Periorbital and orbital cellulitis in the Haemophilus influenzae vaccine era.

BACKGROUND: Prior to development of the Haemophilus-influenzae vaccine, a significant number of periorbital and orbital infections were associated with H influenzae type b bacteremia. The incidence of invasive H influenzae type b disease has decreased dramatically since the introduction of these vaccines. The effect of the H influenzae type b vaccine on the microbiology of periorbital and orbital infections has not been examined. METHODS: Charts of 134 hospitalized patients with the discharge diagnosis of periorbital or orbital cellulitis from 1985 to 1995 were reviewed. RESULTS: In contrast with studies performed in the pre-vaccine era, H influenzae type b was not a significant pathogen. The pathogen was isolated from only 2 of 133 blood cultures performed, and was not isolated from any of the 101 patients discharged after July 1987. Sinusitis, however, remains an important cause of these eye infections. Of patients who underwent radiographic evaluation, sinusitis was present in 96% of children with orbital cellulitis and 81% of patients with periorbital cellulitis. CONCLUSIONS: H influenzae type b is no longer a significant pathogen in periorbital or orbital cellulitis and management should be modified accordingly.

Recombinant tissue plasminogen activator restores perfusion in meningococcal purpura fulminans.

OBJECTIVE: To investigate whether an infusion of recombinant tissue plasminogen activator would dissolve microvascular thromboses and improve organ perfusion in a patient with fulminant meningococcemia. DESIGN: Descriptive case report. SETTING: Fifteen-bed pediatric intensive care unit (ICU) in a university hospital. PATIENT: A 4-month-old male with fulminant meningococcemia, refractory shock, and multiple organ failure. INTERVENTIONS: In addition to standard aggressive ICU care, the patient received a recombinant tissue plasminogen activator infusion at a total dose of 1.25 mg/kg over 4 hrs. MEASUREMENTS AND MAIN RESULTS: Heart rate, arterial blood pressure, urine output, and base deficit (as a reflection of severity of metabolic acidosis) were recorded immediately before the recombinant tissue plasminogen activator infusion and 4 hrs later, after completion of the recombinant tissue plasminogen activator infusion. The amount of exogenous vasopressor and inotropic support required to maintain the patient's hemodynamic status before and after recombinant tissue plasminogen activator infusion were also compared. Subjective observations regarding the patient's peripheral perfusion status were also noted. The patient showed a dramatic improvement in hemodynamics, urine output, and metabolic acidosis, as well as a perceived increase in skin perfusion after recombinant tissue plasminogen activator infusion. CONCLUSIONS: In this patient, recombinant tissue plasminogen activator infusion resulted in improved organ perfusion and cardiac performance. Selective use of recombinant tissue plasminogen activator in the treatment of fulminant meningococcemia merits further investigation.

Cardiac tamponade in an adolescent female: an unusual manifestation of systemic lupus erythematosus.

Systemic lupus erythematosus (SLE) affects approximately 0.6 children per 100,000. The disease is extremely rare in children under 5 years of age and is diagnosed predominantly in adolescent females. Children tend to present with more severe multisystem involvement than adults. Pericarditis occurs in approximately 25% of patients with SLE in all age groups. Progression to tamponade is extremely uncommon in the pediatric population. In the current report, an adolescent girl is diagnosed with SLE after presenting with signs and symptoms consistent with cardiac tamponade. A review of other pediatric patients with a similar presentation is also included.