Preventing tuberculosis transmission at a maternity hospital by targeted screening radiography of migrants.

BACKGROUND: Israel has been the destination of large numbers of illegal migrants from East African countries in recent years. Despite efforts to detect and treat active tuberculosis (TB) at the border, 75% of all active TB cases diagnosed in our hospital were illegal migrants. In 2012, there was a large-scale TB exposure in our maternity ward, neonatal, and paediatric intensive care units following the admission of an infectious but apparently asymptomatic migrant who was in labour. A hospital-wide screening programme was subsequently implemented to prevent exposure of patients and staff to TB. AIM: To report the results of the first year of this intervention in the maternity hospital. METHODS: All illegal migrants from countries where TB is highly prevalent were screened by chest radiography (CR) upon admission to the maternity hospital. The results were immediately categorized by a radiologist as either 'suggestive of active pulmonary TB' or 'non-suggestive'. Patients with CR suggestive of TB were placed in airborne isolation and underwent further evaluation. FINDINGS: Four hundred and thirty-one apparently asymptomatic migrant women underwent CR screening. Most (363, 84%) presented in labour. Eleven women (2.6%) had a CR suggestive of active pulmonary TB which was confirmed in three (0.7% of screened women). No TB cases were missed by the CRs. Neither patients nor hospital staff were exposed to TB. CONCLUSION: Targeted CR screening for TB among high-risk women upon their admission to a maternity hospital had a high yield and was an effective strategy to prevent in-hospital transmission of TB.

Congenital tuberculosis and management of exposure in neonatal and pediatric intensive care units.

SETTING: This report describes the management and outcome of neonatal intensive care unit (NICU) and paediatric ICU (PICU) exposure to a 26-day-old premature infant with congenital tuberculosis (TB). DESIGN: The infant's mother underwent chest X-ray (CXR) and sputum culture. Contacts of the infant were identified. Tuberculin skin tests (TSTs) were performed on 97 infants and children, 156 NICU and PICU visitors and 115 health care workers. RESULTS: The mother's sputum culture was positive for Mycobacterium tuberculosis. No TST conversion occurred in the exposed NICU infants. All neonates received prophylactic isoniazid (INH). One exposed child in the PICU had TST conversion with normal CXR and completed 9 months of INH without developing active disease; 22 (14%) PICU and NICU visitors and 3 NICU personnel had TST conversion without evidence of disease. CONCLUSIONS: The sequence of events described here demonstrates the difficulty in diagnosis and management of TB in this age group. Transmission of TB in NICU and PICUs is unusual but can occur, and calls for a systematic approach to investigation of the exposed infants, family members and health care providers.

Outbreak of multidrug-resistant Pseudomonas aeruginosa infection following urodynamic studies traced to contaminated transducer.

We report a nosocomial outbreak of urinary tract infection by extremely drug resistant Pseudomonas aeruginosa, susceptible only to colistin. Infection in three patients followed urodynamic studies. Two of the three patients were children, one of whom also developed urosepsis. The investigation led to detection of contaminated pressure transducers. Genotyping confirmed that patient and transducer isolates were identical. These transducers were not labelled as 'single use only' despite the possibility that contaminated urine may reflux and mix with the fluid in the device. The issue of re-usable versus single-use urodynamic devices is discussed.

Recurrent meningitis and cerebrospinal fluid leak-two sides of the same vestibulocochlear defect: report of three cases.

Cochlear dysplasia is a rare congenital anomaly. However, early detection of this anomaly can prevent serious consequences. We describe three cases of cochlear dysplasia that presented with recurrent meningitis and cerebro-spinal fluid (CSF) leak in children in which early diagnosis prevented further complications.

Prophylactic antibiotics in pediatric shunt surgery.

INTRODUCTION: The optimal antibiotic prophylaxis for pediatric shunt-related procedures is not clear. There is much inconsistency among different medical centers. This paper summarizes and analyzes the various prophylactic antibiotic regiments used for shunt-related surgeries at different pediatric neurosurgery centers in the world. MATERIALS AND METHODS: A survey questionnaire was distributed through the Pediatric Neurosurgery list-server (an e-mail-based special interest group in pediatric neurosurgery). Forty-five completed questionnaires were received, one per medical center, primarily from pediatric neurosurgeons with the following geographic breakdown: 25 from North America, 13 from Europe, and 7 from Asia and other countries. All centers routinely administered prophylactic antibiotics for shunt-related procedures. The drugs of choice were first-generation cephalosporins (23), second-generation cephalosporins (10), naficillin/oxacillin (4), vancomycin (3), clindamycin (1), amoxicillin (1), and mixed protocols in three centers. The initial drug administration ("first dose") was: in the department before transfer to operating room (5), upon arrival to operating room (11), at induction of anesthesia (13), and at initial skin incision (16). The duration of antibiotic dosage also varied: single dose (13), 24-h administration (26), 48-h administration (2), and longer than 48 h in four centers. RESULTS AND DISCUSSION: Two general tendencies were noted, common to the majority of participating centers. There was a general trend to modify antibiotic treatment protocol in "high-risk" populations. The second common theme noted in more than half of responding centers was the use of long-term antibiotic treatment for externalized devices (such as externalized shunts, external ventricular drains or lumbar drains), usually till the device was in place.

Varicella zoster virus infection associated with erythema multiforme in children.

BACKGROUND: Erythema multiforme (EM) is a vesiculobullous disorder with variable manifestations which predominantly affects the skin. It is regarded as a hypersensitivity disorder which is triggered by multiple factors such as infection, drugs and food. Varicella zoster virus (VZV) has rarely been reported as an etiological agent, despite its high incidence as a pathogen in childhood. PATIENTS: We describe two children in whom EM preceded VZV infection. In the first, a 5-year-old boy, EM was followed 3 days later by a classical disseminated varicella eruption. The diagnosis was reached by clinical, epidemiological and serological means. The second patient was a 13-year-old boy with EM which was followed 2 weeks later by Ramsay-Hunt syndrome. The diagnosis was confirmed by skin biopsy, positive serology and viral culture. CONCLUSION: The association of EM and VZV infection is probably more common than reported. In clinical cases of EM, VZV should be included in the list of possible causative agents.

Pseudomonas aeruginosa bacteremia in children: analysis of trends in prevalence, antibiotic resistance and prognostic factors.

OBJECTIVE: To determine the factors predisposing to Pseudomonas aeruginosa bacteremia as well as the prevalence, source of infection, outcome and prognostic factors in pediatric patients. METHODS: Retrospective review of pediatric patients with P. aeruginosa bacteremia, at a large tertiary care hospital during a 6.5-year period. RESULTS: Seventy patients with P. aeruginosa bacteremia were identified. The annual rate of P. aeruginosa bacteremia remained unchanged during the study period. Antibiotic susceptibility remained unchanged except for two patients with extensive burns who developed resistant strains. Underlying diseases were malignancy (50%), prematurity (6%), burns (7%) and others (37%). The overall mortality associated with P. aeruginosa bacteremia was 20%. The fatality rate was higher among the young infants (compared with older children) and those who received previous antibiotic therapy (P = 0.02). Mortality rate was higher in nosocomial than in community-acquired infections (25% compared with 11.5%). The mortality rate of low birth weight and burns patients was significantly higher when compared with oncology patients or other patients, 75 and 40% compared with 11 and 19%, P = 0.01. Multiple regression analysis revealed a correlation only between the underlying disease and mortality (P = 0.02). In the oncology patients the only significant risk factor for mortality was absolute neutrophil count < or =0.1 x 10(9)/l (P = 0.06). CONCLUSION: P. aeruginosa bacteremia, although apparently not increasing in incidence and antibiotic resistance, is still a common serious complication in immunocompromised children with a high mortality rate. We conclude that the underlying disease is the main determinant of the clinical outcome.

MODED: microcephaly-oculo-digito-esophageal-duodenal syndrome.

We report on 4 families with microcephaly, type A brachydactyly, variable learning disabilities, short stature, duodenal atresia, patent ductus arteriosus (PDA), hallux valgus, restricted elbow and finger movements, and amesophalangy and syndactyly of toes. Three previous families manifested all signs of the syndrome, and in another four reports the phenotype was incomplete. These cases are reviewed. Penetrance of digital and toe anomalies is almost complete and microcephaly is present in 78% of known cases. Short stature was present in 70% of our cases, but this is probably an overestimation. Esophageal and duodenal atresias were present in 25% of known cases. Correction for ascertainment bias gave a lower estimate of 16.6%. Learning disabilities were present in 31% of all patients. Longitudinal follow-up suggested that hypoplasia or absence of the diaphyseal ossification centers is the primary cause of the phalangeal changes. Observations in a 9-year-old girl, followed since age 3.3, suggest that the eventual absence of the middle phalanges of the toes may be caused by fusion.

Coma with abnormal movements and prolonged cognitive disturbances: a new subset of acute encephalopathy.

We describe two children who presented with an acute encephalopathy preceded by a prodromal illness. The disease was marked by an active phase of coma or confusion with abnormal motor movements, followed by a recovery phase with a rapid return of motor function and a gradual improvement in speech and social behavior. No cause was found. These may be additional representative cases of a new syndrome of encephalopathy which is characterized by a distinctive course and a relatively good prognosis.

Increased creatine kinase brain isoenzyme concentration in cerebrospinal fluid with meningitis.

CPK-BB (CK-BB) isoenzyme is an intracellular enzyme released in various neurologic conditions, including central nervous system (CNS) infections. Activity of CK-BB in cerebrospinal fluid (CSF) was determined in 80 children by electrophoresis and densitometry. The possible correlation between CNS infection and CK concentrations was assessed. Significantly elevated concentrations of CK activity (P < 0.01) in the CSF were found in children with bacterial meningitis as compared with children with either aseptic meningitis or normal CSF findings. The data suggest the possibility of utilizing CSF CK activity to differentiate between bacterial and viral meningitis in situations where a routine CSF examination is inconclusive.