Pneumococcal osteomyelitis and arthritis in children. A hospital series and literature review.

Twenty-nine children with pneumococcal osteomyelitis and/or arthritis, 11 of whom had osteomyelitis, were treated at Cook County Hospital, Chicago, Ill, in the past 20 years. They were mostly normal children with a single focus of infection. They represented more than 5% of the hospitalized children with a systemic pneumococcal infection. Most of the pneumococcal isolates were serotyped; serotype 19, in particular, seemed to be unusually common in these children. Twenty-three of the 29 children with pneumococcal osteomyelitis and/or arthritis had been hospitalized in the past 15 years. These 23 children were compared with 161 hospitalized children who had bone and joint infections with other isolated bacteria. The children with pneumococcal osteomyelitis and/or arthritis were indistinguishable from most of the other children, except by age. All but three of the children with pneumococcal osteomyelitis and/or arthritis were between the ages of 3 and 24 months. In this age group, Pneumococcus was the common isolate from children with osteomyelitis, and second only to Haemophilus influenzae from children with bacterial arthritis. Pneumococcal osteomyelitis and/or arthritis has never been rare; the medical literature describes at least 245 other children, most of whom were younger than 2 years.

Enhanced pancreatic CT imaging utilizing a geometric magnification technique.

Computed tomography (CT) using a geometric magnification technique was found to improve spatial resolution in phantom studies when compared with conventional third-generation geometry images. The clinical feasibility of using geometric magnification, small focal spot size, and dynamic contrast enhancement was studied in 143 patients referred to CT for clinically suspected pancreatic disease. This population included 46 patients with a normal pancreas and 36 patients subsequently proven to have primary pancreatic carcinoma. Using this new technique in conjunction with dynamic contrast enhancement resulted in high quality pancreatic images. Despite the limitations in tube current associated with a small focal spot size and low total heat capacity of the system, clinical imaging was not adversely affected. Use of the geometric magnification technique is recommended in departments where it is technically feasible.

Duplex carotid sonography: criteria for stenosis, accuracy, and pitfalls.

Both carotid bifurcations were examined in 353 patients over a 20-month interval using a combination of real-time and pulsed Doppler ultrasound (duplex scanning). Angiographic correlation was available in 72 cases. Stenosis of the internal carotid was evaluated using a Doppler input frequency of 5 MHz and a scan angle of 60 degrees. A peak frequency shift of less than 3.5 kHz was found to be a sign of less than or equal to 30% stenosis; 3.5-4 kHz with moderate turbulence suggested 31-50% stenosis, 4-8 kHz 51-90% stenosis, and greater than 8 kHz greater than 90% stenosis. Subtotal stenosis (greater than 95%) was manifested by a frequency shift of less than 8 kHz, but the waveform was totally distorted. Overall accuracy improved from 77% for the first 6 months to 87% for the last 14 months. For stenosis greater than 50%, sensitivity improved from 82% to 97% during this period. Analysis of errors and suggestions for avoiding them are presented.

The role of duplex carotid sonography, digital subtraction angiography, and arteriography in the evaluation of transient ischemic attack and the asymptomatic carotid bruit.

This article reviews the uses of arteriography, venous digital subtraction angiography, and duplex carotid sonography in the evaluation of patients with an asymptomatic carotid bruit or carotid system transient ischemic attack. It concludes with a description of the authors' guidelines for their use.

Sonographic appearance of extra-axial fluid collections in the infant: further observations.

Extra-axial fluid collections were identified in six infants by transfontanelle cranial sonography. Confirmatory computer tomography (CT) scans were performed following the sonograms in five of these patients. These extra-axial fluid collections were varied in appearance and could be divided into two types depending on their sonographic characteristics. The first group consisted of large, usually concave anechoic collections and the second of small extra-axial fluid collections best seen in the interhemispheric fissure. The large collections were easily identified using a routine 5 MHz transducer system. The smaller collections were not well visualized with a 5 MHz system and required a 7.5 MHz transducer to identify the fluid in the interhemispheric fissure. Additionally, the lateral extent of these small collections could not be visualized through the anterior fontanelle using either transducer and CT was required for definitive evaluation of their lateral extent.

Intracranial hemorrhage in neonates with erythroblastosis fetalis: sonographic and CT findings.

Cranial sonography revealed cerebral hemorrhage in three of seven neonates with erythroblastosis fetalis. Among the three infants with hemorrhage, one was 28 weeks gestational age and experienced germinal matrix hemorrhage with ventricular extension, a finding typical of cerebroventricular hemorrhage in the premature population. The other two infants with intracranial hemorrhage were more gestationally mature, and extensive intraparenchymal cerebral hemorrhages were found at sonography. These hematomas were peripheral in location and one was multifocal. Computed tomography (CT) further revealed hemorrhages in both neonates to be multifocal and in close proximity to the pia-arachnoid. In one case, the hemorrhage appeared to extend centripetally and rupture into the ventricular system. The high incidence, severity, and unusual appearance of intracranial hemorrhages in neonates with erythroblastosis fetalis has not been previously emphasized in the radiologic literature. In severe cases, children with erythroblastosis fetalis should be closely observed for intracranial hemorrhage by either sonography or CT, regardless of gestational age.

Fine-needle biopsy directed by real-time sonography: technique and accuracy.

A real-time mechanical sector scanner and attachable biopsy apparatus was used to guide fine-needle aspirations of 61 consecutive abdominal masses suspected of representing metastatic or primary malignant disease. Among these 61 patients, 15 had pancreatic masses and 32 had hepatic lesions, either solitary or multiple. The other 14 patients had possible recurrence of gynecologic malignancy either locally or within the retroperitoneum, or abdominal wall or retroperitoneal masses. Although various methods of fine-needle biopsy with real-time guidance have been described, the advantages and actual accuracy of this method have not been emphasized adequately. This technique was accurate in 57 (93.4%) of 61 cases, with only two apparent instances of incorrect needle placement. Although many institutions prefer CT guidance over sonography, this method offers numerous advantages and should be the method of choice in fine-needle biopsy guidance in the oncologic population.

Penicillin in infants weighing two kilograms or less with early-onset Group B streptococcal disease.

We studied the effect of penicillin on early-onset Group B streptococcal disease over a 52-month period in neonates who were at high risk of infection. Shortly after birth, 1187 neonates weighing 2000 g or less had blood samples taken for cultures and were randomized into an early-treatment group (given intramuscular penicillin G within 60 minutes of birth) or a control group. The incidence of early-onset disease was 20 per 1000 live births (24 of 1187); the number of infants in the early-treatment group who had disease (10 of 589) was similar to that in the control group (14 of 598). The fatality rates were similar in both groups (6 of 10 vs. 8 of 14). Cultures from blood obtained with one hour of birth were positive in 21 of the 24 infants with disease; 22 of the 24 were symptomatic within four hours of birth. Thus, infection was well established before the first hour of postnatal life. At autopsy, gram-positive cocci were seen in lung sections of four infants in whom cultures of blood obtained after treatment had been sterile; this indicates that giving routine antibiotic therapy before culture samples are obtained can obscure bacteriologic diagnosis. We conclude that penicillin given at birth to neonates weighing 2000 g or less does not prevent early-onset streptococcal disease or reduce excess mortality associated with disease.

Evaluation of the grafted ascending aorta with computed tomography. Complications caused by suture dehiscence.

Patients who have undergone surgery on the thoracic aorta and placement of a synthetic tubular graft need close, long-term radiological follow-up, as they are at risk of not only complications and progression of the underlying disease (atherosclerosis, dissection, or cystic medial necrosis) but also complications of the procedure, notably suture dehiscence leading to formation of an aneurysm around the graft. In a series of 14 asymptomatic postoperative patients studied by computed tomography (CT), the authors detected leakage of contrast material around the graft in 6 patients, 2 of whom required re-operation to correct suture dehiscence. CT is a noninvasive and sensitive method of postoperative evaluation of patients who have undergone an aortic graft.

Diarrhea in Streptococcus pneumoniae bacteremia.

Diarrhea with fever was a significant complaint in 26 of 280 (9.3%) of non-SS children with S. pneumoniae bacteremia and four of 30 (13%) children with sickle syndromes and S. pneumoniae bacteremia. Two additional children with sickle-cell disease and S. pneumoniae bacteremia developed diarrhea within hours of hospital admission; four of the six died. The mortality rate among 24 additional SS patients with S. pneumoniae bacteremia without diarrhea was 12.5% (3/24). Only one of 26 non-SS patients with diarrhea and S. pneumoniae bacteremia died; shs was surgically asplenic and had fulminant 9-hour course. The seasonality of the diarrhea cases was similar to our overall experience, and the serotypes associated with the diarrhea cases were also representative of our overall experience. Although predominantly seen in infants, the oldest non-SS patient was 12 years, and the oldest SS patient was nine years.

Pneumococcal bacteremia in infants and children: a ten-year experience at the Cook County Hospital with special reference to the pneumococcal serotypes isolated.

In a ten-year period we identified 305 hospitalized children with a pneumococcal bacteremia. From these children 293 pneumococcal isolates were serotyped, and 90% belonged to a group of 11 "prevalent serotypes." These 11 serotypes were the prevalent serotypes isolated from children in all disease categories, as well as from children with sickle-cell disease. No more than 1% of the isolates belonged to any one of the other serotypes. A pneumococcal vaccine effective against these 11 prevalent serotypes should be optimal for use in children. Our highest case fatality rates were noted in children with meningitis (13%) and children with sickle-cell disease (20%). A polysaccharide pneumococcal vaccine might not have prevented most of our pneumococcal meningitis, as 80% of these children were less than 1 year old, an age when polysaccharide vaccines are poor antigens. On the other hand, many of our children with sickle-cell disease acquired their pneumococcal bacteremia at an older age and should have benefitted from such a vaccine.

Group B streptococcal osteomyelitis and septic arthritis. Its occurrence in infants less than 2 months old.

Nine infants less than 2 months of age with group B streptococcal (GBS) osteomyelitis or septic arthritis, or both, were seen from January 1975 through January 1978. The infants had local joint signs, usually in the absence of systemic signs. The bones and joints involved were equally distributed between proximal humerus and proximal and distal femur. An infant had involvement of the talus. Treatment consisted of two to three weeks of parenteral antibiotics, arthrotomy in infants with arthritis, and bone decompression in infants with osteomyelitis. Clinical follow-up showed normal growth and function of the affected joint. Of the organisms, five were typed: four were type III and one was type Ib. Group B streptococcal osteomyelitis and/or septic arthritis was the second most common late-onset GSB infection, being surpassed only by meningitis.

Acute Haemophilus pneumonia in childhood.

In our hospital Haemophilus influenzae type B seems to be a common cause of acute childhood pneumonia. In the past five years, 34 children with acute Haemophilus pneumonia were identified. Although these children generally had an uncomplicated segmental pneumonia associated with a bacteremia, 13 of the children had pneumonia with a pleural effusion. These children with Haemophilus pneumonia represented 18% of the children hospitalized with systemic Haemophilus disease and almost a third of those hospitalized with acute bacterial pneumonia from whom the causal agent was isolated.

Early-onset Haemophilus sepsis in newborn infants: clinical, roentgenographic, and pathologic features.

Nine infants with early-onset Haemophilus sepsis were seen between January 1973 and July 1977. Of the five isolated strains that were typed, only one was type B. All infants had respiratory distress, metabolic acidosis, and large alveolar-arterial oxygen tension difference gradients. Eight infants weighed less than 1,500 gm and died; one infant weighed 1,701 gm and survived. Roentgenograms in six of eight showed hyaline membrane disease. Pulmonary pathologic specimens in eight infants revealed hyaline membranes in six and polymorphonuclear leukocytes in the alveolar spaces in four. In two infants, small Gram-negative bacilli were noted within proteinaceous exudates in alveolar ducts. The route and time of infection in these infants with early-onset Haemophilus sepsis are unclear. However, the possibility that the infection occurs before birth and that these infants represent septically aborted prematures is suggested by the high incidence of prematurity in infants with early-onset Haemophilus sepsis and early detection of bacteremia in three infants.