Nasal mupirocin treatment of pharynx-colonized methicillin resistant Staphylococcus aureus: preliminary study with 10 carrier infants.

BACKGROUND: Nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection in infants has become a serious concern and a new means of preventing the transmission of MRSA in the community needs to be considered. METHODS: We performed nasal mupirocin treatment on 10 infants who were MRSA-positive either in the nose or the pharynx and evaluated the effect of mupirocin on the eradication of MRSA. RESULTS: Eradication of MRSA from the nose was successful in two cases and eradication from the pharynx in six (66.6%) of nine cases. The number of treatments required to achieve eradication varied; within three courses for nose carriers and from one to seven courses for pharynx carriers. Eradication was unsuccessful even after five to seven treatments in three pharynx-limited carriers. CONCLUSIONS: These data suggest that the effect of nasal mupirocin treatment on pharynx-colonized MRSA is limited and that repetitive treatment is necessary in some cases. However, in view of the possibility of preferential pharyngeal colonization of Staphylococcus aureus in infancy, nasal mupirocin treatment deserves further evaluation for eradication not only of nose- but also of pharynx-colonized MRSA.

Intravenous gamma-globulin for Kawasaki disease.

We studied the effect of gamma-globulin (IVGG) and aspirin (ASA) on the development of the coronary artery lesions (CAL) of Kawasaki disease (KD) in three different protocols. Within 29 days of the onset of KD the echocardiographic evidence of CAL had developed in 39-42% of the patients in the ASA group, but only in 13.7-20.8% of the patients treated with IVGG (200 or 400 mg/kg X 5). In long-term follow-up observation of CAL of these patients the evidence of CAL in both the ASA and the IVGG group regressed gradually; however, the residual rate of CAL was significantly low in the IVGG group at all times up to 24 months after onset. These facts suggest that when using IVGG for KD, we should select a dose of intact gamma-globulin, 1,000 mg/kg or more in total, to prevent the occurrence of CAL. We have demonstrated not only a significant reduction in the occurrence of CAL in patients treated with IVGG but a reduction in the residual rate of CAL for two years as compared with those treated by ASA.

High-dose intravenous gammaglobulin for Kawasaki disease.

The ability of high-dose intravenous gammaglobulin (IVGG) to prevent the coronary artery lesion of Kawasaki disease has been studied in a multicentre controlled trial of IVGG plus aspirin versus aspirin alone, aspirin being the conventional treatment for Kawasaki disease. Patients were allocated at random to aspirin (45 cases) or IVGG (40 cases), there being no significant intergroup differences in age, sex ratio, duration of disease until the start of treatment, or severity. The development of coronary artery dilatation was monitored by two-dimensional echocardiography. Within 29 days of the onset of the disease, this lesion had developed in 19 cases (42%) in the aspirin group and in 6 cases (15%) in the IVGG group. There were no new instances of this lesion: in the period 30-60 days coronary artery dilatation persisted in 14 and 3 cases, respectively. In patients found to have echocardiographic abnormalities selective coronary arteriography was done 30-60 days after onset of Kawasaki disease and the lesion was confirmed in 1 of the 6 cases in the IVGG group and in 11 of the 19 controls. High-dose IVGG seems to reduce the frequency of coronary artery abnormalities in patients with Kawasaki disease.

Echocardiographic assessment of Qp/Qs in children with atrial septal defect or partial anomalous pulmonary venous connection.

In 24 children with atrial septal defect of the secundum type and/or partial anomalous pulmonary venous connection, the pulmonary to systemic blood flow ratio (Qp/Qs) was estimated by echocardiography. Using M-mode echocardiography, right ventricular diameter (RVD), left ventricular diameter (LVD), total cardiac diameter (TCD) and aortic root (AOR) were measured, and the following 5 indices were obtained: RVD/LVD, RVD/TCD, RVD/AOR, RVD/BSA (body surface area) and TCD/BSA. The single linear correlation coefficients between these 5 indices and Qp/Qs, obtained by the Fick method during cardiac catheterization, were 0.88, 0.80, 0.74, 0.75 and 0.55, respectively. Thus, RVD/LVD ratio was the most sensitive echocardiographic index to assess Qp/Qs in these children. Clinically, however, the multiple linear regression equation derived from 3 indices (RVD/BSA, RVD/LVD and TCD/BSA) might be more useful (r = 0.89). Although the abnormal motion of the interventricular septum was analyzed, the quantification of this motion as an index of Qp/Qs was difficult.

Left ventricle volume characteristics in children with tricuspid atresia before and after surgery.

Left ventricular volume variables (left ventricular end-diastolic volume, ejection fraction, mass and systolic output) were quantified in (1) 13 patients with tricuspid atresia preoperatively (type Ia, 3 patients; type Ib, 9 patients; type IIb, 1 patient), (2) 4 patients after a shunt procedure (Blalock-Taussig, 3; Glenn, 1), and (3) 1 patient after corrective surgery. Cardiac catheterization and angiography were performed at age 1 month to 5.8 years (mean 1.4 years). All patients had decreased pulmonary blood flow. The results were compared with data in 15 patients with no significantly greater than normal in 12 of the 13 patients. Left ventricular mass was significantly greater than normal, but ejection fraction was significantly less than normal. There was a positive correlation between ejection fraction and systemic oxygen saturation. Left ventricular systolic index was normal in 9 of the 13 patients preoperatively. After a shunt procedure, left ventricular end-diastolic volume and systolic index increased significantly in all four patients, and ejection fraction improved greatly in three of the four. After corrective surgery, left ventricular end-diastolic volume and left ventricular systolic index returned to the normal range and left ventricular ejection fraction improved. These findings suggest that patients with tricuspid atresia have impaired left ventricular function.

Hemodynamic and ECG responses to exercise in children with sickle cell anemia.

To determine whether exercise responses are different from normal in children with sickle cell anemia (SCA), we performed dynamic cycle ergometer exercise testing in 47 patients with SCA, aged 5 to 18 years, and 170 healthy, black age-matched control subjects. Seven (15%) of the patients with SCA had definitely ischemic, 16 (34%) had equivocally ischemic, and 24 (51%) had nonischemic ECG responses. Resting heart rate in the three groups of patients with SCA was higher than control values. Maximum exercise heart rate attained was lowest in the definitely ischemic group. All patients with SCA had decreased blood pressure responses and maximum working capacity when compared with control subjects. Hemoglobin concentration was lowest in the definitely ischemic group and correlated with maximum workload. Long-term myocardial ischemia may lead to fibrosis and the decreased myocardial contractility seen in adult patients with SCA.

Idiopathic acute myocarditis with complete atrioventricular block in a baby. Clinicopathological study of the atrioventricular conduction system.

A 17-month-old Japanese girl with an idiopathic acute myocarditis had symptoms of vomiting, slight fever, and liver enlargement, but no edema. Clinical diagnosis of acute myocarditis was not made until she had Stokes-Adams syndrome and electrocardiogram revealed complete atrioventricular block on the day of death. At autopsy, idiopathic acute myocarditis was detected diffusely in the right and left ventricles. Vomiting and liver enlargement were due to congestive heart failure. Serial sections of the atrioventricular conduction system revealed diffuse and severe acute inflammatory changes in the right bundle and the left bundle branches, especially in the terminal portions. Acute inflammation was focally noted in the atrioventricular node and the His bundle. The complete atrioventricular block probably followed the severe acute inflammation of the bundle branches. Our case suggest that idiopathic acute myocarditis may be underdiagnosed in babies, as there is no way to determine whether there is dyspnea and palpitation on exertion, and idiopathic fibrosis of conduction system with or without conduction disturbances in children and adults may be sequelae of healed myocarditis in babies.

Simultaneous surgical treatment of tetralogy of Fallot and coronary artery aneurysm due to mucocutaneous lymph node syndrome in a 4-year-old child.

The simultaneous correction of tetralogy of Fallot and an aneurysm of the coronary artery due to mucocutaneous lymph node syndrome (MCLS) in a 4-year-old boy was successfully performed. Of the four aneurysms found on the coronary angiogram at the age of six months, the smaller three regressed spontaneously leaving slight dilatation and thickening of the arterial wall during the 4-year follow-up period. However, the largest one in the right coronary artery, which remained almost the same size, showed marked stagnation of blood in the aneurysm with the possibility of thrombosis and resultant myocardial infarction. At operation, there was a large aneurysm in the right coronary artery, 9 mm in width and 18 mm in length. The wall of the aneurysm was very thick and tightly adherent to the myocardium. The aneurysm was resected and an aorto-coronary bypass graft was fashioned from a saphenous vein taken from the patient's mother, since an autogenous vein was not available. A ventricular septal defect was closed and pulmonary stenosis was relieved without any difficulty. Postoperative cardiac catheterization and coronary angiography four weeks after the operation revealed satisfactory correction of the tetralogy of Fallot and a patent aorto-coronary vein graft. Several problems regarding surgical treatment of coronary artery aneurysm due to MCLS are discussed.