Culture-positive invasive aspergillosis in a medical center in Taiwan, 2000-2009.

We reviewed 776 patients who were culture positive for Aspergillus species at the hospital from 2000 to 2009. The isolates were collected for species identification by oligonucleotide hybridization and sequence analysis. A total of 96 cases of proven or probable IA were identified according to published criteria. The incidence of IA has increased significantly during the study period. Aspergillus fumigatus and A. flavus (41.7% each) were equally prevalent causative species. IA due to unusual species including A. nidulans (n=2), A. versicolor (n=2), and A. tubingensis (n=1) were also found. Among patients with IA, 55.2% had hematological disorder, 19.8% had underlying lung disorder, and 10.4% had autoimmune disease. The isolates species (P<0.001) and underlying disease (P<0.001) significantly affect the association of a positive culture with invasive disease. The overall mortality at three months was 62.5%, which remained stable throughout the study period. Multivariate analysis identified prior steroid use (P=0.007) as a significant risk factor for death, while surgery (P=0.030) and voriconazole (P=0.012) had protective effects. In conclusion, autoimmune disorders and underlying pulmonary diseases should also be considered as important predisposing factors of IA. Further emphasis on surgery and voriconazole in the management of IA might be beneficial.

Healthcare-associated bacteraemia caused by Leuconostoc species at a university hospital in Taiwan between 1995 and 2008.

We studied twenty patients with Leuconostoc spp. bacteraemia at a tertiary hospital in northern Taiwan between 1995 and 2008. All isolates were identified to species level using conventional and commercial automated methods in conjunction with 16S rRNA sequencing analysis. Leuconostoc lactis (15/20, 75%) constituted the most common species but required molecular methods for accurate identification. Minimum inhibitory concentrations (MICs) of 10 antimicrobial agents were determined using the broth microdilution method. Among these 20 patients, 19 had healthcare-associated Leuconostoc spp. bacteraemia and 11 patients (55%) had underlying malignancies. Eleven had been hospitalised for more than 30 days (median: 32.5 days; range: 0-252 days) before the bacteraemic episode. At the time of bacteraemia, 11 had a Pitt bacteraemia score of ≥ 4 (median: 4; range: 0-7) and 12 had a modified Acute Physiological Assessment and Chronic Health Evaluation (APACHE II) score of ≥ 20 (median: 22; range: 5-37). Azithromycin (MIC: 0.12 µg/mL), moxifloxacin (MIC: 0.25-0.5 µg/mL), daptomycin (MIC: 0.03-0.25 µg/mL) and tigecycline (MIC: 0.06-0.12 µg/mL) exhibited good in vitro activity against Leuconostoc spp. although bacteraemia due to L. lactis was associated with high mortality in immunocompromised patients.

Correlation between antimicrobial consumption and resistance among Staphylococcus aureus and enterococci causing healthcare-associated infections at a university hospital in Taiwan from 2000 to 2009.

This study investigated the correlation between antibiotic consumption and resistance among Staphylococcus aureus and enterococci causing healthcare-associated infections at a university hospital in Taiwan from 2000 to 2009. Overall, the trend of total consumption (defined daily dose [DDD] per 1,000 patient-days) of glycopeptides, including vancomycin and teicoplanin, significantly increased during 2000 to 2003 and remained stable during 2004-2009. Vancomycin consumption significantly increased during 2003 and decreased after 2004. A significant decrease in the resistance rate with time was found for oxacillin- and gentamicin-resistant S. aureus. In contrast, the rates of vancomycin- and teicoplanin-resistant enterocci increased significantly. A significant correlation was found between the increased use of extended-spectrum cephalosporins, ß-lactam-ß-lactamase inhibitor combinations, carbapenems and the decreased prevalence of methicillin-resistant S. aureus (MRSA). In contrast, the increased use of teicoplanin, extended-spectrum cephalosporins, ß-lactam-ß-lactamase inhibitor combinations, and carbapenems was correlated with the increased prevalence of vancomycin-resistant enterococci (VRE). In conclusion, this 10-year study in a single institution identified different correlations between the prescription of antibiotics and the resistance rates of MRSA and VRE. Strict implementation of infection control policy based on these correlates would be helpful in decreasing the presence of these multidrug-resistant pathogens in hospitals.

Bacteraemia caused by Weissella confusa at a university hospital in Taiwan, 1997-2007.

Human infections caused by Weissella confusa are rarely reported. Ten patients with bacteraemia caused by W. confusa who were treated at a tertiary-care hospital in Taiwan during 1997-2007 were studied. All isolates were initially misidentified as various Lactobacillus and Leuconostoc species by two commercial automated identification methods, and were confirmed to be W. confusa by 16S rRNA sequencing analysis. MICs of these isolates for ten antimicrobial agents were determined by the agar dilution method. The characteristics of these patients included underlying malignancy (n = 4), presence of a central catheter (n = 6), surgery within the previous 3 months (n = 4) and concomitant polymicrobial bacteraemia (n = 5, 50%). Mortality was directly attributed to bacteraemia in two patients. All isolates exhibited high trimethoprim-sulphamethoxazole and ceftazidime MICs (≥ 128 mg/L) and were inhibited by linezolid, daptomycin, ceftobiprole and tigecycline at 4, 0.12, 2 and 0.12 mg/L, respectively. In conclusion, W. confusa should be included in the list of organisms causing bacteraemia in immunocompromised hosts. Novel antibiotics, including daptomycin, moxifloxacin, doripenem and tigecycline, exert good activity against W. confusa.

In vitro activity of nemonoxacin, tigecycline, and other antimicrobial agents against Helicobacter pylori isolates in Taiwan, 1998-2007.

The minimum inhibitory concentrations (MICs) of 330 nonduplicate Helicobacter pylori isolates to nemonoxacin, tigecycline, and eight other antimicrobial agents were determined by using the agar dilution method. Sequencing the quinolone resistance-determining regions (QRDRs) in the gyrA gene of these isolates was also performed. Resistance to clarithromycin showed an increasing trend during the ten-year study period and was highest (38%) in 2005. Tigecycline had potent in vitro activities against all isolates, with an MIC(90) of 0.06 µg/ml. Among the quinolones tested, nemonoxacin (MIC(50) of 0.12 µg/ml and MIC(90) of 0.25 µg/ml) and gemifloxacin had one to two-fold better in vitro activities than ciprofloxacin, levofloxacin, and moxifloxacin. Among the nine isolates (2.7%) with levofloxacin resistance, four (44.4%) were also resistant to metronidazole, three (33.3%) to clarithromycin, and two (22.2%) to amoxicillin. Isolates with levofloxacin resistance exhibited one or two of three amino acid alterations (Ser-70, Asn-87, and Asp-91) involved in QRDRs in the gyrA gene. A double mutation at Ser70Cys and Asn87Ile had a higher level of resistance. The results of this study suggest a potentially useful role of nemonoxacin and tigecycline in the treatment of infections caused by H. pylori. The gyrA mutation at Ser-70 is a novel finding and has an impact on levofloxacin resistance.

Mass psychogenic illness in nationwide in-school vaccination for pandemic influenza A(H1N1) 2009, Taiwan, November 2009-January 2010.

From 16 November 2009 to 22 January 2010, Taiwan investigated 23 clusters of mass psychogenic illness after vaccination (MPIV) in the nationwide in-school vaccination programme against the 2009 pandemic influenza A(H1N1). The median age of the 350 ill students (68% female) was 13 years. Intense media coverage of these events has driven public concerns about the safety of the pandemic influenza vaccine. In the future, countries should incorporate surveillance and communication strategies for MPIV in their pandemic preparedness plans.

Accuracy of the funnel technique of thoracic pedicle screws insertion in scoliosis surgery--an evaluation by CT-scans.

Pedicle screw system has increasingly been used for correction of thoracic scoliosis. It offers several biomechanical advantages over hook system as it controls all three-column of the spine with enhanced stability. Of many techniques of pedicle screw placement in the thoracic spine, the funnel technique has been used in Sarawak General Hospital since 2002. This prospective study aims to assess the accuracy of the placement of thoracic pedicle screws using the funnel technique in the corrective surgery of idiopathic scoliosis. A total of 88 thoracic pedicle screws were inserted into the T4 to T12 vertebrae of 11 patients. Post-operative CT-scan was performed to evaluate the position of the pedicle screw. Seventy six (86.4%) screws were noted to be totally within the pedicle. There was no screw with medial violation of the pedicle, 8 (9.1%) screws breeching the lateral wall of the pedicle and 4 (4.5%) screws with anterior and lateral penetration of the vertebral body. No clinical sequel with the mal-positioned screws was noted. In conclusion, the funnel technique enabled simple, accurate and reliable insertion of pedicle screw even in the scoliotic thoracic spine without the need of any imaging guidance. It is however imperative for the surgeon to have a thorough knowledge of the thoracic spine anatomy, and to be familiar with the technique to insert these screws diligently.

Clinical features of atypical Kawasaki disease.

From 1989 through 1998, a total of 132 children admitted to the National Taiwan University Hospital were identified as having Kawasaki disease. Twenty (15%) of them did not meet the diagnostic criteria of Kawasaki disease, but were considered atypical Kawasaki based on the specific clinical signs and exclusion of other causes by serologic study and culture result. The patients' age ranged from 5 months to 11 years, with a mean of 22.2 months and a median of 15 months. The male to female ratio was 1.9:1. Twenty-five percent (5/20) of them had coronary arterial lesion. No difference was found in the age distribution, sex, and rate of coronary artery involvement between typical and atypical Kawasaki disease. All patients were treated with intravenous immunoglobulin and aspirin except for 2 patients. At follow-up, patients with coronary arterial lesions had a prognosis as good as those with typical Kawasaki disease. According to these observations, atypical Kawasaki disease may be part of Kawasaki disease occurring via the same pathogenesis, but has incomplete manifestation. Clinical practitioners should have a high index of suspicion to diagnose and initiate prompt treatment to reduce the comorbidity of coronary arterial disease in patients with atypical Kawasaki disease.

Haemophilus influenzae type b meningitis with subdural effusion: a case report.

Haemophilus influenzae type b causes invasive infection in children under 2 years of age. The disease may be complicated with hearing impairment, lowered learning ability, and other neurologic sequelae. The incidence of invasive H. influenzae type b has declined dramatically after the introduction of routine administration of protein-conjugated H. influenzae type b vaccine in the United States and some other countries. Because of its low incidence in Taiwan, many clinicians are not familiar with the initial symptoms and management of H. influenzae type b. This case report describes a 7-month-old H. influenzae type b meningitis patient who had initial presentations of prolonged intermittent fever and vague neurologic signs. Left peripheral facial palsy with hearing loss in left ear and bilateral frontal subdural effusion developed during the first 5 days of cefotaxime therapy. Betamethasone was then given for 4 days to relieve the severe inflammation. Drug-induced fever was observed after 11 days of antibiotic use and subsided with prednisolone treatment. Left ear hearing impairment persisted during the follow-up period, but the children did not experience other significant development delay.

Immunogenicity and fecal poliovirus excretion in sequential use of inactivated and oral poliovirus vaccines.

BACKGROUND AND PURPOSE: Though inoculation with inactivated poliovirus vaccine (IPV) is advocated, sequential use of IPV and live oral poliovirus vaccines (OPV) has many advantages. This study aimed to define the immunogenicities of IPV and OPV in Taiwanese children after the use of a sequential schedule of IPV-OPV and also to determine whether prior IPV inoculation hampers the fecal passage of OPV. METHODS: Fifty-nine infants were recruited to receive IPV-OPV sequential vaccinations consisting of IPV given at the ages of 2 and 4 months and OPV given at the ages of 6 and 18 months. Blood samples were taken at ages 2, 6, 18, and 19 months for antibody determination, and stool samples were collected to isolate vaccine strains of poliovirus after the second dose of OPV, at the age of 18 months. RESULTS: None of the children had severe systemic or local reactions. Protective antibodies were detected in all infants at the age of 6 months, 2 months after the second IPV dose. The antibody titers were augmented at the age of 19 months, 1 month after the booster dose of OPV. Stool samples collected 7 days after the second dose of OPV yielded at least one type of poliovirus in 9 of 18 children. Analysis of stool samples revealed that poliovirus was excreted by the 28th day in only two of the children. CONCLUSIONS: Our study showed that both IPV and OPV exhibit immunogenicity in Taiwanese children. Side effects of an IPV-OPV sequential schedule were mild and infrequent. Viral shedding in stools after OPV vaccination was preserved in a substantial proportion of subjects. These findings suggest that this sequential vaccination schedule can maintain herd immunity.

Bacterial cholangitis in patients with biliary atresia: impact on short-term outcome.

Bacterial cholangitis (BC) is a common complication in patients with biliary atresia (BA) and is characterized by fever, acholic stools and positive blood cultures. The diagnosis is often empirical because the yield of blood cultures is low. It is difficult to differentiate BC from other febrile episodes. In order to characterize the clinical and laboratory features of BC in patients with BA, identify risk factors, and correlate cholangitis with outcome, 37 patients with BA from 1993 to 1998 who underwent a Kasai operation in our hospital were studied. The follow-up period ranged from 6 to 59 months. A total of 107 febrile episodes were documented in these patients. The diagnostic criteria for cholangitis were fever, increased jaundice, or acholic stools. The clinical features, laboratory data, results of bacterial cultures, and outcomes were analyzed retrospectively. A total of 107 febrile episodes, including 78 bouts of cholangitis and 29 non-cholangitis infections, were found in 34 patients. Patients with BC had higher postoperative bilirubin levels (P = 0.02) and less frequent use of prophylactic antibiotics (P = 0.05) than those with non-cholangitis infections. Abnormal white blood cell counts (> 12,000 or <4,000 mm3) tended to be present in patients with BC (P = 0.08). There were no statistical differences in the risk factors and laboratory data between culture-positive (n = 16) and -negative (n = 62) cholangitis cases. The occurrence of cholangitis significantly reduced survival in both patients with good (P = 0.03) and inadequate bile flow (P = 0.03). All 9 patients who had never had cholangitis survived during the follow-up period. Repeated attacks of BC further decreased survival probability. The responsive organisms were mainly enteric bacteria, including Escherichia coli, Enterobacter cloacae, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumanni, and Salmonella typhi. The sensitivity tests justified empirical therapy with ceftriaxone. The effectiveness of prophylactic trimethoprim-sulfamethoxazole or neomycin warrants further studies. BC was a highly prevalent postoperative complication in patients with BA, especially those with inadequate bile drainage. It significantly affected early mortality. Aggressive and complete treatment with empirical ceftriaxone was appropriate.

Design and power of a population pharmacokinetic study.

PURPOSE: This paper investigated the influence of critical design factors on the power of a population pharmacokinetic (PK) study for identifying subpopulations that have different drug clearance than the typical population. METHODS: A study simulation approach was used for the power estimation. The design factors included the number of subjects, sampling scheme, and compliance. RESULTS: The false positive rates of incorrectly identifying a subpopulation were estimated for several scenarios. The false positive rates of the population PK study was relatively low, except when the numbers of subjects with full profiles and the subjects with troughs were distributed between populations in an unbalanced manner. The total number of subjects did not seem to have as much influence on study power as the number of subjects in the subpopulation, as long as the total number of subjects was significantly larger than the subpopulation. The variability of sampling time played an important role in both the statistical power and the accuracy of the estimated difference in clearance. Taking three samples provided greater power and better accuracy than taking two samples per subject. Taking only trough samples provided little power and poor estimation of clearance difference. Adding subjects with full profiles to a study with only trough samples taken in other subjects did not satisfactorily improve the clearance estimation. It was critical to account for dosing record in the population PK analysis to achieve appropriate power and accuracy. If the variability in dosing time was accounted for in the analysis, it improved the accuracy of the estimated difference in clearance. Missing dose administrations reduced the study power and resulted in deviation of estimated clearance difference. CONCLUSIONS: The power of a study should be determined prospectively to ensure appropriate study design for specific study objectives.

Empirical monotherapy with meropenem in serious bacterial infections in children.

The efficacy and safety profile of meropenem were analyzed according to data collected from hospitalized pediatric patients aged 4 days to 20 years who had serious bacterial infections and were treated in a major teaching hospital in Taipei. Of the 53 patients enrolled, 47 were analyzed for clinical efficacy and 53 for safety. The satisfactory clinical response rate was 57% in lower respiratory tract infection, 58% in septicemia, 100% in complicated urinary tract infection, osteomyelitis, and central nervous system infection, 83% in skin and soft tissue infection, and 93% in intra-abdominal infection. Eleven (21%) patients experienced adverse events related to meropenem. The most commonly observed adverse reactions were elevated hepatic enzymes (7.5%), increased alkaline phosphatase (3.8%), and thrombocytosis (3.8%). There was no meropenem-related seizure, withdrawal, or death. The results of this study suggested that meropenem is well tolerated even in young infants, and is effective in treating serious childhood bacterial infection. However, this study also identified a proportion of hospitalized pediatric patients with isolates that were resistant to meropenem. The trends in meropenem resistance among nosocomially acquired bacteria should be monitored closely.

Immunogenicity and reactogenicity of the combined hepatitis A and B vaccine in young adults.

The combination of hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccinations can offer convenience, increased compliance and cost saving. We have studied the immunogenicity, reactogenicity and safety of combined hepatitis A and B vaccination in young adults (16-35 years old). Eighty healthy young adults were divided into two random groups. One group received the combined hepatitis A and B vaccine (HAB) in one arm while the other group was administered concomitant hepatitis A and B vaccines (HAV + HBV) in the right and left arms, respectively. The immunogenicity, reactogenicity and safety were assessed after each dose in both the groups. In local symptoms, the percentage of the combined HAB group was lower than the HAV + HBV group, and the general symptoms were noted in approximately 30% of each group without any significant difference. No serious adverse effects were noted. All the subjects were seropositive for antibody to hepatitis A virus (anti-HAV) after one dose of vaccine, and remained seropositive after three doses in both groups. The seropositive rate for antibody to hepatitis B surface antigen (anti-HBs) was significantly higher (84%) in the combined HAB group than the concomitant HAV + HBV group (62%), (p<0.05) after dose two, and all the subjects were seropositive (100%) after the third dose. The GMTs of anti-HAV and anti-HBs were not significantly different between groups 1 and 2 (p>0.1) except in month 6 when the GMT of anti-HBs was higher in HAB group (p=0.0039). The combined HAB vaccine was found to be safe, well tolerated and had less local symptoms in young adults. The immunogenicity and reactogenicity were similar to the concomitant HAV + HBV vaccines.

Rotavirus gastroenteritis in children: 5-year experience in a medical center.

Rotavirus infection is the leading cause of childhood gastroenteritis. We retrospectively reviewed cases of rotavirus gastroenteritis at National Taiwan University Hospital from January 1993 to December 1997. During the study period there were 429 patients with rotavirus infection with ages ranging from 1 day to 16 years with a median of 13 months. The male-to-female ratio was 1.2:1. Infection occurred before the age of 2 years old in 76% of patients. The seasonal peak occurred in the late winter and early spring during 1993 to 1996, but the case number increased in late spring and summer in 1997. The G serotype of the rotavirus was identified in 302 patients (70%). Vomiting and dehydration developed more frequently following infection with G1 rotaviruses, while an increased frequency of seizures was noted following G2 infection; the differences were not statistically significant. One patient had two episodes of infection; the first one was caused by G1 rotavirus, and the strain causing the second infection could not be typed. In conclusion, the results suggest that there is a strong seasonal variation in the incidence and characteristics of rotavirus infection in Taipei area. The infections caused by G1 and G2 rotaviruses were clinically indistinguishable.

Enteric adenovirus infection in children in Taipei.

Enteric adenoviruses (EAds), including type 40 (Ad40) and 41 (Ad41), can cause acute and severe diarrhea in young children. To delineate the epidemiological features of pediatric EAds infection in Taiwan, we conducted a retrospective study of all cases of EAds gastroenteritis in children treated at National Taiwan University Hospital for the period from July 1993 to December 1997. Stool samples were tested for the presence of Ad40 or Ad41 by enzyme immunoassay (EIA). A total of 64 cases of EAds infection in 63 children aged from 8 days to 81 months old with a median age of 9.5 months treated during the study period were identified. The male-to-female ratio was 1.63 (39/24). No obvious seasonal clustering of EAds cases was noted. Most patients (76.6%) were infected before the age of 2 years. Clinical features included diarrhea (96.9%), fever (54.7%), vomiting (45.3%), mild dehydration (43.8%), symptoms of upper respiratory tract infection (21.9%), and abdominal pain (12.5%). Analysis of fecal samples in patients with diarrhea showed watery diarrhea in 72.2%, diarrhea with mucus in 20%, diarrhea with blood in 3.1% and diarrhea with mucus and blood in 1.6 % of all patients. Nearly one-half (43.5%) of the patients had diarrhea for more than 7 days. Thirty-seven patients (57.8%) were hospitalized due to gastroenteritis or other unrelated diseases, and 11 patients (17.2%) acquired enteric adenovirus infection during hospitalization for other underlying disease. Twelve patients (18.8%) had mixed infections, which included rotavirus, respiratory syncytial virus (RSV) and Salmonella species. There were no deaths in this series. The findings of this study suggest that EAds are important etiologic microbes of pediatric gastroenteritis.

Immunogenicity and safety of an inactivated hepatitis A vaccine in Taiwanese adults and children.

The safety and immunogenicity of an inactivated hepatitis A vaccine (AVAXIM, 160 antigen units) was evaluated in 190 subjects: 50 children aged from 2 to 5 years, 70 children aged from 6 to 17 years and 70 adults aged from 18 to 30 years in a monocentric, open, non-controlled, phase III trial conducted in Taipei, Taiwan from December 1996 to October 1997. The vaccine was administered intramuscularly, with a two-dose schedule 6 months apart. Clinical adverse events were monitored during the seven days following each injection. Hepatitis A virus (HAV) antibody titers were measured by modified radioimmunoassay on the day of inclusion and four weeks after both the first dose and booster injection. Among the 190 subjects who received the first dose, 174 (91.6%) were initially HAV seronegative and 16 (8.4%) were HAV seropositive at inclusion. One hundred and seventy-four subjects (91.6%) received the booster dose and completed the study. One month after the first dose, all the subjects, whatever the age, presented HAV antibody titers over 20 mIU/ml. In children (2 to 17 years), the GMT was 136 mIU/ml at week 4 and 7,906 mIU/ml four weeks after the booster dose. In adults (> or = 18 years), GMT values were 93 mIU/ml at week 4 and 3,655 mIU/ml four weeks after the booster. These results show a strong anamnestic response to the second dose of vaccine and are compatible with long-term antibody persistence in each age group. The vaccine was safe and well tolerated. No vaccine-related serious adverse event occurred. No immediate reaction occurred. The majority of the reactions were reported by adults after the primary injection. Local reactions (pain and redness) were reported by 9.0% and 4.0% of the subjects after the primary and the booster doses, respectively. Systemic reactions (mainly myalgia/arthralgia or asthenia) affected less than 10% of the subjects after the first dose and less than 3% after the booster. Results from this study in a Taiwanese population are consistent with those obtained with the same vaccine in previous European studies in children and adults, and suggest that AVAXIM (160 AU) is suitable for use in all subjects aged over 2 years.

Pertussis seroepidemiology in Taipei.

PURPOSE: We evaluated the seroprevalence of pertussis among apparently healthy Taipei residents. METHODS: From January 1992 through December 1994, we recruited subjects from a well baby clinic (children < 3 years), kindergartens, primary, and secondary schools and colleges (3-20 years), a health exam clinic (> 20 years), and obstetric clinics (pregnant women). Subjects were stratified into 12 groups according to age and pregnant women were considered separately. The serum antibody titers against filamentous hemagglutinin (FHA) and pertussis toxin (PT) were measured by enzyme-linked immunosorbent assay. RESULTS: The anti-PT and anti-FHA titers were elevated in the 4 to 6-month and 19 to 20-month age groups, coinciding with regular pertussis vaccinations. The anti-PT titers rose again in the 3 to 4-year age group, reflecting a higher prevalence of natural pertussis infection. The anti-PT titers gradually decreased among older age groups, although a peak occurred in the 11 to 15-year age group. The sequential changes in anti-FHA titers followed those of anti-Pt titers in the younger age groups, but the anti-FHA titers were persistently elevated beyond 15 years of age. The antibody levels were similar in the two sexes, except that anti-PT titers were higher in males of 19 to 20 months and 21 to 30 years of age. Anti-PT titers were equivalent between neonates (0-2 months) and pregnant women, but anti-FHA titers were much lower in neonates. CONCLUSIONS: The seroprevalence patterns in this study indicate that young children, adolescents, and even adults remain at risk of pertussis, despite the current immunization program. Booster vaccinations after completion of the current four-dose immunization schedule, possibly continuing into adolescence, should be considered to block the transmission of infection.

Fibrinofibrous pericarditis mimicking a pericardial tumor.

Primary pericardial disease is rare in children. The clinical features usually reflect limited venous return and cardiac output. Tuberculous pericarditis is the leading cause of pericardial disease in developing nations. A definitive diagnosis in children is frequently difficult and the manifestations are protean. We report a 10-month-old girl with fibrinofibrous pericarditis that manifested as constrictive pericarditis with prolonged fever, hepatomegaly, edema, and poor appetite. Echocardiography showed a solid mass that originated from the thickened pericardium and compressed the whole heart. In contrast, computed tomography revealed pericardial thickening with fluid collection. The symptoms and signs dramatically improved after surgical pericardiectomy. Pathologic analysis confirmed the diagnosis of tuberculous fibrinofibrous pericarditis. The patient received a 1-year course of antituberculosis therapy and has remained symptom free for 2 years. We suggest that a discrepancy between echocardiography and computed tomography (CT) findings might indicate a diagnosis of fibrinofibrous pericarditis.

Bacteremic pneumonia caused by a single clone of Streptococcus pneumoniae with different optochin susceptibilities.

Two isolates of Streptococcus pneumoniae having different optochin susceptibilities were recovered from a blood sample of a 2-year-old boy with community-acquired pneumonia. The two isolates were documented to belong to a single clone on the basis of the isolates' identical serotype (23F), antibiograms by the E-test, random amplified polymorphic DNA patterns generated by arbitrarily primed PCR, pulsed-field gel electrophoresis, and restriction fragment length polymorphism of the penicillin-binding protein genes pbp2b and pbp2x.