Sudden death due to disseminated cryptococcosis in a child with leukemia in remission.

Cryptococcus neoformans typically causes an insidious illness with symptoms related to meningitis or to lung involvement. This is the first reported sudden death due to cryptococcosis, which occurred in a child with leukemia that was in remission. The child had suddenly looked seriously ill and cried with abdominal pain and then died within 25 minutes. Disseminated cryptococcal infection of the lungs, heart, and pancreas was an unexpected finding at autopsy. This clinical experience raises the question whether fungal infections should now be considered in immunosuppressed patients who have an apparent septic collapse.

Fatal hemolysis caused by ceftriaxone.

After receiving ceftriaxone intravenously, a boy with leukemia died suddenly of massive hemolysis. The diagnosis was made retrospectively only after a similar case of sudden fatal immune hemolysis after intravenous administration of ceftriaxone was reported.

Pediatric resident objectives for hematology/oncology.

Pediatric residents are exposed to a massive amount of scientific information and data from each pediatric subspecialty discipline. The residents may or may not know what is important and what is relevant from a general pediatrician's point of view. Educational objectives have been written by three pediatric hematologists/oncologists to guide the resident specifically as to the minimal expectations of knowledge and performance in this discipline. Other pediatric residency programs may wish to use the objectives as a starting point or an outline for their own objectives.

Carotenemia. A review.

Awareness of carotenemia is important to avoid confusion with jaundice and unnecessary diagnostic studies. It is surprising how little information can be found about this relatively common condition in the standard pediatric textbooks. Ingestion of excessive amounts of carrots is the usual cause of carotenemia, but it can also be associated with ingestion of many other yellow vegetables, as well as some green vegetables. Mothers may unknowingly be giving their infants large amounts of carrots in the form of commercial infant food combinations. Carotenemia is a benign condition; vitamin A poisoning does not occur despite massive doses of carotene because the conversion of carotene to vitamin A is slow. Hypothyroidism, diabetes mellitus, hepatic and renal diseases may be associated with carotenemia, but are not caused by ingestion of carotene. The absence of yellow pigment in the sclera and oral cavities distinguishes carotenemia from jaundice. A similar disorder, lycopenemia, is associated with an orange-yellow skin pigmentation as a result of ingestion of large amounts of tomatoes.

The dying child and the family.

The physician involved in the care of a child with a fatal disease has an obligation not only to give the best possible medical care to the child but also to provide emotional support and guidance for the family and the patient. Many emotional problems can be resolved or prevented by discussions with the parents and by encouraging them to express their anxieties and questions. The death of a child is the ultimate tragedy, and everything should be done to prevent further problems which add to the anguish the parents must endure. Support of the parents begins when the diagnosis is first presented, must be continued throughout the child's course, and should often extend beyond the death of the child. Understanding the child's reactions to death is important and helps the physician respond appropriately to the child's questions. Some older children wish to discuss their disease with the physician and in such cases their questions should be answered honestly, while at the same time offering hope.

Methotrexate-induced sudden fatal pulmonary reaction.

A teenage girl in bone marrow remission with acute lymphocytic leukemia died suddenly from pulmonary edema. She had taken her first oral dose of methotrexate and cyclophosphamide 10 hours previously when she was feeling well and was asymptomatic. One week previously she had received the last of four intrathecal injections of methotrexate. Autopsy showed marked pulmonary edema as well as chronic lung changes, as previously described in patients with methotrexate pneumonitis. There is usually at least a 12-day interval from the onset of administration of methotrexate to the onset of the lung toxicity. The authors suggest the patient was sensitized by the intrathecal methotrexate and then reacted with angioneurotic edema of the lung when given the first oral dose of methotrexate. Careful examination for infectious agents, including electron microscopy, was negative.

Osteogenic sarcoma in a patient with aplastic anemia.

Osteogenic sarcoma developed in a 14-year-old boy 13 years after he had partially recovered from chloramphenicol-induced aplastic anemia. A possible relationship is considered between aplastic anemia, chloramphenicol, testosterone, prednisone, and osteogenic sarcoma. Leukemia has been reported following chloramphenicol-induced aplastic anemia and liver tumors have been associated with testosterone therapy. Certain chemicals have caused osteogenic sarcoma in animals. Thus, we believe there are sufficient a priori reasons to question an etiologic relationship between the cause or treatment of aplastic anemia and osteogenic sarcoma.