High prevalence of Mycobacterium tuberculosis infection and disease in children and adolescents with type 1 diabetes mellitus.

SETTING: Western Cape Province, South Africa. OBJECTIVES: To describe the prevalence of tuberculosis (TB) infection and disease in children with type 1 diabetes and to investigate the association between glycaemic control and prevalence of TB infection and disease. DESIGN: Cross-sectional hospital-based study conducted at two public referral hospitals. All children and adolescents (aged <21 years) with type 1 diabetes underwent a Mantoux tuberculin skin test (>or=10 mm classified as Mycobacterium tuberculosis infection), measurement of glycosylated haemoglobin and a chest radiograph. Patients with symptoms suggestive of TB were investigated using mycobacterial culture. Radiologically and/or bacteriologically confirmed disease was classified as TB disease. RESULTS: Of 291 eligible patients, 258 (88.7%) were included (58% female). The prevalence of M. tuberculosis infection was 29.8% (95%CI 24.2-35.4); nine patients were diagnosed with prevalent TB disease (point prevalence disease 3488 per 100,000 population). Poor glycaemic control (hazard ratio 1.39, 95%CI 1.18-1.63 per unit increase in glycated haemoglobin [HbA1c]) and contact with a TB source case (P = 0.0011) was associated with prevalent TB disease. CONCLUSIONS: There is a high prevalence of TB disease in diabetic children and adolescents in this setting. Routine TB screening of children with type 1 diabetes may be indicated in settings highly endemic for TB. Preventive treatment should be considered for diabetic children with proof of TB exposure and/or infection.

Phototherapy and exchange transfusion for neonatal hyperbilirubinaemia: neonatal academic hospitals' consensus guidelines for South African hospitals and primary care facilities.

The purpose of this document is to address the current lack of consensus regarding the management of hyperbilirubinaemia in neonates in South Africa. If left untreated, severe neonatal hyperbilirubinaemia may cause kernicterus and ultimately death and the severity of neonatal jaundice is often underestimated clinically. However, if phototherapy is instituted timely and at the correct intensity an exchange transfusion can usually be avoided. The literature describing intervention thresholds for phototherapy and exchange transfusion in both term and preterm infants is therefore reviewed and specific intervention thresholds that can be used throughout South Africa are proposed and presented graphically. A simplified version for use in a primary care setting is also presented. All academic heads of neonatology departments throughout South Africa were consulted in the process of drawing up this document and consensus was achieved.

Prescribing insulin in type 1 diabetes mellitus: an update for general practitioners

The pancreas in a non-diabetic patient constantly secretes a small amount of insulin (basal secretion). After meals; a larger amount of insulin is secreted (bolus secretion) to cope with the increased blood glucose that occurs following a meal. The goal of insulin therapy in diabetics is to mimic this secretion pattern to provide enough insulin throughout a 24-hour period to meet the basal requirements and to deliver higher boluses of insulin to meet the glycaemic effect of meals. To achieve good diabetes control; an individually tailored insulin treatment regimen is required

Aetiology and outcome of severe community-acquired pneumonia in children admitted to a paediatric intensive care unit.

OBJECTIVE: To determine the aetiological agents and outcome of severe community-acquired pneumonia (SCAP) in children admitted to the paediatric intensive care unit (PICU) at Kalafong Hospital, Pretoria. PATIENTS AND METHODS: An audit was done after a protocol was implemented to identify the aetiological agents in children with life-threatening SCAP admitted to the PICU from the emergency room. The following investigations were done as per protocol: blood culture, culture of the tracheal aspirate, immunofluorescence and culture of the nasopharyngeal aspirate, microscopy and culture of the gastric juice for Mycobacterium tuberculosis, and determination of HIV status. The following data, documented prospectively, were obtained from patient records: date of admission, age, gender, weight, duration of ventilation, duration of stay in the PICU, survival or death, and severity of illness as determined by means of the score for acute neonatal physiology (SNAP) or paediatric risk of mortality (PRISM) score depending on the child's age. RESULTS: Twenty-three children were admitted over a 1-year period (1 November 1994-30 October 1995). Their median age was 10 weeks (range 2 weeks-5 years) and the sex distribution was equal. Two children were HIV-infected. Twenty children received mechanical ventilation for a median period of 6.5 days (range 2-16 days). Aetiological agents were identified in 15/23 children (65%). Respiratory syncytial virus (RSV) was the most common pathogen, identified in 7/23 children, Klebsiella pneumoniae was the most common bacterial pathogen, identified in 5 children (2 blood cultures and 3 tracheal aspirates). Tuberculosis was not diagnosed. The mean PRISM score was similar in survivors and children who died. The case fatality rate was 30%. The 7 children who died had a median arterial oxygen tension/fraction of inspired oxygen (PaO2/FiO2) ratio of 94 (range 32-111) and the 16 survivors had a median ratio of 146 (range 51-252) (P = 0.01) on admission. Both HIV-infected children died and postmortem examination showed a pneumonia due to Pneumocystis carinii and cytomegalovirus. CONCLUSIONS: SCAP occurs in very young children. One or more pathogens were isolated in 65% of cases. Viral pathogens predominated, with RSV being the most common. The yield of positive blood cultures was low at 17%. Streptococcus pneumoniae and Haemophilus influenzae were not found. The case fatality rate was 30% and death was more likely with a low PaO2/FiO2 ratio on admission.

Fatal liver failure due to ketoconazole treatment of a girl with Cushing's syndrome.

A patient is reported who developed fatal liver failure on ketoconazole treatment for Cushing's syndrome. It is recommended that metyrapone be used when hypercortisolism has to be controlled as a temporary measure in childhood and adolescence.

The use of dexamethasone in women with preterm premature rupture of membranes--a multicentre, double-blind, placebo-controlled, randomised trial. Dexiprom Study Group.

OBJECTIVE: To assess whether administration of dexamethasone in women with preterm premature rupture of membranes (PPROM) has an effect on the prevalence of maternal sepsis, neonatal respiratory distress syndrome (RDS), perinatal mortality and neonatal sepsis in a developing country. SETTING: Six public hospitals in South Africa that deal mainly with indigent women. METHOD: A multicentre, double-blind, placebo-controlled, randomised trial was performed on women with PPROM and fetuses of 28-34 weeks' gestation or clinically estimated fetal weight between 1,000 and 2,000 g if the gestational age was unknown. Women were randomised to receive either dexamethasone 24 mg intramuscularly or placebo in two divided doses 24 hours apart. All women received amoxycillin and metronidazole and were managed expectantly. Hexoprenaline was administered if contractions occurred within the first 24 hours after admission to the trial. OUTCOME MEASURES: The maternal outcome measures were clinical chorio-amnionitis and postpartum sepsis. The outcome measures for infants were perinatal death, RDS, mechanical ventilation, necrotising enterocolitis, and neonatal infection within 72 hours. RESULTS: One hundred and two women who delivered 105 babies were randomised to the dexamethasone group and 102 women who delivered 103 babies, to the placebo group. The groups were well balanced with regard to clinical features. There was a trend towards fewer perinatal deaths in the dexamethasone group: 4 compared with 10 (P = 0.16, odds ratio 0.37, 95% confidence intervals 0.09-1.34). A subanalysis of mothers who delivered more than 24 hours after admission to the study and their infants revealed a significant reduction in perinatal deaths; 1 death in the dexamethasone group and 7 in the placebo group, P = 0.047 (Fisher's exact test). No woman in either group developed severe sepsis, and the incidence of sepsis in the women did not differ significantly. Eleven infants in each group developed sepsis. CONCLUSION: This is the first randomised trial in women with PPROM to compare the effects of the use of corticosteroids with placebo, where all women received prophylactic antibiotics concomitantly with the corticosteroids. A trend towards an improved perinatal outcome was demonstrated in the women who received dexamethasone. There was no increased risk of infection in the women or their infants where dexamethasone was administered. Administration of corticosteroids to women with PPROM has more advantages than disadvantages in developing countries.

On-site screening for syphilis at an antenatal clinic.

OBJECTIVE: To determine the validity, predictive value and accuracy of the rapid plasma reagin card test performed on site to diagnose active syphilis in pregnant women so that immediate treatment can be offered to prevent congenital syphilis. DESIGN: Open, descriptive study. SETTING: Antenatal clinic, Mamelodi Hospital, Pretoria. PATIENTS: Four hundred and seventy-four pregnant women attending the antenatal clinic for the first time were entered into the study. METHODS: A rapid plasma reagin test was performed on site with no specialised equipment and the results were compared with those of the reference laboratory. RESULTS: In the event of rapid plasma reagin titres of 1:8 and higher, indicative of active syphilis, the on-site rapid plasma reagin test had a sensitivity of 90.5%. The test had a sensitivity of 100% if the rapid plasma reagin titres were 1:16 and higher. CONCLUSION: The on-site rapid plasma reagin test identified all women with rapid plasma reagin titres higher than 1:8. This implies that all women whose fetuses were in danger of acquiring congenital syphilis were identified at the clinic and could be treated immediately.

Zygomycotic necrotizing cellulitis in a premature infant.

A premature infant with fatal zygomycotic necrotizing cellulitis is reported. Zygomycosis occurs as either an indolent or an acute fulminating form. Cutaneous zygomycosis is a fulminant form of the disease and affects mainly immunocompromised patients. Premature infants with perinatal complications are immunocompromised and therefore at risk for zygomycotic disease, including cutaneous zygomycosis. The different presentations of cutaneous zygomycosis are discussed. Early diagnosis and treatment are essential to ensure patient survival. The clinical differential diagnosis of zygomycotic necrotising cellulitis is mentioned as well as methods for the rapid confirmation of the diagnosis.

Growth, feeding practices and infections in black infants.

OBJECTIVE: To investigate the growth, early feeding practices and prevalence of infections in black infants. DESIGN: Longitudinal study with prospective documentation of data. SETTING: Kalafong Hospital, Pretoria. PATIENTS: Term, appropriately grown infants with a positive rapid plasma reagin test on cord blood were enrolled. Infants who on follow-up did not have congenital syphilis were studied. RESULTS: At birth the mean weight-for-age Z-scores corresponded with those of the National Center of Health Statistics (NCHS) reference population and increased during the first 3 months. A fall-off in growth performance in respect of weight gain occurred from 3 months and continued until 15 months when the study was terminated. At 6 and 12 months, 86% and 81% of infants respectively were receiving breast-milk. By 3 months, 78% of infants were receiving a supplementary food. At 9 months, 40% of infants had experienced an infection during the preceding 3 months. During the study, upper airway infections comprised 74% of all episodes of infection. CONCLUSIONS: Compared with the NCHS reference population, black infants grow adequately during the first 3 months of life. This is followed by a persistent fall-off in growth performance associated with the introduction of supplementary food.

Aftermath of failed diagnosis of late-presenting congenital diaphragmatic hernias.

A congenital posterolateral diaphragmatic (Bochdalek) hernia generally presents with symptoms within a day after birth. This article reports on 3 children whose hernias produced symptoms for the first time beyond a week of age. One 3-year-old child died acutely with symptoms resembling that of a tension pneumothorax. In 2 children symptoms only developed at 12 and 23 days of age. They were initially thought to have lower lobe pneumonias and delayed diagnosis led to the death of one. Although the late presentation of a congenital posterolateral diaphragmatic hernia is rare, it is important to recognise it because with appropriate therapy all such children should have a normal life expectancy, whereas unsuspected hernias in older children carry a mortality that is even worse than that of neonatal cases. The first requisite for the diagnosis of a congenital diaphragmatic hernia (CDH) is a high index of suspicion. Cystic lesions or masses in the lower lung fields should suggest the possibility of a CDH with herniated abdominal content at any age. Congenital diaphragmatic hernias should be included in the differential diagnosis of apparent lower lobe pneumonias in all children below a month of age.

The value of incorporating avoidable factors into perinatal audits.

OBJECTIVE: To assess whether incorporating a system of identifying, classifying and grading avoidable factors into a perinatal audit can be useful in identifying problem areas. DESIGN: Descriptive study. SETTING: Black urban population, Pretoria, South Africa. SUBJECTS: All perinatal deaths of infants weighing more than 1,000 g from urban areas served by Kalafong Hospital between August 1991 and July 1992. METHODS: All perinatal deaths were classified according to the primary obstetric cause of death and neonatal cause of death, and whether any avoidable factors were present which could have contributed to the death. RESULTS: The perinatal mortality rate was 26/1,000 deliveries. Avoidable factors occurred in 58% of perinatal deaths. Our problem areas which were immediately remedial were identified as labour management-related problems, administrative problems in obtaining syphilis results, and estimation of fetal weight. Other problem areas which need to be solved are patient education, early attendance at clinics, improved documentation and continuing education of medical personnel. CONCLUSION: The use of this classification of avoidable factors has enabled the detection of problem areas that can be improved immediately at very little cost.

Congenital anomalies in black South African liveborn neonates at an urban academic hospital.

STUDY OBJECTIVE: The aim was to study the spectrum of clinical problems and outcomes in infants born at an urban academic hospital. In consequence, as part of the overall study, the incidence of congenital anomalies and the outcomes of affected infants were recorded. DESIGN: This was a prospective, hospital-based study, undertaken on liveborn infants born over a 3-year period, 1 May 1986 to 30 April 1989. SETTING: Kalafong Hospital, Pretoria. MAIN RESULTS: A total of 17,351 liveborn infants was examined and the total congenital anomalies incidence was 11.87 per 1,000 livebirths. The central nervous system was the system most frequently involved (2.30 per 1,000 livebirths), followed by the musculoskeletal system (2.13 per 1,000 livebirths). The commonest individual congenital anomaly was Down syndrome (1.33 per 1,000 livebirths), followed by neural tube defects (0.99 per 1,000 livebirths) and ventricular septal defects (0.69 per 1,000 livebirths). In 11% (2.25 per 1,000 livebirths) of neonatal deaths, infant loss was attributable to congenital anomalies. CONCLUSIONS: The incidence of congenital anomalies in black South African neonates, born in an urban setting, is as high as in other First- and Third-World countries, and the incidence of some individual congenital anomalies is higher. This study indicates the need for further research and the establishment of prenatal, genetics and paediatric facilities to manage these problems.

An audit of the use of antibiotics in presumed viral meningitis in children.

The antibiotic management of 139 consecutive patients with presumed viral meningitis evaluated during a 6-month period was examined. The presumptive diagnosis of viral meningitis was made in retrospect by consensus among the authors, using clinical and routinely available laboratory information. Sixty-eight (51.9%) of 131 patients with complete records were treated with antibiotics after diagnosis, 25 for 2 days or less and 43 for longer than 2 days. Antibiotic treatment was retrospectively judged to be unjustified in 35 (81.4%) of the 43 patients treated for longer than 2 days. When compared with untreated patients antibiotic treatment was started in younger female children with lower cerebrospinal fluid glucose values and longer duration of symptoms. There was no difference between the two groups in other cerebrospinal fluid values, peripheral white blood cell count or history of preceding antibiotics. In contrast no associations were found with treatment beyond 2 days, compared with treatment for 2 days or less. Thus the decision to stop antibiotic treatment early did not appear to be made according to consistent clinical criteria. This apparent lack of consistent criteria suggests the need to develop clinical guidelines for such decisions, both to aid clinicians and to provide standards for medical audit.

On-site screening for maternal syphilis in an antenatal clinic.

STUDY OBJECTIVE: To determine the sensitivity, specificity, negative predictive value and positive predictive value of the rapid plasma reagin (RPR) test as performed on site in an antenatal clinic to facilitate immediate diagnosis and treatment of maternal syphilis. DESIGN: Open, descriptive study. SETTING: Antenatal clinic, Kalafong Hospital, Pretoria. PATIENTS: One thousand two hundred and thirty-seven pregnant patients attending an antenatal clinic for the first time were entered into the study. METHODS: An RPR test was performed on site in the antenatal clinic and by the reference laboratory where a Treponema pallidum haemagglutination test was also performed. MEASUREMENTS AND RESULTS: The results of the RPR test were compared with results reported by the laboratory for sensitivity, specificity, negative and positive predictive values. The RPR test performed on site had a sensitivity of 92.8%, a negative predictive value of 99.5%, a specificity of 96.3%, and a positive predictive value of 64.7%. CONCLUSION: Maternal syphilis can be diagnosed in the majority of cases during the first visit to an antenatal clinic.