Increased number of activated T cells in lymphocyte subsets of maltreated children: data from a pilot study.

OBJECTIVE: Maltreatment in childhood has been related to enduring changes in the immune system of adults, such as increased cell-mediated immune response. PURPOSE: Due to the lack of data in children, this study examined lymphocyte subset numbers and distribution during youth. METHODS: In 27 cases of 42 healthy but maltreated children, fully participating at follow-up 1-3years after the intervention of child protection team, and 19 cases of previously matched controls, analysis of blood samples by fluorescent activated cell sorter was consented. RESULTS: With regard to age references, total lymphocyte counts were aberrant in maltreated children but not in controls. When compared to controls, the percentages and absolute numbers of activated (HLA-DR+) CD4+helper and CD8+cytotoxic T cells were significantly higher in maltreated children. CONCLUSIONS: According to the typical distribution of HLA-DR+cells we assumed an increased stimulated cell-mediated immune function in maltreated children.

Tetramer monitoring to assess risk factors for recurrent cytomegalovirus reactivation and reconstitution of antiviral immunity post allogeneic hematopoietic stem cell transplantation.

BACKGROUND: Reactivation of cytomegalovirus (CMV) is a major cause of morbidity after allogeneic hematopoietic stem cell transplantation (HSCT). In healthy individuals, virus-specific T cells (CMV-CTL) control the reactivation of latent CMV. The monitoring of virus-epitope-binding CD8(+) T cells using major histocompatibility complex-I-peptide complexes (tetramers) has recently been established, allowing assessment of the reconstitution of CMV-CTL post HSCT. PATIENTS AND METHODS: In order to study immune reconstitution and reactivation control through CMV-CTL, we regularly monitored all patients undergoing allogeneic HSCT in our department for 2 years, who matched at least 1 of 6 commercially available tetramers for common human leukocyte antigen (HLA) types. To verify risk factors for CMV reactivations in our cohorts, clinical characteristics of all patients transplanted within the last 10 years were included in statistical analyses determining the relative risk for single and recurrent CMV reactivations. RESULTS: As expected, CMV serostatus, HLA match, and donor source significantly influenced the risk of recurrent CMV reactivation. Applying CMV-CTL tetramer monitoring for 2 years allowed the monitoring of 114 (85%) of 134 patients, by testing a set of tetramers representing 6 epitopes from 3 different CMV proteins. The presence of CMV-CTL before day + 50 and their expansion post reactivation seem to protect against recurrent CMV reactivations. The mean number of CMV-CTL by day +100 was >5-fold higher in the recipient CMV-positive/donor-positive (R +/D +) group (91/µL) compared with the R +/ D- (13/µL) and the R -/D +(2/µL) group. Seventy-nine percent of patients from the R +/D + setting recovered >10 CMV-CTL per µL by day + 100, while almost 50% of the other groups failed to mount a CMV-specific response by that time (R +/D -: 58%; R -/D +: 43%). CONCLUSION: Tetramer monitoring can help to predict (recurrent) CMV reactivation and is a useful approach to monitor individual patients with increased risk for recurrent reactivation post HSCT; thus, it could help to identify patients in need of adoptive transfer of CMV-CTL or to optimize the use of antiviral drugs.

Oral bleeding: Child abuse alert.

Physicians must be aware of histories, behaviours and physical findings of maltreated children. We report two cases of physical child abuse in which the initial symptom was oral bleeding. In both cases, the diagnosis was delayed and was made only after severe injuries were inflicted. Injuries to the oral cavity and oral bleeding of uncertain origin in infants should be considered seriously and should be carefully assessed in relation to adequacy of history to explain the mechanism of injury. When an infant has been injured and no adequate explanation is available to account for the mechanism, inflicted injury must be suspected and evaluated, so that in cases of child maltreatment, diagnosis and protection of the child from further injury can take place as early as possible.

Community-acquired pneumonia in children due to Mycoplasma pneumoniae: diagnostic performance of a seminested 16S rDNA-PCR.

A 16S rDNA-PCR assay for Mycoplasma pneumoniae applied to nasopharyngeal secretion (NPS) or pharyngeal swab (PS) from children with community-acquired pneumonia (CAP) was prospectively compared to serological tests including complement fixation (CF) test, a mu-capture enzyme immuno assay (EIA) for the detection of specific IgM, and an EIA for the detection of specific IgG. During a 24-months-period diagnosis of active M. pneumoniae infection was established in 32 (12.6%) of 253 patients for whom paired sera were available. In the acute phase, the sensitivities of PCR from NPS and PS, CF test, IgM EIA, and IgG EIA were 90.0%, 79.3%, 46.9%, 78.1%, and 59.4%, respectively. The corresponding specificities were 98.1%, 98.6%, 97.6%, 87.1%, and 72.4%, respectively. Thus, the 16S rDNA-PCR assay provides a highly sensitive and accurate tool for the rapid diagnosis of M. pneumoniae infection in children with CAP.

A toddler with burns, stomatitis, and skin graft loss.

The authors report on a healthy 21-month-old toddler with 13% TBSA deep scald burns who was successfully grafted (take 100%). In the immediate postoperative phase, the patient developed classical aphthous stomatitis and subsequent herpes viremia leading to severe viral "graftitis". Although immediately administered intravenous acyclovir therapy appeared to be effective, one third of grafts were lost and had to be replaced. The lesson from this case is 2-fold: Herpes infection may threaten even perfectly engrafted fresh skin transplants, and, freshly grafted or soon to be grafted burn patients should be given intravenous antiviral therapy as soon as a herpes infection is diagnosed.

[Interesting cases in clinical practice concerning Kawasaki syndrome and child abuse]. / Interessante Fälle aus der Praxis zu den Themen Kawasaki-Syndrom und Kindsmisshandlung.

Typical cases and families are reported to inform the reader about two new or newly recognized conditions of infants and young children, Kawasaki syndrome and child abuse. Although such patients have usually to be cared for in hospitals, it is the responsibility of the general practitioner to suspect the diagnosis in a very early phase and to refer the child immediately. Kawasaki syndrome, also called mucocutaneous lymph node syndrome, is an acute disease of infants and young children with yet unknown cause. The main symptoms are high fever, conjunctivitis, red and dry lips, palmar and plantar erythema, skin rashes and cervical lymphadenopathies. The danger of the disease is the occurrence of coronary arteritis, leading to coronary aneurysms and thrombosis. Treatment with high-dose immunoglobulins and acetylsalicylic acid is usually successful. Child abuse may lead to very different pathological manifestations. The incidence of these conditions and their recognition have markedly increased within the last 20 years, partially because of increased awareness by doctors and social workers, partially because of decreasing patience of parents and caretakers towards crying and "difficult' children. The intensity of injuries is escalating in single patients and in families. Every child who raises a suspicion of maltreatment should immediately be referred to a children's hospital, where a local multidisciplinary child protecting group will take care of it and decide on therapeutic, social and/or legal steps to prevent further injuries.

Addison disease 10 years after bone marrow transplantation for Wiskott-Aldrich syndrome.

UNLABELLED: We report a 10-year-old boy with familial Wiskott-Aldrich syndrome (WAS) who underwent successful bone marrow transplantation (BMT) at the age of 9 months. With the exception of auto-immune haemolytic anaemia due to warm antibodies lasting 15 months there had not been any complication after BMT. Ten years later the patient presented with diarrhoea, hyperpigmentation of skin and oral mucosa, fatigue and polyuria. Diagnosis of Addison disease was confirmed by typical electrolyte imbalance and absent cortisol response to adrenocorticotrophic hormone. Adrenal antibodies were positive. On therapy with oral gluco- and mineralocorticoids, the symptoms disappeared and electrolytes normalized. To our knowledge auto-immuno endocrinopathy after BMT for WAS has not yet been reported. CONCLUSION: This is the first report of auto-immune adrenal insufficiency after BMT for WAS. The aetiopathogenesis of this condition remains unknown since auto-immune diseases as toxic side-effects of the ablative treatment before BMT have not yet been reported, and a relapse of WAS and cotransplantation of auto-immune adrenal insufficiency have been ruled out.

[Child abuse--a pediatric emergency?]. / Kindsmisshandlung--ein pädiatrischer Notfall?

Many cases of child abuse mark the culmination of a complex psychosocial process and proceed in a chronic way. An acute intervention in these chronic cases is not only inefficient, but also counterproductive; only a careful evaluation by a multidisciplinary team that pays attention to all circumstances and a stepwise action following a generally agreed plan will meet with success. This type of proceeding applies especially for cases of chronic sexual abuse that originates from close family range. A model of the procedure is presented. Real emergencies in the contest of child abuse have therapeutic and diagnostic character. From a therapeutic point of view a child must be immediately protected from further violence and other deeds threatening his health. This strategy is especially indicated for infants and young children. An immediate intervention is also obligatory, if there is a suspicion of sexual abuse not longer than 72 h ago or if signs of physical abuse have to be documented.

Dexamethasone therapy for bacterial meningitis in children. Swiss Meningitis Study Group.

Routine use of steroids as adjunctive treatment of bacterial meningitis remains controversial. We have carried out a prospective, placebo-controlled, double-blind study of dexamethasone in 115 children with acute bacterial meningitis in Switzerland. The patients were randomly assigned to receive either placebo (n = 55) or dexamethasone (n = 60) in addition to optimum antibiotic treatment (100 mg/kg daily ceftriaxone). Dexamethasone therapy (0.4 mg/kg) was started 10 min before the first dose of ceftriaxone and given every 12 h for 2 days. Baseline demographic, clinical, and laboratory features of the two groups were similar. After 24 h treatment meningeal inflammation as shown by cerebrospinal fluid (CSF) glucose concentration was significantly less with dexamethasone than with placebo (mean increase in glucose 63 [76] vs 40 [75]%, p = 0.008). However, other indices of inflammation showed similar changes in both groups. Addition of dexamethasone did not affect the rate at which CSF became sterile. Both groups showed prompt clinical responses and similar frequencies of complications (15 vs 12%). Monitoring for possible adverse effects of dexamethasone revealed no abnormalities. At follow-up examinations 3, 9, and 15 months after hospital discharge, 9 (16%) of 55 placebo recipients and 3 (5%) of 60 dexamethasone recipients had one or more neurological or audiological sequelae (p = 0.066); the relative risk of sequelae was 3.27 (95% CI 0.93-11.47). Our results and those of similarly designed studies lead us to believe that adjunctive dexamethasone therapy improves outcome from bacterial meningitis in infants and children. We recommend its use, preferably in the dose regimen used in this study.

[3-day fever: agreement between clinical diagnosis and seroconversion of type 6 human herpesvirus (HHV-6)]. / Dreitagefieber: Ubereinstimmung zwischen klinischer Diagnose und Serokonversion gegen das Humane Herpesvirus Typ 6 (HHV-6).

The aim of this study was to investigate the correlation between clinical diagnosis of exanthema subitum and seroconversion of herpes virus type 6 (HHV-6). 90 children with fever of unknown origin were investigated by 11 pediatricians in the Canton of Zürich, Switzerland, between October 1989 and June 1990. Antibodies against HHV-6 were determined at the first consultation and 2-3 weeks later. History and clinical findings were investigated and the clinical probability of the diagnosis exanthema subitum was estimated. 82 of the 90 children could be evaluated. 33 of them already had HHV-6 antibodies in their first blood sample although their history was negative concerning exanthema subitum. In 24 children exanthema subitum was proven by seroconversion. The clinical diagnosis was much more reliable at the second consultation compared to the first one. The clinical course of the disease was highly variable. Duration of fever differed widely and in some children the exanthema was atypical or even absent.

Food-borne botulism: an uncommon disorder.

We report food-borne botulism in a 28-month-old boy and his father in order to illustrate this rare disease. Diagnosis and treatment are reviewed.

[Electroencephalographic evaluation potentials in severely burned patients in intensive care]. / Elektroenzephalographische Beurteilungsmöglichkeiten bei schwerverbrannten intensivpatienten.

In severely burned patients water and electrolyte imbalance is the most obvious disturbance during the shock period but problems also occur because of large protein losses and absorption of toxic products from the damaged skin. These factors may impair brain function and this may be further affected by the action of drugs used for therapy. Brain function was assessed in 12 burned patients by EEG recordings. The EEG records showed no changes specific to burned patients. Changes were seen similar to those seen in patients under intensive care for other surgical conditions and seemed to be related to the level of consciousness and to the drug therapy.

[EEG parameters in the monitoring of ventilated intensive care patients under various sedation methods]. / EEG-Parameter in der Uberwachung beatmeter Intensivpatienten unter verschiedenen Sedierungsstrategien.

Visual evaluation of the EEG and spectral analysis of the background activity are useful in monitoring changes of cerebral function caused by sedatives, hypoxia and changes in state of health. Continuous slow changes of the EEG are indicative of critical situations of cerebral blood flow or metabolism. Monitoring cerebral function of 40 sedated and ventilated patients on an intensive care unit, we found typical EEG changes dependent on different regimes of sedation, amount of sedatives and patient condition. In patients sedated with etomidate, there was a good correlation between the relative power of the delta and beta-band and patient condition. Sedation with thiopental caused flattening and slowing of the EEG, as well as a decrease of total power, if the doses were increased. The EEG was an aid to predicting the outcome of intensive care and to demonstrate the degree of cerebral damage. In patients with septicaemia, cerebral function was more depressed than in patients with cardiac failure. Spectral analysis and computed parameters proved to be valuable in monitoring cerebral changes caused by sedation and state of health in ventilated patients.

[Drug therapy of eclampsia. An obstetric-anesthesiologic problem in the intensive care unit]. / Die medikamentöse Therapie der Eklampsie. Ein geburtshilflich-anästhesiologisches Problem auf der Intensivpflegeeinheit.

The study presented was based on the concept, that the eclamptic convulsions reflect multiple damages of the central nervous system. Primary damage occurs in the cerebral vessels, which leads to 1. volume overload of the cerebral tissue, 2. loss of fluid out of the vascular system, 3. intracranial pressure fluctuation caused by the loss of cerebral autoregulation. All of these damages combined with an additional metabolically induced decreased convulsive threshold could provoke convulsions. A new therapy is therefore suggested combining dexamethasone and a highly concentrated albumin-solution together with a careful stabilization of blood pressure to reduce the intracranial overload of volume and to avoid intracranial pressure fluctuation. Additionally phenytoin normalizes the generalized decreased convulsive threshold. This method has been successfully applied in clinical treatment since 1977. By omitting strong sedatives like diazepam the patient is mentally alert and more cooperative during therapy, which is important in order to avoid further post partum complications. Compared to the currently preferred magnesium-therapy, the new method does not include the danger of neuromuscular block of transmission resulting in acute respiratory arrest. Furthermore the application of multiple individual substances allows a better adaptation of the therapy to the clinical situation.

[Transcutaneous electrical nerve stimulation (TENS) in the treatment of a peripheral lesion of the brachial plexus]. / Transkutane elektrische Nervenstimulation (TENS) zur Therapie einer peripheren Plexus-Brachialis-Läsion.

This case report describes the clinical history of a patient on dialysis, who suffered from a lesion of the brachial plexus, secondary to a mechanical damage after attempted suicide. Therapy with transcutaneous electrical nerve stimulation (TENS) revealed both sufficient analgesia and a striking improvement of the functional situation. Possible causes of the therapeutic success are discussed. The analgesia of TENS therapy, which has almost no side-effects, with the secondarily improved psychic situation, is regarded as the major responsible factor. This method appears to be a rewarding alternative in the treatment of pain syndromes secondary to peripheral nerve lesions.

EEG monitoring in anesthesiology and intensive care.

Knowledge of the actual state of cerebral function and of the changes induced by psychotropic drugs is important not only to neurologically oriented specialties but also to other branches of medicine concerned with altering cerebral function. This applies especially to anesthesiology which involves numerous procedures leading to a temporary loss of cognitive brain function. Recently, the application of EEG combined with spectral analysis performed during anesthesia and intensive-care treatment has attracted attention: we investigated the changes in EEG during standardized anesthesiological and therapeutical procedures pre-, intra- and postoperatively, or during intensive-care treatment in 1,500 patients undergoing general surgery from 1977 to 1982. Two-track EEG leads accompanied by spectral analysis were used on line. The evaluation of routinely applied EEG monitoring justifies the following statements: EEG monitoring can be adapted technically and organized to comply with the working conditions and daily activities of an anesthesiological department. Spectral analytic representations allow the assessment of the EEG by the anesthesiologist. The various methods of general anesthesia produce specific EEG changes which can be obliterated by the cumulative effect of drugs. The actual depth of anesthesia is visible in the EEG. During a defined constant anesthetic depth, potentially hazardous cerebral dysfunctions can be detected early and treated accordingly. EEG monitoring can be useful in solving urgent medical problems of intensive-care therapy.

[Report of 2 cases of irreversible Horner syndrome after puncture of the internal jugular vein]. / Berich über 2 Fälle eines irreversiblen Horner-Syndroms nach Punktion der Vena jugularis interna.

Two cases are presented with irreversible Horner's syndrome after cannulation of the internal jugular vein during the intraoperative period. In the first case the cannulation succeeded only after several attempts. In the second case the cannulation succeeded the first time. All cannulations were performed by experienced anaesthesiologists. This means, that a strict indication for the cannulation of the internal jugular vein must be considered, because of the possibility of irreversible damage, even if the cannulation is performed by an experienced physician.