Acute liver failure caused by isoniazid in a child receiving carbamazepine.

We report a case of a 10-year-old boy, being treated for seizures with carbamazepine, who developed acute liver failure within four days of initiation of therapy for suspected tuberculosis with isoniazid, rifampin, pyrazinamide, and ethambutol. Isoniazid-induced liver disease was diagnosed. The likely role of carbamazepine and rifampin in potentiating the hepatotoxicity of isoniazid, and the importance of early recognition of isoniazid-induced liver disease, are discussed.

Quadriplegia complicating Escherichia coli meningitis in a newborn infant: case report and review of 22 cases of spinal cord dysfunction in patients with acute bacterial meningitis.

We report a case of Escherichia coli meningitis complicated by spinal cord dysfunction in a neonate. This very rare complication of bacterial meningitis was probably caused by ischemia of the cord resulting from vasculitis. We review the 22 other reports of patients with this complication and discuss its pathogenesis.

Hepatosplenic cat-scratch disease and abdominal pain.

BACKGROUND: There have been several recent reports that cat-scratch disease (CSD) causes a multiplicity of atypical clinical syndromes. We recently diagnosed hepatosplenic CSD in a child who was seen with fever and abdominal pain. We report this case and 10 other patients with hepatosplenic CSD and highlight the importance of abdominal pain in this clinical entity. METHODS: This was a retrospective review of charts of patients with a diagnosis of cat-scratch disease at Egleston Children's Hospital between January, 1985, and June, 1996. From these cases patients with hepatosplenic CSD were selected for study. RESULTS: Seven children (64%) had significant abdominal pain, and in three children abdominal pain was their chief complaint. All children in the study had pathologic evidence of CSD or elevated titers of antibodies to Bartonella henselae. Ultrasound examination showed that all children had microabscesses in the spleen, and eight had abscesses in the liver. CONCLUSIONS: One of the most remarkable findings in this large series of cases of hepatosplenic CSD was that 64% of the patients complained of abdominal pain. All children in this study received antibiotics. It was our clinical impression that once antibiotics had been started, the patients appeared to improve very quickly. With an increased index of suspicion, the use of B. henselae serology and an abdominal ultrasound examination, the diagnosis of this underrecognized disease might be more readily made.

Neonatal Torulopsis glabrata fungemia.

Torulopsis glabrata is a yeastlike fungus that has recently become recognized as an important opportunistic pathogen. Only four cases of T glabrata infection in neonates have been reported. We report two cases of fungemia caused by this organism in premature infants. Both patients were treated with amphotericin B and survived the fungemia, but one patient later died of bacterial sepsis. Both patients had been treated with surfactant, artificial ventilation, intravascular catheters (arterial and venous), broad spectrum antibiotics, and hyperalimentation, which appear to be risk factors for T glabrata fungemia. A review of the literature indicates that T glabrata is susceptible to amphotericin B and 5-fluorocytosine and is resistant to fluconazole. In addition, it is less susceptible to ketoconazole, clotrimazole, and itraconazole than is Candida albicans. We recommend that T glabrata infections be treated initially by reducing iatrogenic risk factors and beginning amphotericin B therapy. If necessary, 5-fluorocytosine should be added to the drug regimen.

Antibiotic resistance in bacteria.

Antibiotic resistance in bacteria has emerged as a medical catastrophe. This results from the speed at which bacteria multiply and are spread, and the ease with which they can change their genetic material or acquire new genes. They exert biochemical resistance by preventing entry of the drug, by rapidly extruding the drug, or by enzymatically inactivating the drug or altering its molecular target. The presence of antibiotics in the internal environments of human beings and animals provides a selective pressure for any resistant organisms to become predominant. Examples of antibiotic resistance in several important human pathogens are Streptococcus pneumoniae, enterococci, staphylococci, enteric bacilli, Haemophilus influenzae, Neisseria gonorrhoeae, Neisseria meningitidis, and Mycobacterium tuberculosis.

Infective endocarditis in neonates.

We studied retrospectively the predisposing factors and signs of infective endocarditis (IE) in neonates and infants younger than 3 months of age, and we suggest diagnostic criteria. The charts of 16 infants less than 3 months of age, diagnosed with IE during a 5-year period, were reviewed for possible maternal and infant risk factors and for pathognomonic clinical and laboratory features. No apparent maternal risk factors were noted. Infant risk factors were congenital heart disease (4), patent ductus arteriosus (PDA) (5), and the use of central venous catheters (14). The main clinical findings were cardiac murmurs (12), petechiae (2), skin abscesses (7), arthritis (2), hepatomegaly (9), and splenomegaly (2). Echocardiography revealed a mass or vegetation in nine patients. Of the 27 microorganisms isolated from blood, the most common were staphylococci (15) and Candida sp. (6). Urine cultures were positive in six patients and cerebrospinal fluid cultures were positive in one. Other laboratory findings were not of diagnostic value. We conclude that the main risk factors for neonatal IE are central venous catheters and congenital heart disease, including PDA. The main causative microorganisms are staphylococci and Candida sp. The main investigations of diagnostic value are blood and urine cultures and echocardiography. We propose the diagnostic categories of definite, probable, and possible cases of neonatal IE, based primarily on clinical, blood culture, and echocardiographic data.

Third generation cephalosporin-resistant gram-negative bacilli in the feces of hospitalized children.

In view of the widespread use of third generation cephalosporins in hospitalized infants, we attempted to determine whether their use was associated with the emergence of resistance in fecal Gram-negative bacilli. Stools from infants hospitalized for varying durations were cultured on MacConkey agar containing 4 micrograms/ml of cefotaxime. All isolates growing on this medium were identified and their susceptibilities to 29 antimicrobial agents were determined. Sixty-five infants were studied of whom 44 were receiving a third generation cephalosporin, 7 another antibiotic and 14 no antibiotic. Thirty-one strains resistant to third generation cephalosporins (minimal inhibitory concentrations > or = 16 micrograms/ml) to cefotaxime, ceftriaxone or ceftazidine) were isolated from 26 infants. The proportions of infants with resistant strains were not significantly different whether they were: (1) receiving a third generation cephalosporin or not; (2) hospitalized for longer or shorter than 2 days or not; (3) older or younger than 3 months or not. Notably 8 infants harbored resistant strains within 24 hours of admission. The commonest resistant strains isolated belonged to the genera Enterobacter (10), Citrobacter (6), Serratia (3), Cedecea (3) and Chromobacterium (3). In conclusion hospitalized infants had a high incidence of fecal colonization with Gram-negative bacilli resistant to third generation cephalosporins. These bacteria were predominantly those known to produce broad spectrum beta-lactamases. This colonization was not necessarily associated with the infant receiving such antibiotics or with prolonged hospitalization.

Hemolysis and infection: categories and mechanisms of their interrelationship.

Different cause-and-effect relationships between hemolytic and infectious processes are categorized in a clinically useful manner as follows: infections causing hemolysis by invasion of red blood cells (RBCs), by hemolysins, or by immune mechanisms; oxidative damage to RBCs during infections; hemolysis secondary to infection-induced pathologic processes; hemolytic effects of antimicrobial therapy; and predisposition of an individual to infection caused by an underlying hemolytic disorder or therapy for that disorder. The mechanisms of these interrelationships are discussed in detail.

Infective endocarditis in black South African children: report of 10 cases with some unusual features.

Ten black South African children with infective endocarditis seen over a 2-year period are reported. In five cases, including two neonates, the infection was nosocomial and in five cases it occurred in children with previously normal hearts. Of the bacteria isolated from nine cases, five were Staphylococcus aureus (all from nosocomial cases), one was Haemophilus influenzae and three were corynebacteria. The unusual aspects of this series are discussed, with an emphasis on preventing nosocomial cases and on making the diagnosis in children without underlying heart disease.

Nosocomial infections in black South African children.

Nosocomial infections in infants and children were prospectively studied in the general wards of a hospital serving a developing community. Of 1350 admissions in 5 months, 193 (14.3%) developed 302 infections (22.4/100 admissions). The major risk factors were malnutrition, age less than 2 years and prolonged hospitalization. The most common sites of infection were the lower respiratory and gastrointestinal tracts. The most frequently isolated organisms were Staphylococcus aureus and Klebsiella species and the site of most frequent isolation was the lower respiratory tract for which the method most commonly used was endotracheal aspiration. Seventy percent of isolates were resistant in vitro to conventional antibiotics. Thirty-one percent of infections developed while the patient was awaiting a diagnostic procedure or waiting to be sent home. During the study period 60 patients (4.4% of admissions) were admitted with a nosocomial infection acquired elsewhere (31 at this hospital and 29 from other hospitals). Measles and its complications accounted for 28 of these cases and 7 deaths. This study provides information on nosocomial infections in children from a developing community.

Inhibition of varicella-zoster virus in vitro by human peripheral blood mononuclear cells.

A functional in vitro assay of cell-mediated immunity to varicella-zoster virus (VZV) is described. This procedure uses an enzyme-linked immunosorbent assay (ELISA) to measure the inhibitory effect of human peripheral blood mononuclear cells on VZV antigen production by VZV-infected cell monolayers. When mononuclear cells from VZV-immune, tetanus-immune donors were stimulated with either VZV antigen or tetanus toxoid they reduced VZV antigen production. In contrast, mononuclear cells from VZV-nonimmune, tetanus-immune donors reduced VZV antigen only when stimulated with tetanus toxoid, but not when stimulated with VZV antigen. Cell-free supernatants recovered from the VZV inhibition assays contained the anti-VZV activity. The magnitude of the anti-VZV activity of the supernatants equalled the inhibition observed when the stimulated mononuclear cells were added to the VZV-infected monolayers. Treatment of either mononuclear cells or supernatants with anti-interferon gamma antibody indicated that their VZV inhibitory capability was largely due to the production of interferon gamma by stimulated mononuclear cells.

Endotracheal aspiration for the bacteriological diagnosis of nosocomial- and measles-associated pneumonia.

Endotracheal aspirates were obtained from 51 young children for the microbiological diagnosis of pneumonia acquired in hospital or associated with measles or severe protein-energy malnutrition. The procedure proved safe and the information obtained assisted in the management of most cases. There was a fairly good correlation between the findings of Gram stain and those of culture of the aspirates, which improved when only Gram stains showing many or moderate numbers of bacteria were used. The bacteria most frequently isolated were Gram-negative enteric bacilli, Staphylococcus aureus, Streptococcus viridans, Streptococcus pneumoniae and Haemophilus influenzae, many strains of which were resistant to conventional antibiotics. The role of endotracheal aspiration in the microbiological diagnosis of pneumonia in the above-mentioned types of patients is compared with that of percutaneous lung puncture, percutaneous transtracheal aspiration and expectorated sputum.

Cryptosporidiosis in black South African children.

The incidence of cryptosporidiosis in young children was determined by staining of faecal specimens with a modified Kinyoun stain. Seventeen of 92 (18,4%) children with diarrhoea and 1 of 29 (3.4%) controls excreted Cryptosporidium oocysts, suggesting that this was an important enteric pathogen in these children.