Tick-borne meningoencephalitis in a 4.5-month-old infant.

BACKGROUND: The course of tick-borne encephalitis (TBE) in children is supposed to be mild though severe neurological sequelae have been reported. Only occasionally infants are affected. PATIENTS AND METHODS: Case report, review of literature. RESULTS: We describe the first case of tick-borne encephalitis in a 4.5-month-old male infant in Germany. 11 days after a tick-bite he developed acute illness with fever, focal and generalized seizures. Meningoencephalitis caused by the TBE virus was diagnosed by cerebrospinal fluid (CSF) pleocytosis and detection of TBE-RNA in the CSF. Neurological follow-up showed no abnormalities. CONCLUSIONS: The acute meningoencephalitis in the present case and the neurological short and long term morbidity of 3 additional published cases of TBE suggest the considerable burden of this disease in infancy. As parents can transmit the tick to their infant informations about exposure-prophylactic measurements are recommended.

Myotonic dystrophy initially presenting as tachycardiomyopathy successful catheter ablation of atrial flutter.

Myotonic dystrophy is a genetic muscular disease that is frequently associated with cardiac arrhythmias. Bradyarrhythmias, such as sinus bradycardia and atrioventricular block, are more common than tachyarrhythmias. Rarely, previously undiagnosed patients with myotonic dystrophy initially present with a tachyarrhythmia. We describe the case of a 14-year-old boy, who was admitted to the hospital with clinical signs and symptoms of decompensated heart failure and severely reduced left ventricular function. Electrocardiography showed common-type atrial flutter with 2 : 1 conduction resulting in a heart rate of 160 bpm. Initiation of medical therapy for heart failure as well as electrical cardioversion led to a marked clinical improvement. Catheter ablation of atrial flutter was performed to prevent future cardiac decompensations and to prevent development of tachymyopathy. Left ventricular function normalized during followup. Genetic analysis confirmed the clinical suspicion of myotonic dystrophy as known in other family members in this case.

Pediatric acute lung injury.

Among ventilated children, the incidence of acute lung injury (ALI) was 9%; of that latter group 80% developed the acute respiratory distress syndrome (ARDS). The population-based prevalence of pediatric ARDS was 5.5 cases/100.000 inhabitants. Underlying diseases in children were septic shock (34%), respiratory syncytial virus infections (16%), bacterial pneumonia (15%), near-drowning 9%, and others. Mortality ranged from 18% to 27% for ALI (including ALI-non ARDS and ARDS) and from 29% to 50% for ARDS. Mortality was only 3%-11% in children with ALI-non ARDS. As risk factors, oxygenation indices and multi-organ failure have been identified. New insights into the pathophysiology (for example the interplay between intraalveolar coagulation/fibrinolysis and inflammation and the genetic polymorphism for the angiotensin-converting enzyme) offer new therapeutic options. Lung protective mechanical ventilation with optimal lung recruitment is the mainstay of supportive therapy. New therapeutic modalities refer to corticosteroid and surfactant treatment. Well-designed follow up studies are needed.

Mechanical ventilation affects alveolar fibrinolysis in LPS-induced lung injury.

The aim of the present study was to determine the effects of mechanical ventilation on alveolar fibrin turnover in lipopolysaccharide (LPS)-induced lung injury. In a randomised controlled trial, Sprague-Dawley rats (n = 61) were allocated to three ventilation groups after intratracheal LPS (Salmonella enteritidis) instillations. Group I animals were subjected to 16 cmH(2)O positive inspiratory pressure (PIP) and 5 cmH(2)O positive end-expiratory pressure (PEEP); group II animals to 26 cmH(2)O PIP and 5 cmH(2)O PEEP; and group III animals to 35 cmH(2)O PIP and 5 cmH(2)O PEEP. Control rats (not mechanically ventilated) received LPS. Healthy rats served as a reference group. Levels of thrombin-antithrombin complex (TATc), D-dimer, plasminogen activator inhibitor (PAI) activity and PAI-1 antigen in bronchoalveolar lavage fluid were measured. LPS-induced lung injury increased TATc, D-dimer and PAI activity and PAI-1 antigen levels versus healthy animals. High pressure-amplitude ventilation increased TATc concentrations. D-dimer concentrations were not significantly raised. Instead, PAI activity increased with the amplitude of the pressure, from 0.7 U.mL(-1) in group I to 3.4 U.mL(-1) in group II and 5.0 U.mL(-1) in group III. There was no change in PAI-1 antigen levels. In conclusion, mechanical ventilation creates an alveolar/pulmonary anti-fibrinolytic milieu in endotoxin-induced lung injury which, at least in part, might be due to an increase in plasminogen activator inhibitor activity.

Incidence and short-term outcome of acute lung injury in mechanically ventilated children.

The aim of this study was to determine the incidence and short-term outcome of mechanically ventilated children suffering from acute lung injury (ALI) on a paediatric intensive care unit (PICU). Between January 1 1998 and January 1 2000, all mechanically ventilated children were evaluated using the criteria of an American-European Consensus Conference. Of the 443 children eligible for analysis, 44 (9.9%) were diagnosed as suffering from ALI. Of these, 79.5% developed the acute respiratory distress syndrome (ARDS); 54.5% (24 of 44) fulfilled the ARDS criteria at inclusion and 25% (11 of 44) later. PICU mortality for ALI was 27.3% (12 of 44) and within the ARDS subgroup 31.4% (11 of 35). Of the 12 children who died, 11 had ARDS; the main cause of death was cerebral damage (seven of 12). Acute lung injury and acute respiratory distress syndrome are rare diseases on a paediatric intensive care unit with a high mortality. Most of the children with acute lung injury develop acute respiratory distress syndrome. In the acute respiratory distress syndrome subgroup, mortality is higher than in the acute lung injury nonacute respiratory distress syndrome subgroup. Further investigations should confirm prognostic factors (e.g. respiratory parameters) for prediction of outcome.

The hyponatraemic hypertensive syndrome in a 2-year-old child with behavioural symptoms.

UNLABELLED: In this case report we present a 2-year-old girl with the classical signs of the hyponatraemic hypertensive syndrome. She initially presented with a history of behavioural abnormalities and hyponatraemia (126 mmol/l) and her blood pressure was as high as 220/160 mmHg. After admission, somnolence developed. Intravenous anti-hypertensive therapy was started immediately. The hyponatraemia was treated with i.v. sodium supplementation. The cause of this syndrome proved to be fibromuscular dysplasia of the left renal artery. Finally, a left nephrectomy was performed. With this therapy, blood pressure and serum sodium normalised and the girl promptly regained normal consciousness and behaviour. CONCLUSION: Behavioural abnormalities in the history of a child without any other neurological symptoms might be one of the first signs of hypertensive encephalopathy. In combination with hyponatraemia, these symptoms should alert the physician to consider the hyponatraemic hypertensive syndrome.

Pulse methylprednisolone therapy for impending cardiac tamponade in immunoglobulin-resistant Kawasaki disease.

We describe a boy with Kawasaki disease (KD) whose clinical course was marked by a rapid improvement upon treatment with intravenous immunoglobulin (IVIG) and oral aspirin, which - within 14 days - was followed by the development of a large pericardial effusion with symptoms of impending cardiac tamponade as part of a polyserositis syndrome (pleural effusions, ascites). Upon treatment with pulsed methylprednisolone, the pericardial and pleural effusions and ascites rapidly disappeared within 48 h. This is the first case reported with a polyserositis syndrome and impending cardiac tamponade during KD.

[Prevalence of drugs in meconium]. / Prävalenz von Drogen im Mekonium.

BACKGROUND: The number of newborn infants with symptoms suggesting drug withdrawal is increasing. As only part of prenatally exposed infants show typical drug withdrawal, and drug-use reported by addicted mothers is often unreliable the prevalence of neonates that were exposed to illicit drugs before birth is unknown. The purpose of this study was to evaluate prospectively the prevalence of drugs in meconium and to define risk factors for intrauterine drug exposure. METHODS: During a period of 4 months meconium was collected twice in 420 nonselected newborn infants. Meconium was analysed with a modified test developed for toxicology screening in urine. Information on pre- and postnatal risk factors including drug-use during pregnancy was obtained. RESULTS: Among 415 mothers four reported illicit drug use and ten licit drug use during late pregnancy. In all these infants meconium drug test was positive. After exclusion of these infants and of five second twins 401 infants with negative drug history remained. 45 of them (11%) had one or two drugs in the meconium: opiate 17x, amphetamine 16x, barbiturate 15x, benzodiazepine 3x, cannabinoid 2x, cocaine 1x (in 9 infants two substances were detected). None was positive for LSD or phencyclidine. The infants with positive drug tests had the following risks compared to those with negative tests: prematurity (odds ratio 2.3, 95% confidence interval 1.3-4.3). Microcephaly or macrocephaly (2.0:1.01-4.1), Apgar-Score below 5 at 1 min (2.4:1.5-5.4), Apgar score below 7 at 10 min (4.0: 1.6-9.9), mother academic (2.8:1.2-6.2). CONCLUSIONS: Newborn infants may have been exposed to illicit drugs in utero even if their mothers deny drug use and even if they do not show withdrawal symptoms. Prematurely born infants and infants with problems in postnatal adaptation have an increased risk of having been exposed to drugs.

[Detection of drugs in meconium]. / Nachweis von Drogen im Mekonium.

BACKGROUND: The number of newborn infants exposed to drugs in utero is on the increase in many European countries. As drug use reported by addicted pregnant women is unreliable there is a need for an accurate test to determine the drugs to which an infant has been exposed in utero. The purpose of this study was to evaluate the reliability of toxicology testing in meconium compared with traditional urine testing. METHODS: From twenty newborn infants born to drug-dependent mothers, meconium and urine were collected as soon as possible after birth and tested for drugs with the same radioimmunoassay. Five neonates were premature (Gestational weeks less than 37), six were small and three microcephalic for gestational age. RESULTS: Meconium was positive for drugs in 19 infants (95%) (Methadone 9, Morphine 9, Cocaine 6, Cannabis 4). Urine testing revealed the presence of drugs in 13 babies (65%) (Methadone 9, Morphine 6, Cocaine 4, Cannabis 1, Barbiturates 1). Five infants did not have any drug withdrawal, five had mild and ten severe withdrawal symptoms necessitating treatment with chlorpromazine and in four instances additional pethidine. CONCLUSIONS: Meconium is not only easier to collect but also at least as reliable as urine for drug detection in neonates.