Clinical, radiologic and magnetic resonance monitoring for skeletal toxicity in pediatric patients with cystic fibrosis receiving a three-month course of ciprofloxacin.

Because of arthropathic toxicity observed in growing animals the quinolone antibiotics are not recommended for use in children. Recently, magnetic resonance imaging performed in juvenile animals was found to predict ciprofloxacin-induced cartilage damage at the knee joint. We conducted clinical, laboratory, radiologic and magnetic resonance imaging investigations in 13 prepubertal (age range, 6 to 13 years) and 5 postpubertal patients (age range, 14 to 24 years) with cystic fibrosis at the start and the end of a 3-month course of ciprofloxacin (30 mg/kg of body weight/day, administered orally in two equal doses) and at follow-up 4 to 6 months later. Our comprehensive monitoring gave no evidence for arthropathogenicity. Detailed physical skeletal function tests, height velocity values, laboratory studies of bone metabolism and conventional radiographs of both knees revealed no abnormalities. Moreover the serial magnetic resonance images of the left knee demonstrated lack of joint effusion, intact two-layer appearance of the cartilage and unaffected thickness of the articular cartilage measured at five anatomically different points. Our results together with the published data on quinolone use in pediatrics suggest that ciprofloxacin does not cause arthropathy in humans.

The paradox of adult respiratory distress syndrome in neonates.

Six full-term newborn infants are described who suffered from severe adult respiratory distress syndrome (ARDS). The triggering event was intrauterine/perinatal asphyxia in five, and group B streptococcal (GBS) septicemia in three. All had severe respiratory distress/failure and were ventilated mechanically with high concentrations of inspired oxygen and positive end-expiratory pressure. Radiography of the chest showed dense bilateral consolidation with air bronchograms and reduced lung volume. Persistent pulmonary hypertension (PPH) was documented in all cases. The coincidence of ARDS and PPH rendered respiratory management extremely difficult. For this reason high-frequency ventilation was instituted in all patients in order to improve CO2 elimination and induce respiratory alkalosis. Acute complications of respiratory therapy were encountered in five patients (pneumothorax, pulmonary interstitial emphysema, pneumopericardium). Three infants died (irreversible septic shock, progressive severe hypoxemia, and sudden cardiac arrest) after 17, 80, and 175 h of life. Histologic examination of the lungs was possible in all fatal cases and revealed typical changes of acute to subacute stages of ARDS. Three infants survived, the mean time of mechanical respiratory support being 703 h. Two patients were still dependent on oxygen after 1 month of life, and all survivors had increased interstitial markings and increased lung volumes on their chest roentgenograms at this time.

Unsustained central sexual precocity in four girls.

Four girls who presented with breast enlargement at 4-5.8 years of age have been followed without specific therapy for up to 4 years. Three had normal CT brain scans, one had normal skull and sella x-rays. Stimulation of gonadotropins by LHRH was excessive in all but plasma estradiol levels were only intermittently elevated. Initially, bone age was advanced and height velocity was increased in three of the four. Ultrasound visualized an enlarged uterus in two and waxing and waning ovarian cysts in all. The clinical course was characterized by persistence of physical signs over at least 3.4 years in one patient, fluctuation in another, and marked regression in two. We propose that some patients with central precocious puberty may spontaneously have a nonprogressive course which has to be considered when evaluating the efficiency of drugs interfering with puberty.

Reversible ceftriaxone-associated biliary pseudolithiasis in children.

Serial abdominal ultrasonography was performed in 37 children being treated with ceftriaxone for serious infections. Biliary concrements developed in 16 patients, causing symptoms in 3, one of whom also had urolithiasis with renal colic and obstructive ureteropyelectasia. After cessation of ceftriaxone treatment, ultrasound abnormalities and symptoms gradually disappeared, with complete sonographic resolution after 2 to 63 days.

Computed tomographic lung density in children.

The effects of patient age, anatomic level, anteroposterior location, and phase of respiration on pulmonary density were analyzed retrospectively in 33 children and prospectively in 13 children. Density standards were positioned on the chest wall for correction of scanner performance changes. The subgroup of 32 children over 7 years of age, ie, with respiratory cooperation, was analyzed separately using moderate inspiration; its mean lung density (MLD) of three levels was -792 HU (95% range, -702-882 HU). Although MLD decreased with increasing age, a significant linear regression was found only in the prospective subgroup. Densities of the apical, subcarinal, and basal levels of the lung were not different. From maximal expiration to maximal inspiration, MLD decreased by 158 HU in the subgroup studied prospectively. Anteroposterior density gradients averaged 56 HU at the subcarinal level and increased with maximal expiration.

Repair of cloacal malformation using combined posterior sagittal and abdominal perineal approaches.

Cloacal malformations in female infants are not very common and their treatment is most challenging because every case differs from the others. In the light of a well-documented case, the authors describe the complexity of the malformation, the difficulties of making a correct detailed diagnosis, and the chronology of repair. They stress the advantage of the posterior sagittal approach for the first part of the operation, changing for the second part to a supine and later to a lithotomy position. In most cases a satisfactory reconstruction is possible, anatomically as well as functionally.

Blunt liver trauma in children: the role of computed tomography in diagnosis and treatment.

In a retrospective evaluation of 12 children with blunt liver trauma studied by computed tomography (CT), all patients studied preoperatively had subcapsular hematomas (6/6). Eleven of twelve patients had parenchymal lesions that were located predominantly in the superior subsegments of the right lobe: 9/12 posteriorly (segment no. 7) and 7/12 anteriorly (segment no. 8) where transections were most frequent. Lacerations were accompanied by intraparenchymal hematomas. Intravenous bolus contrast enhancement visualizes segmental anatomy and is absolutely necessary in order to map lacerations, recognize nonviable tissue, and relate them to major vessels. Except in critically unstable patients, noninvasive imaging of hepatic and other combined abdominal lesions can avoid diagnostic laparotomy or justify planning of a tailored, maybe less radical surgical procedure. Complications, such as abscess formation, can be demonstrated and drained percutaneously. Despite cost, CT is currently the single best imaging method in acute liver trauma.

Long-term sequelae in children surviving adult respiratory distress syndrome.

Nine children surviving severe adult respiratory distress syndrome were studied 0.9 to 4.2 years after the acute illness. They had received artificial ventilation for a mean of 9.4 days, with an Fio2 greater than 0.5 during a mean time of 34 hours and maximal positive end expiratory pressure levels in the range of 8 to 20 cm H2O. Three children had recurrent respiratory symptoms (moderate exertional dyspnea and cough), and two had evidence of fibrosis on chest radiographs. All patients had abnormal lung function; the most prominent findings were ventilation inequalities, as judged by real-time moment ratio analysis of multibreath nitrogen washout curves (abnormal in eight of nine patients) and hypoxemia (seven of nine). Lung volumes were less abnormal; one patient had restrictive and two had obstructive disease. A significant correlation between intensive care measures (Fio2 greater than 0.5 in hours and peak inspiratory plateau pressure) and lung function abnormalities (moment ratio analysis and hypoxemia) was found. A possibly increased susceptibility of the pediatric age group to the primary insult or respiratory therapy of adult respiratory distress syndrome is suggested.