Acute perforated neonatal appendicitis associated with chorioamnionitis.

Perforation of the appendix is rare in term neonates and even more rare in prematures. In most of the reported cases it is a complication of necrotizing enterocolitis (NEC) but can also complicate Hirschsprung's disease (HD), cystic fibrosis (CF) or acute appendicitis (AA). We present a pre-term newborn, born to a mother who had bacteriaemia associated with chorioamnionitis. On his sixth day of life he had clinical and radiological signs of perforated abdominal viscus. Laparotomy and histologic findings indicated acute perforated appendicitis. The association of acute perforated appendicitis with chorioamnionitis points to the role of maternal foetal infection in the aetiology of neonatal acute appendicitis.

Chlamydia trachomatis disguised as an asymptomatic scrotal mass in adolescents.

We present two cases of adolescents who presented with painless scrotal masses suggestive of testicular cancer. Diagnostic workup of both these patients revealed Chlamydia trachomatis and both patients were successfully treated with doxycycline. Both patients initially denied sexual activity. We suggest that a high index of suspicion is warranted in adolescent patients that present with asymptomatic scrotal masses and precise tests for C. trachomatis be done to rule out an infectious cause.

Does the addition of fentanyl to bupivacaine in caudal epidural block have an effect on the plasma level of catecholamines in children?

We evaluated the effect of adding fentanyl to bupivacaine, compared with bupivacaine alone, on the stress response. The effect was evaluated by determining blood levels of epinephrine (E) and norepinephrine (NE) in pediatric patients receiving caudal epidural blocks. Sixty children, 1-8 yr of age, scheduled for elective herniorrhaphy, were randomly allocated to two groups of 30 patients each. Group A received inhaled anesthesia and caudal epidural block with bupivacaine 0.25% alone, 1.0 mL/kg. Group B received identical anesthesia; however, fentanyl 1 microg/kg was added to the bupivacaine in the caudal block. Blood samples for E and NE plasma levels were drawn at induction time (H(0)), at the end of surgery (H(1)), and in the postanesthesia care unit (H(2)). In both groups, there was a significant decrease in the E and NE plasma levels, when comparing H(1) and H(2) with H(0) within the same group (P < 0.001). There were no significant differences in the E and NE plasma levels between the two groups at H(0), H(1), and H(2) (P = 0.5, P = 0.12, P = 0.5, respectively). Pain scores (modified Children's Hospital of Eastern Ontario Pain Score) were also similar in both groups (P = 0. 19). This study suggests that adding fentanyl 1 microg/kg to bupivacaine in the caudal epidural block in children does not influence plasma levels of E and NE, nor does it improve the analgesic intensity of the caudal block.

Postoperative outcome in high-risk infants undergoing herniorrhaphy: comparison between spinal and general anaesthesia.

The incidence of inguinal hernia is higher in premature infants, particularly in low birth weight neonates. This latter group may also incur increased postoperative respiratory complications and inpatient admissions. The purpose of this study was to compare the effects of general and spinal anaesthesia on postoperative respiratory morbidity and on the length of hospital stay in high-risk infants undergoing inguinal herniorrhaphy. Forty patients, all high-risk infants who underwent unilateral or bilateral herniorrhaphies, were randomly assigned to receive general anaesthesia (n = 20) or spinal anaesthesia (n = 20). There was a significant difference in respiratory morbidity between the two groups, as well as a significant difference in the inpatient hospital stay. The present study suggests that spinal anaesthesia can be used safely for high-risk infants, preterm or formerly preterm, undergoing inguinal hernia repair.

[Conservative approach in children with central line infection].

In 1994-1995, central venous lines were placed in 47 children. All except 1 were of the Broviac type, with subcutaneous tunneling via the internal or external jugular vein. Ages were between 7 days and 16 years. Indications for central venous cannulation were chemotherapy (35 cases), TPN (5), prolonged parenteral antibiotics (4), and repeated blood transfusions (3). The catheter was the source of infection in 13 children (28%), 11 of whom were immunocompromised. The commonly identified bacteria were Staphylococcus aureus (4 cases), Pseudomonas aeruginosa (4), coagulase-negative Staphylococcus (2), and various gram-negative rods (3). All cases were treated with antibiotics through the catheter. The most commonly used were oxacillin (4), ceftazidime (4), and amikacin (4). In 10, treatment succeeded without having to remove the line. In 2 others, tunnel infection developed and the catheter had to be removed. 1 child forcefully removed his catheter before treatment could be started. There were no further complications in the group treated conservatively, except for a case of superior vena cava thrombosis in a girl with recurrent infection of the tunnel. In 7 out of 13 treatment was continued and completed at home. This saved 65 days of hospitalization out of 210. We conclude that the conservative approach to treatment is feasible in most cases of infection when the source is the central venous catheter itself. However, when the tunnel is infected, conservative treatment may be ineffective. Treatment can be carried out in the home, with economy in cost and in use of hospital beds, and is preferred by patients and their parents.

[Onchocerca volvulus--a rare cause of a mass in children].

The parasite Onchocerca volvulus is well-known in its endemic areas in South and Central America and West Africa. It is transmitted to man by simulium flies and causes systemic infection with skin, lymphatic and ophthalmic manifestations and can cause blindness (river blindness). Treatment with Ivermectin is effective but sometimes there is need for surgical intervention to prevent or treat complications. We describe an 11-year-old girl, a new immigrant from Ethiopia, who had a firm mass in her left thigh, caused by Onchocerca volvulus. It was completely excised. This is a very rare condition in Israel, which must be considered in patients coming from endemic areas.

[Combined penetrating trauma of the rectum and urinary bladder].

Combined penetrating trauma of the rectum and urinary bladder is rare, and constitutes a diagnostic and therapeutic challenge. Most of the literature discusses trauma to either urinary bladder or rectum alone. The combination of penetrating trauma to both rectum and the urinary system is associated with high morbidity and mortality. There is controversy regarding the preferred approach to this type of combined trauma.

[Aneurysmal bone cyst of a lumbar vertebra in a child].

An aneurysmal cyst of the 3rd lumbar vertebra was diagnosed in a 6-year-old girl. She presented with right loin pain and a palpable mass in the region of the second and third lumbar vertebrae. X-ray of the vertebrae, but not computerized tomography, was characteristic for the tumor. The diagnosis was confirmed by histologic examination. Aneurysmal cyst of the vertebra is rare in children.

Ultrasonic diagnosis of mediastinal cystic hygroma.

The incidence of cystic hygroma, which represents dilated obstructed jugular lymph sacs, is 1 in 6000 pregnancies. Cystic hygromas can be located in the nuchal area or in any other location. The prenatal ultrasonic diagnosis of a cystic hygroma in the mediastinum is presented.

[Interposition of colon for short bowel syndrome].

Massive small bowel resection causes short bowel syndrome, manifested by signs and symptoms of malabsorption and by short digestion and transient times. A case of the syndrome is presented, in which an infant had massive bowel resection with interposition of the colon performed for volvulus. The signs of volvulus appeared only a few hours after birth.