Brucella melitensis bacteremia in children: review of 62 cases.

Brucella bacteremia is not uncommon in children living in endemic areas. Reports on brucella bacteremia, however, are scarce. Its clinical features and complications are unknown. This retrospective review describes the clinical and laboratory characteristics, the relapse rate, and response to different regimens of antimicrobials in children with brucella bacteremia over a 5-year period. Antimicrobial susceptibility testing was performed on all isolates. Data on 62 children with brucella bacteremia were collected between 1996 and 2000. All isolates were of Brucella melitensis species. Most children were between five and 10 years of age; males were twice as affected as females (66% vs 34%). Fever and arthralgia were the most common presenting symptoms, 81% and 48% respectively. Fever and arthritis were the most common physical findings, 81% and 19% respectively. Forty-five (73%) patients presented within 10 days of illness onset. Brucella titers were measured in all patients; 95% had a positive titer of 1:320 or more. Resistance to co-trimoxazole (sulfamethoxazole + trimethoprim) increased from 22% in 1996 to 66% in year 2000. Rifampicin and co-trimoxazole were the most commonly used combination in 50%, rifampicin, co-trimoxazole, supplemented with gentamicin or streptomycin in 27%. The median duration of therapy was 6 weeks. The overall relapse rate was 13% (95% CI, 4.6%-21.2%) but was higher among those with symptoms lasting >10 days (P<0.001). There was a high relapse rate among patients infected with co-trimoxazole-resistant species and treated with co-trimoxazole compared to patients infected with sensitive species who also received co-trimoxazole (22% vs. 8%), but this was not statistically significant (P = 0.16). Patients with brucella bacteremia present early in their course of illness. Their clinical features, however, did not differ from brucellosis patients who did not have bacteremia. Despite the high rate of in-vitro resistance to co-trimoxazole, this did not correlate with a significant relapse rate.

Physician's perceptions of fever in children. Facts and myths.

OBJECTIVE: To ascertain the knowledge and attitude of physicians, regarding fever in children. METHODS: A self-administered questionnaire was mailed to 600 randomly selected pediatricians, family practice physicians, emergency medicine physicians and general practitioners, who practice in Saudi Arabia. Appropriateness of responses to questions was determined on the basis of current medical literature. A rectal temperature of 38.0 degrees C is generally accepted as indicative of fever in children. RESULTS: Of the 600 physicians surveyed, 419 (70%) completed and returned the questionnaire; 17% of the physicians were consultants, 28% specialists and 55% general practitioners. Fifty-eight percent of the physicians had 10 years or more of experience. A rectal temperature of less than 38.0 degrees C was considered to indicate fever by 38% of physicians. Nearly 84% of physicians would initiate antipyretic therapy at a temperature of 38.5 degrees C or less and 56% cited a temperature of 40.0 degrees C or less to be dangerous. Only 5% believed that fever was not dangerous, while the remaining cited the principal danger of fever to be convulsions (69%), brain damage (35%), or death (8%). The responses to the main purpose of antipyretic treatment were to prevent convulsions (70%), to make the child comfortable (55%) and to prevent brain damage (29%). Approximately 53% of physicians reported that the most serious consequences of febrile convulsions were brain damage, learning disability, epilepsy, or death. Only 26% of physicians agreed that a sleeping child with fever should be left undisturbed. Approximately 25% advised inappropriate dosage or administration intervals of paracetamol. Almost all physicians recommended sponging or bathing to reduce fever. All respondents try to educate parents regarding fever and its management. CONCLUSION: A significant number of the surveyed physicians have demonstrated a serious lack of knowledge of the nature, dangers and management of an extremely common health problem. Physicians differ substantially in their knowledge of, and attitude toward fever in children, which is perhaps attributed to their different background in medical education and clinical training.

Candida meningitis in children: report of two cases.

Candida meningitis is rare in children. However reports have been increasing recently. We report two cases of meningitis caused by Candida species. The first case was a term male infant who was admitted at 14 days of age with the diagnosis of possible sepsis. He had received multiple courses of antibiotics without improvement. Later his cerebrospinal fluid (CSF) culture grew Candida tropicalis. The damage done by the infection was severe and the patient died. The second case was a 2-month old girl who was born at 34 weeks of gestation. She was admitted to the Neonatal Intensive Care Unit (NICU) and given antibiotics as prophylaxis. Despite this she developed recurrent episodes of fever that required multiple courses of antibiotics. After discharging her, she continued to have fever. Upon investigation, her blood and CSF grew Candida albicans. She was treated and responded to therapy.

Brucella bacteraemia: clinical and laboratory observations in 160 patients.

OBJECTIVES: To describe the clinical, serological, and prognostic features of bacteraemic brucellosis in an endemic region. METHODS: Retrospective case series of 160 patients admitted from 1983 to 1995 to a hospital providing secondary and tertiary level medical care in Saudi Arabia. All patients had positive blood cultures for Brucella species, predominantly Brucella melitensis. RESULTS: Bacteraemia was documented in 38% of 545 cases of brucellosis admitted to our institution during the study period. The main clinical syndromes were febrile illness alone (44%) or fever with arthritis (42%). Of 68 isolates that were speciated, 93% were Brucella melitensis. Initial agglutinating antibody titre was > or =1:320 in 96% of the patients. Antimicrobial resistance of B.melitensis isolates was: co-trimoxazole, 29%; rifampicin, 3.5%; streptomycin, 0.6%; and tetracycline, 0.6%. No increase in resistance was noted over the 13-year study period. Commonly used antimicrobial regimens consisted of streptomycin plus tetracycline or rifampicin plus doxycycline given for 6 weeks. Seven patients (5%) had relapse of their symptoms after antimicrobial therapy. Three of these had infective endocarditis with repeated bacteraemia. These patients required aortic valve replacement and recovered after surgery. The remaining four patients responded to a second course of therapy. CONCLUSIONS: Brucella bacteraemia is an acute febrile disease often associated with rheumatologic complaints. Most patients have an agglutinating antibody titre > or =1:320 and respond well to standard chemotherapy regimens with low mortality.

Parental perceptions of fever in children.

BACKGROUND: Fever is a common medical problem in children which often prompts parents to seek immediate medical care. The objective of this study was to survey parents about their knowledge and attitude concerning fever in their children. PATIENTS AND METHODS: The study involved the random selection of Saudi parents who brought their febrile children to the emergency rooms or walk-in clinics of four hospitals in Riyadh. Parents of 560 febrile children were interviewed using a standard questionnaire to obtain sociodemographic information and current knowledge of fever. Approximately 70% of the respondents were female, and the ages of the most were in the range of 20-40 years. More than 80% of the parents had two or more children. RESULTS: More than 70% of parents demonstrated a poor understanding of the definition of fever, high fever, maximum temperature of untreated fever, and threshold temperature warranting antipyresis. About 25% of parents considered temperatures less than 38.0 o C to be fever, another 25% did not know the definition of fever, 64% felt that temperatures of less than 40.0 o C could be dangerous to a child, and 25% could not define high fever. Another 23% believed that if left untreated, temperatures could rise to 42.0 o C or higher, but 37% could not provide an answer, and 62% did not know the minimum temperature for administering antipyretics. Approximately 95% of parents demonstrated undue fear of consequent body damage from fever, including convulsion, brain damage or stroke, coma, serious vague illness, blindness, and even death. CONCLUSION: Parental misconceptions about fever reflect the lack of active health education in our community. Health professionals have apparently not done enough to educate parents on the condition of fever and its consequences, a common problem.

Increased incidence of hyperbilirubinaemia in 'unchallenged' glucose-6-phosphate dehydrogenase deficiency in term Saudi newborns.

The incidence of severe hyperbilirubinaemia was significantly higher among the G6PD-deficient Saudi infants born at term than in non-deficient babies (34% vs 9%) (p less than 0.005). No apparent offending factors were detected in either the babies or their mothers. All babies who developed hyperbilirubinaemia did so during the 1st week of life. The highest mean bilirubin level for all jaundiced G6PD-deficient babies was recorded on the 4th postnatal day. Although the incidence of severe hyperbilirubinaemia among our neonates was relatively high, only two of them (7%), a boy and a girl, required exchange transfusions. Five of 29 jaundiced babies with G6PD deficiency were readmitted after discharge because of significant jaundice. One required exchange transfusion. Since G6PD deficiency seems to be a relatively common cause of neonatal jaundice in Saudi newborns, early detection of this enzymopathy by cord blood screening is justified to avoid morbidity and deaths.