Danaparoid sodium (Orgaran) in four children with heparin-induced thrombocytopenia type II.

UNLABELLED: We report on four children with heparin-induced thrombocytopenia type II. In three patients, therapy with unfractionated heparin was associated with development of cardiac thrombi or with thrombosis progression up to the inferior vena cava or with aggravation of peripheral arterial occlusion. In the fourth child, the disease was recognized early on, and no complication occurred. Heparin-induced thrombocytopenia type II was confirmed by heparin-induced platelet activation assay and/or heparin/platelet factor 4-ELISA. Concomitant elevated antiphospholipid antibodies were seen in all patients. Danaparoid sodium applied at a dosage of between 1.2 and 7.1 U/kg/h stopped the disease progression in each patient. Three children had a clinical recovery with partial recanalization, but for the child with peripheral arterial occlusion disease, amputation of some of the toes became necessary. CONCLUSION: Our data indicate that heparin-induced thrombocytopenia type II is a potential life-threatening disease in children and danaparoid sodium is beneficial in this age group.

Controlled mechanical hypoventilation in a paediatric burn patient as treatment of acute respiratory distress syndrome.

The paediatric patient we are describing suffered a scald injury covering 83 per cent of the total body surface area (TBSA). This injury was complicated by Klebsiella pneumoniae septicaemia resulting in multiorgan failure (MOF). Acute respiratory distress syndrome (ARDS), gastrointestinal insufficiency, hepathopathy and wound conversion to full thickness posed the main problems. The boy was ventilated with pressure-controlled mechanical ventilation. The concept of permissive hypercapnia (PHC) resulted in a complete resolution of ARDS within 4 weeks. From our experience, further lung injury among infants and children suffering from severe ARDS can be avoided by using controlled mechanical hypoventilation. It is a simple and safe technique that allows adequate oxygenation.

Congenital central hypoventilation syndrome (Ondine's curse syndrome) in two siblings: delayed diagnosis and successful noninvasive treatment.

UNLABELLED: Congenital central hypoventilation syndrome (CCHS, Ondine's curse syndrome) is a rare respiratory disorder; less than 100 cases have been reported. Familiality of the disease has been discussed, but only few familial cases have been reported so far. In this report we describe the occurrence of CCHS in two male siblings. Diagnosis was established only at the age of 4 years in the first case, although the patient had disease related symptoms since early infancy. The second patient was one of dizygotic twins, he was diagnosed with CCHS at the age of 8 months. Up to that age only moderate desaturations had been observed. The other twin was unaffected by the disease. Both patients were successfully treated by nocturnal positive-pressure ventilation via a specially adapted face mask. They show satisfactory physical and neurologic development. CONCLUSION: Our cases support the assumption of familiality in CCHS although the mode of inheritance remains to be clarified. Polygraphic recordings including capnography should be performed in siblings of CCHS patients early in life in order to avoid secondary complications. Noninvasive treatment by ventilation via special face masks is feasible.

Procel burn cover used as a total body dressing in burns.

A 26-month-old boy sustained a scald injury covering 83 per cent of his total body surface area (TBSA). He also developed sepsis and multiorgan failure (MOF). Locally he was treated with Procel burn cover and silver sulphadiazine cream (SSD) for 23 days. By using Procel, the dressing-change time was shortened significantly. Procel burn cover controlled core and skin temperature more effectively compared to conventional dressing, and the staff acceptance increased because of its easy and fast use. Based on our observation, this material can be used successfully as a total body dressing with children with extensive partial thickness burns or temporarily in full thickness burns until wound excision can be performed.

[Ultrasound diagnosis of parapharyngeal abscess in infancy]. / Sonographische Diagnose eines Parapharyngealabszesses im Säuglingsalter.

An ultrasound examination in a 18-month old boy with sudden respiratory obstruction revealed a huge parapharyngeal abscess which was confirmed via magnetic resonance tomography and on operation. Even in young infants high resolution sonography can nicely visualize neck pathology and should therefore be integrated in the diagnostic workup of undefined symptoms of upper respiratory tract obstruction.

[Ceftriaxone-induced cholelithiasis--a harmless side-effect?]. / Ceftriaxon-induzierte Cholelithiasis--eine harmlose Nebenwirkung?

43 children suffering from borreliosis, meningitis and septicemia were treated with ceftriaxone. A six year old boy with acute jaundice due to ceftriaxone induced cholelithiasis encouraged us to reevaluate the frequency of ceftriaxone induced cholelithiasis and its' sequelae in children in a prospective study. Out of 43 children (age 6.3 years, 4 months to 16 years, male: female 25:18), 20 children (46.5%) showed sonographical evidence for ceftriaxone induced cholelithiasis after a treatment of at least 10 days. Two of them even had signs of intrahepatic cholestasis, 3 kids suffered from severe abdominal pain, non of them showed serologic abnormalities. Another 5 children (11.6%) had sludge in the gallbladder without evidence for cholelithiasis. In all patients the "pseudocholelithiasis" spontaneously resolved within at most 2 months. We suggest a sonographical examination of the gallbladder at the end of the ceftriaxone treatment in order to detect cholelithiasis, which might call for further monitoring and maybe dietary treatment.

Prospective evaluation of clinical scoring systems in infants and children with cardiopulmonary insufficiency after cardiac surgery.

OBJECTIVE: To document severity of illness and to evaluate the predictive value of clinical scoring systems in infants and children with cardiopulmonary insufficiency after cardiac surgery. DESIGN: Prospective study with follow up to hospital discharge. SETTING: A multidisciplinary pediatric ICU in a University Hospital. PATIENTS: Between 1/1989 and 4/1992 441 infants and children with congenital heart disease underwent open heart surgery. 128 of these patients developed postoperative cardiopulmonary insufficiency and were entered into this study. METHODS: Data relevant to the Acute Physiologic Score for Children (APSC), Pediatric Risk of Mortality (PRISM), Therapeutic Intervention Scoring System (TISS) and Organ System Failure (OSF) score were collected in all patients during the first 4 days of postoperative intensive care. RESULTS: The mean age of the patients was 1.5 +/- 0.2 years. The mean duration of mechanical ventilation and ICU care was 6.2 +/- 0.6 and 8.1 +/- 0.7 days, respectively. On the first postoperative day the mean APSC and PRISM scores of survivors and nonsurvivors were 13.9 +/- 1.3 vs 24.5 +/- 1.3 (p < 0.001) and 6.1 +/- 0.5 vs 19.6 +/- 1.9 (p < 0.001), respectively. The mean TISS and OSF scores of survivors and nonsurvivors were 46 +/- 0.8 vs 57.8 +/- 1.4 (p < 0.001), and 2.2 +/- 0.2 vs 3.4 +/- 0.2 (p < 0.001), respectively. The overall hospital mortality rate was 9.9%, the hospital mortality rate of patients with postoperative cardiopulmonary insufficiency 34%. Patients with an APSC score < 10 and a PRISM score < 5 had a survival rate of 100%, whereas patients with an APSC score > 30 and a PRISM score > 25 had a mortality rate of 100%. The area under the receiver operating characteristic (ROC) curve for APSC, PRISM and TISS was 0.847, 0.826 and 0.793, respectively. CONCLUSION: APSC, PRISM and TISS describe accurately severity of illness in infants and children with cardiopulmonary insufficiency after cardiac surgery and all scores identify those patients at increased risk for mortality.

Late-onset miliary pneumonitis after near drowning.

We report a 7-year-old pediatric patient with an apparently self-limiting, subacute miliary pneumonitis that occurred 6 weeks after a near-drowning accident in shallow, muddy water. After biopsy, histological examination revealed aspirated foreign bodies (algae and pollen grains) in the affected lung areas and a foreign body reaction in the form of a granulomatous inflammation. The lack of any detectable infectious agents suggested a causative role of these aspirated algae and pollen grains in the development of lung disease.

Tick-borne encephalitis in a 3-month-old child.

Tick-borne encephalitis has not been reported in infants younger than 12 months of age. We report a 3.5-month-old child with a serologically proven tick-borne encephalitis. The infant had a history of a tick bite 3.5 weeks before the first symptoms of encephalitis appeared. The family lives in an endemic area of the disease. There were no prodromal signs and the course of the disease was monophasic. In an endemic area, prophylactic treatment with hyperimmunoglobulin after a tick bite should be considered even in very young infants, but in most children active immunization is probably not necessary because of infrequent exposure. Active immunization is still recommended after the 1st year of life.

[Epigastric colic after ceftriaxone therapy]. / Oberbauchkolik nach Ceftriaxon-Therapie.

The following article describes a girl with right upper quadrant abdominal colic following Ceftriaxon therapy for purulent meningitis. Ultrasound made it possible to demonstrate sludge-balls, floating in the gallbladder, a follow up examination was normal. Moreover the features of gallbladder precipitations following Ceftriaxon therapy will be described, and the clinical consequences will be discussed.

Reduction of colonization and infection rate during pediatric intensive care by selective decontamination of the digestive tract.

OBJECTIVE: To compare the effects of two different antibiotic regimes on the colonization and infection rates of critically ill pediatric patients. DESIGN: A prospective randomized trial. SETTING: A pediatric ICU in a university hospital. PATIENTS: Fifty critically ill pediatric patients who required intensive care for at least 4 days were randomly allocated to either the selective parenteral and enteral antisepsis regimen (treatment group, n = 25) or the control group (n = 25). INTERVENTIONS: The treatment group received oral nonabsorbable antimicrobial agents (polymyxin E, gentamicin, and amphotericin B) and parenteral cefotaxime, whereas the control group received either perioperative antibiotic prophylaxis or antibiotic therapy according to clinical or microbiological evidence of infection. RESULTS: Both groups were comparable for age, body weight, sex, and severity of illness. Colonization with Gram-negative microorganisms and yeasts in the oropharynx, and digestive and respiratory tracts increased rapidly up to 52% in the control group, whereas there was no colonization with these microorganisms in the treatment group. The occurrence rates of acquired secondary infections in the control and treatment groups were 36% and 8%, respectively (p less than .025). There were no differences between groups in the duration of intensive care or mortality rate. CONCLUSION: Selective oropharyngeal and gastrointestinal decontamination combined with systemic cefotaxime application allows for a significant reduction of the colonization rate with Gram-negative bacteria and yeasts in critically ill pediatric patients undergoing prolonged intensive care. In addition, it significantly reduces the Gram-negative infection rate of the respiratory system. However, this therapeutic approach does not alter ICU length of stay or mortality rate.

[Ultrasonography findings in a case with infantile herpes encephalitis]. / Sonographische Befunde bei einem Fall mit Säuglingsherpesenzephalitis.

We present the case of an eleven months old infant, who suffered from herpes simplex type I encephalitis. Cerebral ultrasound examination showed on 5th day of disease signs of focal echodensity. At that time CT showed a focal meningeal enhancement and CSF findings were normal. Suspicions changes were also obtained by MR-Imaging and EEG on the same day. Herpes simplex virus was identified in the CSF with Polymerase chain reaction days later. There are no typical clinical signs for herpes encephalitis, CT, NMR, EEG findings as well as antigen and antibody-tests do naturally take their time. Cerebral sonography in infants offers to be the best bed-side method for early suspicion of herpes encephalitis, which may support diagnostic workup and can help to start a specific therapy (Acyclovir) as soon as possible.

[A clinical score system for children with ARDS]. / Klinische Score Systeme bei Kindern mit ARDS.

In a retrospective study we developed a simple acute respiratory distress syndrome (ARDS) scoring system in order to analyze the severity of ARDS as precisely as possible. From March 1983 to May 1990, 17 children with ARDS were admitted and treated at the pediatric intensive care unit of the University Hospital of Graz. The ARDS score was evaluated as a predictor of outcome. The score is based on four variables: mean airway pressure, oxygenation index, additional number of organ system failure and a radiological score, each of which was assigned a score between 0 and 3 (Table 3). The score was recorded on admission or immediately after respiratory failure and after 24, 48 and 72 h. The patients were divided into survivors and non-survivors. After 24 h of mechanical ventilation the ARDS score was 7.16 +/- 0.79 in survivors and 10.4 +/- 0.4 points in non-survivors (P less than 0.0006). Similar differences were found after 48 and 72 h of therapy. In addition, the predictive power of the ARDS score after 24 h was tested at a level of 8 points. The sensitivity and the positive predictive value were 90%, while specificity and negative predictive value were 85.7%. The correct prediction was 88.2%. We conclude that this simple ARDS score can be an useful prognostic factor in patients with ARDS.

Haemophilus influenzae epiglottitis occurring simultaneously in two siblings.

Intrafamilial spread of Haemophilus influenzae type B disease has often been described for meningitis, but rarely for epiglottitis. Here we report for the first time epiglottitis occurring simultaneously in two siblings and comment on the value of chemoprophylaxis and vaccination to prevent secondary and primary disease.