Staphylococcus aureus meningitis associated with pyogenic infection of the sacroiliac joint.

Although we have reported the first case of Staphylococcus aureus meningitis due to pyogenic arthritis of the sacroiliac joint, this finding is actually not surprising, given the strong association between this form of meningitis and underlying bone, joint, and soft tissue infections. The physician faced with a case of meningitis due to S aureus in a patient without a history of trauma or neurosurgical manipulation must do a prompt and thorough search for underlying infectious conditions. In the case of sacroiliitis in particular, a high index of suspicion needs to be maintained, given the difficulties and delays in diagnosis associated with this infection. Radionuclide scanning with 99mTc or 67Ga is usually helpful in the early confirmation of this condition, the presence of which may be suspected on the basis of thorough physical examination.

Serological response to measles revaccination in a highly immunized military dependent adolescent population.

In the spring of 1986, there was a measles outbreak in the city of El Paso, Texas, with 92 cases reported to the City-County Health Department. Of those 92 cases, 31 (32%) occurred within a public high school's student population of 2524. A mass measles vaccination program was undertaken at that high school in order to limit the outbreak. The student enrollment included a military dependent population of 368 students. Despite documented histories of prior measles immunizations in this military dependent subgroup, three individuals contracted the disease. Since this subgroup of students represented a highly immunized adolescent population, it was of interest to serologically determine their immune status prior to and following reimmunization with the expectation that such a study would provide information relating to the level of "protective" immunity. Prevaccination and postvaccination sera were obtained from 95 students. Results of measuring anti-measles antibody activity by ELISA indicate that 13 (14%) students responded to revaccination and experienced a fourfold or greater rise in IgG antibody levels. There were no detectable IgM responses. All of the students who responded to revaccination produced an anamnestic response (IgG boost only). Since most of these individuals had received first immunizations at 15 months of age or older, these findings suggest that secondary vaccine failure (waning immunity) was responsible for the putative "lowered" immunity in these individuals, instead of primary vaccine failure (maternal antibody suppression). These findings support current recommendations for measles booster revaccination of school-age children and adolescents.

Erythromycin prophylaxis for recurrent otitis media.

Patients with recurrent otitis media without persistent middle ear effusion were studied for antibiotic prophylaxis efficacy. In the first phase, erythromycin ethylsuccinate was used as prophylaxis for otitis media in 45 patients in a dose of 10 mg/kg twice daily. Acute otitis media occurred in eight of 45 (18%) while receiving erythromycin, and in 22 of 41 (54%) following prophylaxis termination. The attack rate (episodes of otitis media per 2-month period) was 0.86 before prophylaxis, 0.20 during prophylaxis, and 0.79 following prophylaxis. In a second phase of the study, erythromycin was compared with sulfisoxazole for otitis media prophylaxis in a group of 42 children. Sulfisoxazole (500 mg per dose) was administered twice daily. Acute otitis media occurred in five of 28 (18%) children while receiving erythromycin and in nine of 21 (43%) children while receiving no prophylaxis. The attack rate (episodes of otitis media per 2-month period) was 0.81 before erythromycin prophylaxis, 0.18 while receiving erythromycin, and 0.50 after erythromycin prophylaxis. Acute otitis media occurred in eight of 14 (51%) children while receiving sulfisoxazole, and in two of five (40%) children while receiving no prophylaxis. The attack rate (episodes of otitis media per 2-month period) was 0.78 before sulfisoxazole, 0.72 while receiving sulfisoxazole, and 0.56 after sulfisoxazole prophylaxis. Erythromycin antimicrobial prophylaxis for children with recurrent otitis media was superior to no prophylaxis and to sulfisoxazole prophylaxis in this study of patients with recurrent otitis media without persistent middle ear effusion.

"Latchkey". Three voices with one message.

Two to five million children, 6 through 13 years old, are unsupervised at home after school. This practice, called "latchkey," involves issues of children without adult supervision for periods of time and questions of safety and social isolation. There are no published age guidelines for "latchkey" or data on actual practice. To investigate age guideline opinions and the factors that influence them, a survey of pediatricians (the professional voice), military police (the legal voice), and parents (the popular voice) was undertaken. Solicited opinions concerned ages at which children can be left alone for brief or extended periods and can be allowed to babysit younger children. The three "voices" expressed similar mean ages and distributions for each of the "latchkey" questions. For less than 15 minutes without supervision, the means approximated 9 years; for periods of 1 hour or longer, 12 years; and for babysitting, 14 years. The data presented do not address actual or appropriate practice, but instead provide a basis to begin investigation.

Peritonsillitis: abscess or cellulitis?

Peritonsillitis encompasses both cellulitis and abscess. To determine the distinguishing factors for cellulitis and abscess, we reviewed 29 patients, 15 with cellulitis and 14 with abscess. Common presenting complaints included dysphagia, trismus, drooling, voice change and fever. Unilateral tonsillar enlargement was usually present, and uvular deviation was noted in 10 of 29 patients. The mean ages of patients with abscess was 15.0 years, and that of patients with cellulitis was 10.8 years. The two groups differed significantly by age (P = 0.02), and discriminant analysis showed age, dysphagia and drooling to be discriminators for abscess patients, while bilaterality or fever were not. Trismus was a discriminator for cellulitis patients. Etiology for abscess included Group A and non-Group A beta-hemolytic streptococci, Group D streptococcus, alpha-streptococcus, anaerobic diphtheroids and coagulase-negative staphylococci. The etiology of the cellulitis was Group A and non-Group A beta-hemolytic streptococci and Streptococcus pneumoniae. Peritonsillitis appeared to increase in frequency. On presentation patients with cellulitis are similar to patients with abscess. Abscess is more likely in adolescents. Recommended therapy is intravenous penicillin and prompt drainage for patients failing to respond.

Uvulitis and Hemophilus influenzae b bacteremia.

Uvulitis and Hemophilus influenzae b (HIb) bacteremia occurred in two infants. Uvulitis may be associated with HIb bacteremia, with or without epiglottitis. An acutely inflamed uvula in a febrile infant should alert the physician to the possibility of HIb bacteremia and potentially serious sequelae. Hospitalization and parenteral antibiotic therapy are recommended.

Acoustic reflectometry in the detection of middle ear effusion.

Acoustic reflectometry, a new technique for detecting middle ear effusion, was compared with results from tympanocentesis or myringotomy in 75 patients (141 ears). There was a highly significant association (P less than .0001) for ears having middle ear effusion with high reflectivity (5 through 9 units) and for ears having no middle ear effusion with low reflectivity (0 through 4 units). In a pediatric population with middle ear effusion present in 98 of 141 ears and using reflectivity readings greater than 4 to indicate middle ear effusion, the sensitivity of this technique was 86.7% and the specificity was 69.8%. False-positive errors usually occurred in ears with thick tympanic membranes, or in ears in which reflectivity was determined prior to the induction of anesthesia. False-negative errors usually occurred in ears with both air and fluid. This technique was validated by direct comparison with tympanocentesis or myringotomy and can be used with pneumatic otoscopy and impedance tympanometry to follow children with middle ear effusion.

Measles reimmunization in children immunized before 1 year of age.

An outbreak of measles presented an opportunity to examine the immune response of children initially immunized with measles vaccine before 1 year of age to reimmunization at 15 months of age with measles, mumps, and rubella vaccine. Eighteen previously immunized children had higher acute and convalescent hemagglutination inhibition titers than 13 control children. None of the previously immunized children had measles-specific IgM appear in convalescent serum samples. These results indicate a brisk secondary immune response to measles reimmunization in children immunized before 1 year of age. They support the recommendation of the American Academy of Pediatrics of reimmunization at 15 months of age for those children whose initial measles immunization was before 1 year of age.

Assessing middle ear disease: beyond visual otoscopy.

Visual otoscopy, the first step in the diagnosis of middle ear conditions, permits an assessment based on the color and appearance of the tympanic membrane. With pneumatic otoscopy, the mobility of the tympanic membrane can be evaluated. Several other techniques can be used to augment visual and pneumatic otoscopy. Impedance tympanometry provides an objective record of tympanic membrane movement. The acoustic otoscope evaluates middle ear contents by the reflectivity of sound from the tympanic membrane.

Urinary tract infections in children.

A five-year review of pediatric patients with urinary tract infections shows that absolute colony counts are not satisfactory as the sole criterion for urinary tract infection. Prior to culture results, patients can be treated empirically if the urine is nitrite-positive or if there is more than an occasional organism per high power field on unspun urine. In this series, no diagnostic or therapeutic benefit resulted from localizing studies. Patients with enuresis and infection should undergo radiologic evaluation for an anatomic abnormality.

Adherence of Haemophilus influenzae to buccal epithelial cells.

The role of adherence of Haemophilus influenzae to epithelial surfaces in the pathogenesis of infection is unknown. Fluorescent-antibody and radiolabeled adherence methods were adapted to study H. influenzae adherence to human buccal epithelial cells. By the fluorescent-antibody method, 19 of 21 (90%) nontypable H. influenzae strains were found to be adherent compared with 2 of 42 (5%) type b strains (P less than 0.0001). Using a radiolabeled adherence method, we found that 9 of 12 (75%) nontypable H. influenzae strains were adherent to buccal epithelial cells whereas only 3 of 32 (9%) type b strains were adherent (P = 0.001). Results of H. influenzae adherence examined by both methods correlated significantly (P = 0.01). H. influenzae adherence to adult pharyngeal, nasal, and buccal epithelial cells was comparable. Type b H. influenzae did not adhere to the buccal epithelial cells of well children, children with H. influenzae type b disease, or children with upper respiratory infections. In contrast, nontypable H. influenzae did adhere to the buccal epithelial cells of well children and children with upper respiratory infections. These observed in vitro differences in adherence between nontypable and type b H. influenzae strains may explain differences in colonization, pathogenesis, and types of infection due to nontypable and type b H. influenzae.

The immunoglobulin response to reimmunization with rubella vaccine.

An adolescent military dependent population, 86% of whom had documented history of rubella immunization, was screened by two commercially available rubella hemagglutination inhibition tests. All those who were R-HAI antibody negative were immunized, and postvaccination sera were examined for the development of rubella-specific antibody (R-IgM). R-IgM was not found in any of the previously immunized subjects despite the lack of R-HAI antibody. R-IgM was detected in two seronegative subjects who had no documentation of previous rubella immunization. Thus, although the R-HAI antibody had waned, the engrams of previous immunization remained, resulting in a secondary response on re-exposure. The development of a secondary immune response, despite the absence of detectable r-HAI antibody, casts doubt on the validity of R-HAI as a screening test to determine rubella immunity. The data support continuing mass immunization of preschool children and vaccination of all older females who lack documentation of rubella immunization.