QuantiFERON®-TB Gold In-Tube reliability for immigrants with parasitic infections in Boston, USA.

Accurate testing and treatment for latent tuberculous infection is necessary for tuberculosis elimination. Certain parasite infections are associated with increased tuberculin skin test positivity; species-specific effects on QuantiFERON®-TB Gold In-Tube (QGIT) have not been described. To determine whether infection with helminths or protozoa affects QGIT results. We retrospectively analyzed QGIT and parasite testing results for immigrants screened in Boston, MA, USA, from 2012 to 2017. We also prospectively measured cytokines in QGIT supernatants for a subset (n = 68) with 1) helminths, 2) Blastocystis hominis, 3) other protozoa, and 4) no parasites. Of 527 immigrants screened, 141 (26.8%) were QGIT-positive and 229 (43.4%) had parasites detected: 27/527 (5.1%) had helminths and 202/527 (38.3%) protozoa. Cytokine analysis revealed increased interleukin-10 concentrations with protozoa (P = 0.04), and non-significantly higher T-helper 2 concentrations with helminths compared with no parasites. No significant differences emerged in QGIT positivity or interferon-gamma concentrations in any group. Study results support the use of QGIT in parasite-endemic settings. .

Meningococcal disease among children who live in a large metropolitan area, 1981-1996.

Neisseria meningitidis is an important cause of serious bacterial infections in children. We undertook a study to identify meningococcal infections of the blood, cerebrospinal fluid, or both of children in a defined geographic area to describe the burden of disease and the spectrum of illness. We reviewed the medical records of all children aged <18 years who had meningococcal infections at the 4 pediatric referral hospitals in Boston, Massachusetts, from 1981 through 1996. We identified 231 patients with meningococcal disease; of these 231 patients, 194 (84%) had overt disease and 37 (16%) had unsuspected disease. Clinical manifestations included meningitis in 150 patients, hypotension in 26, and purpura in 17. Sixteen patients (7%) died. Although meningococcal disease is devastating to a small number of children, we found that the burden of pediatric disease that it caused at the 4 pediatric referral centers in this geographic region was limited; that patients with overt meningococcal disease are most likely to have meningitis; and that individual practitioners are unlikely to encounter a patient with unsuspected meningococcal disease.

War trauma experience and behavioral screening of Bosnian refugee children resettled in Massachusetts.

The authors assessed war violence exposure and behavioral symptoms in Bosnian refugee children in Massachusetts and the utility of behavioral screening of refugees during the Refugee Health Assessment (RHA), required of newly arrived refugees. The study was a survey of 31 Bosnian refugee children in 1996 at the International Clinic of Boston Medical Center, the state's largest contracted provider of the RHA. Subjects were also offered referrals to appropriate mental health services. Sixty-eight percent experienced long-term separation from a parent. Eighty-one percent were directly exposed to armed combat. Seventy-one percent experienced the death of a close friend or relative. Fifty-two percent experienced economic deprivation. Families reported behavioral symptoms for 77% of children. Only one family expressed interest in psychosocial services of any kind. Large numbers of Bosnian refugees are likely to have experienced traumatic war violence and are at risk of behavioral symptoms. The RHA affords opportunities to screen for behavioral problems but not to intervene. Primary care providers and other clinicians should be aware of likely recurrences of symptoms in high-risk children such as these.

Immune response to pneumococcal conjugate and polysaccharide vaccines in otitis-prone and otitis-free children.

We compared responses to pneumococcal conjugate and polysaccharide vaccines in 48 otitis-free and 64 otitis-prone children. Pre- and postimmunization concentrations of antibodies to pneumococcal serotypes 6B, 14, 19F, and 23F were measured by enzyme-linked immunosorbent assay. Postimmunization mean concentrations of antibodies to all four serotypes were significantly higher for children receiving conjugate vaccine than for those receiving polysaccharide vaccine; the difference in responses was primarily due to a better response to conjugate vaccine in the otitis-prone group. Significantly higher postimmunization concentrations of antibodies to all four serotypes and to one of the four serotypes were found in otitis-prone children and otitis-free children who received conjugate vaccine, respectively. Pneumococcal conjugate vaccine has the potential to reduce the incidence of disease due to vaccine serotypes, even among children with recurrent otitis media.

Comparison of ceftriaxone and trimethoprim-sulfamethoxazole for acute otitis media. Greater Boston Otitis Media Study Group.

OBJECTIVE: The purpose of this prospective, randomized, single-blind trial was to assess the clinical efficacy of a single intramuscular dose of ceftriaxone compared with 10 days of oral trimethoprim-sulfamethoxazole (TMP-SMZ) in treating acute otitis media (AOM). METHODS: Children aged 3 months through 3 years diagnosed with AOM (signs of acute illness plus evidence of middle-ear effusion) were randomized to treatment with either a single intramuscular dose of ceftriaxone (maximum dose of 50 mg/kg) or 10 days of oral trimethoprim-sulfamethoxazole (8 mg of TMP and 40 mg of SMZ/kg/day in two divided doses). Children were evaluated at scheduled visits on days 3, 14, and 28, and the parents were telephoned on day 5. Children were assessed as cured, improved, or failed on day 3, and as cured or failed on days 14 and 28. Children ill at other times during the study period were, if possible, seen and assessed by the study team. RESULTS: Of 596 children enrolled during the study period, 484 were evaluable. Characteristics of evaluable subjects did not differ significantly by drug. On day 3, 223/241 children in the ceftriaxone group (92.5%) and 231/243 (95.1%) in the TMP-SMZ group were cured or improved. On day 14, 158/197 (80.2%) in the ceftriaxone group and 174/212 (82.1%) in the TMP-SMZ group were cured. On day 28, 108/136 (79.4%) in the ceftriaxone group and 124/155 (80%) in the TMP-SMZ group were cured. Persistence of middle-ear fluid did not differ between groups at day 14 (55% in the ceftriaxone group vs 47% in the TMP-SMZ group; P = .16) or at day 28 (39% vs 43%; P = .48). Pain at the injection site persisting at day 3 occurred in 8.4% of children receiving ceftriaxone. New diarrhea was more common in the ceftriaxone group (23.6% vs 9.2%; P < .001). CONCLUSION: A single intramuscular dose of ceftriaxone is comparable in clinical efficacy to 10 days of oral TMP-SMZ for treatment of AOM.

Does lactose maldigestion really play a role in the irritable bowel?

Patients who met International Congress of Gastroenterology criteria for irritable bowel syndrome (IBS) and had breath hydrogen lactose testing were interviewed to determine whether detection of lactose maldigestion (LM) had an impact on their symptoms. Of 199 patients initially evaluated, 161 (81%) were contacted and asked to rate their symptoms. At baseline, 47 (29%) of the IBS group had LM. Before testing, 23 (49%) were aware that ingestion of lactose-containing food was associated with their gastrointestinal symptoms. Lactose-maldigesting IBS subjects (IBSLM, n = 47) and those who had IBS and no LM (n = 114) were similar in terms of age, sex, and ethnic background. Interviews performed 41 +/- 1.1 (SEM) months after baseline evaluation revealed no significant differences in abdominal pain, altered bowel habits, bloating/distension, mucus, and relief with defecation among those with IBS or LMIBS. Overall symptoms resolved, improved, did not change, or worsened in a manner not statistically different between IBS and IBSLM groups. IBSLM subjects (a) felt that identifying LM helped them gain awareness of food-symptom relationships (78.7%), (b) experienced some improvement in symptoms (83%), (c) were avoiding lactose foods (87.2%), or (d) used lactase enzyme supplements (38.3%). Identifying LM did not significantly affect rated variables.

The problem of resistant bacteria for the management of acute otitis media.

The emergence of pneumococci resistant to penicillin has prompted an examination of the role of resistant organisms in the response to treatment for AOM. At this time, antibiotic-resistant organisms play a small role in the number of episodes of AOM that do not respond to initial therapy. Amoxicillin remains the drug of choice for treatment of AOM. For children who do not respond, assessment of clinical status is important. Children who are well-appearing may respond to a beta-lactamase stable oral agent. Children who are ill may require tympanostomy and presumptive therapy for infection due to resistant organisms.

Serious bacterial infections in febrile infants and children selected for lumbar puncture.

Lumbar puncture (LP) is performed frequently in pediatric emergency departments to diagnose meningitis in infants and young children with fever. Children selected to have LP who do not have meningitis may, however, have other serious bacterial infections. We surveyed lumbar punctures performed in the Boston City Hospital Pediatric Emergency Department and monitored the incidence of meningitis and other serious bacterial infections. Meningitis was diagnosed in 8% of children who underwent LP. An additional 10.5% of children who underwent LP and had normal cerebrospinal fluid had positive cultures of blood (3.1%), urine (4.1%) or stool (3.3%). The decision to perform lumbar puncture identifies children at risk of having not only meningitis but other serious bacterial illnesses. Those children 2 years of age and younger with normal cerebrospinal fluid should be considered for cultures of blood, urine and possibly stool.

Otitis media in children born to human immunodeficiency virus-infected mothers.

Acute otitis media (AOM) is thought to occur frequently in children infected with human immunodeficiency virus (HIV). We compared experience with AOM of 28 HIV-infected children with that of 33 children who seroreverted to HIV antibody negative status by age 18 months. The mean number of episodes/year of AOM for children who seroreverted decreased from 1.33 in the first year of life to 0.13 in the third year, whereas the mean number of episodes/year in HIV-infected children increased from 1.89 to 2.40. By age 3 years, all HIV-infected children had experienced 1 or more episodes of AOM, and 80% had experienced 6 or more, whereas 75% of children who seroreverted had experienced 1 or more episodes, and none had had 6 or more. HIV-infected children with normal T4 lymphocyte counts had a mean of 1.18 episodes of AOM in the first year of life compared with 2.35 episodes in HIV-infected children with decreased counts (P = 0.023). HIV-infected children with low counts had a nearly 3-fold increased risk of recurrent AOM (47% vs. 18%).