy alone. Deep infections (66%) noted were: meningitis (9%), osteomyelitis or arthritis (26%), abscesses of the gastrointestinal tract or adjacent organs (20%), and others (11%). Deep infections were more likely to occur in the extremes of age (<6 months or >60 years, p< 0.04), associated with adverse outcomes with an overall mortality rate of 9%, or required major surgery (15%).