Musculoskeletal infections in adolescents.

Musculoskeletal infections are uncommon disorders in adolescents and represent unique diagnostic and therapeutic challenges to the clinician. The pathogenesis, treatment, and prognosis of many musculoskeletal infections vary markedly in children compared to adults based in part on behavioral differences, bone growth, and changing vascularity patterns. Since adolescents can exhibit manifestations of infection common to either age range, a familiarity with the differences is essential for successful management. This article reviews common musculoskeletal infections affecting normal adolescent population, but also includes special considerations. Hematogenous osteomyelitis and suppurative arthritis are reviewed in detail, including pathogenesis, etiology, signs and symptoms, diagnosis, laboratory tests, radiologic imaging, and treatment. Also discussed are contiguous osteomyelitis with and without vascular insufficiency, puncture wound osteomyelitis, vertebral osteomyelitis, osteomyelitis with sickle cell disease, chronic osteomyelitis, pyomyositis, acute bacterial myositis, and nonstreptococcal myonecrosis.

Catfish-related injury and infection: report of two cases and review of the literature.

Two cases of serious infection following catfish spine-related injuries are presented, and the literature on this topic is reviewed. The organisms usually involved in such infections are Vibrio species, Aeromonas hydrophila, Enterobacteriaceae, Pseudomonas species, and components of the flora of the human skin. Irrigation, exploration, and culture of these wounds as well as immunization of the patient against tetanus are recommended. Patients with hepatic disease or chronic illness and immunocompromised individuals are at unusually high risk of fulminant infection due to Vibrio and Aeromonas species and should be treated with antibiotics after sustaining a water-associated wound. Patients with normal host defense mechanisms but with late wound care, punctures involving a bone or a joint, progressive inflammation hours after envenomation, fever, or signs of sepsis are at high risk for secondary infection and should receive definitive wound care and antibiotics. For moderate to severe infections, one of the following combinations constitutes a reasonable empirical regimen: (1) a tetracycline and a broad-spectrum, beta-lactamase-stable beta-lactam antibiotic, or (2) a tetracycline, a beta-lactamase-stable penicillin, and an aminoglycoside.

Endotoxin concentrations in cerebrospinal fluid correlate with clinical severity and neurologic outcome of Haemophilus influenzae type B meningitis.

Endotoxin concentrations were measured in paired samples of cerebrospinal fluid from 38 patients with Haemophilus influenzae type b meningitis. On admission, the median concentration of endotoxin in cerebrospinal fluid was 104 ng/mL and decreased rapidly in follow-up samples. From 17 to 48 hours after admission, 50% of the patients had concentrations of less than 1 ng/mL. Endotoxin concentrations correlated significantly with concentrations of interleukin 1 beta, protein, and glucose in cerebrospinal fluid, duration of secondary fever, and neurologic abnormalities during hospitalization and on follow-up examinations. Twenty-eight percent of patients with endotoxin concentrations of 100 ng/mL or more on admission had long-term complications, compared with none of those with lower endotoxin concentrations (relative risk, 2.31; 95% confidence interval, 1.53 to 3.48). These results indicate that quantitation of endotoxin in cerebrospinal fluid could be a valuable aid in identifying those children at increased risk of complications during Haemophilus influenzae type b meningitis and provide additional evidence that the Haemophilus influenzae type b meningitis lipo-oligosaccharide is important in the pathogenesis of meningitis.

Right atrial myxoma with a nonembolic intestinal manifestation.

A 5-year-old male with right atrial myxoma without interatrial communication who presented with abdominal pain, vomiting, fever, and guaiac positive stool is reported. He was later found to have ischemia of a jejunal segment necessitating segmental resection. Although his symptoms persisted postoperatively, surgical removal of a right atrial myxoma was followed by complete resolution of his intestinal symptoms. We demonstrated that the mesenteric vasculitis was of nonembolic origin, and we speculate autoimmune arteritis as a possible mechanism.

Magnetic resonance imaging and dexamethasone therapy for bacterial meningitis.

We conducted a third placebo-controlled, double-blind study of dexamethasone as adjunctive therapy for bacterial meningitis. Thirty-one patients received cefuroxime sodium (300 mg/kg per day in 3 doses) and dexamethasone phosphate (0.6 mg/kg per day in 4 doses for 4 days), and 29 received cefuroxime and placebo. The groups were comparable at the beginning of therapy. Magnetic resonance imaging performed between days 2 and 5 of therapy was used to assess brain water content indirectly. There were no differences between the 2 treatment groups with respect to the T1- or T2-weighted images. Fifty-two patients (88%) had normal magnetic resonance images; 5 patients had parietal or bifrontal extra-axial fluid collections, and 2 children had areas of abnormal signal intensity in the brain on T2-weighted images. Abnormal findings on magnetic resonance imaging did not alter clinical management, and there was no correlation between the results of magnetic resonance imaging and the outcome of meningitis. The number of patients in this study was too small to determine any statistically significant differences in rates of hearing impairment; however, the cerebrospinal fluid findings and clinical outcome in dexamethasone-treated patients further support the previously reported beneficial effect of corticosteroid treatment in patients with bacterial meningitis.

Micropenis and congenital adrenal hypoplasia.

Micropenis is often an early sign of congenital hypopituitarism. It has also been associated with congenital adrenal hypoplasia in infants with anencephaly and pituitary agenesis. This report is on two infants with micropenis and congenital adrenal hypoplasia. One presented with a similar clinical course and postmortem findings to previously reported cases of adrenal hypoplasia and pituitary agenesis. The other patient represents the first reported case of an infant with micropenis and congenital adrenal hypoplasia in the absence of pituitary agenesis. The histologic patterns of adrenal hypoplasia, as well as the etiologic and clinical implications of its association with micropenis, are discussed.