Giant cell vasculitis with extravascular granulomas in an adolescent.

We describe an 18-year-old white male who developed lower extremity ischemia requiring amputation. He presented at 14 with pulmonary infiltrates, hepatosplenomegaly, fever, rash, adenopathy, uveitis, and arthralgias; clinical and laboratory findings were consistent with Mycoplasma pneumoniae infection. Despite adequate treatment with antibiotics, he developed chronic arthralgias and fevers, with rash and pericardial effusion. Criteria for the diagnosis of systemic lupus erythematosus were not met; juvenile rheumatoid arthritis was diagnosed presumptively. Over the subsequent 4 years he developed lymphadenopathy with biopsy-proven nonnecrotizing granulomas, chronic leg ulceration with granulomatous histology, and acute-onset impending gangrene of the left foot. A biopsy of the posterior tibial artery demonstrated giant cell arteritis. Although the histologic features were consistent with Takayasu's arteritis, complete aortic arteriography was normal. Examination of the amputated leg showed multifocal segmental giant cell arteritis. Clinicopathologic features suggested, but were not fully consistent with, juvenile systemic granulomatosis. His disease may represent a separate sarcoid-like entity in the broad spectrum of vasculitis.

Subcutaneous fat necrosis of the newborn with hypercalcemia.

A newborn infant with subcutaneous fat necrosis and hypercalcemia is presented. Literature on the association between subcutaneous fat necrosis of the newborn and hypercalcemia is reviewed. Affected infants generally experience severe perinatal difficulties. Both vaginal deliveries and cesarean sections can be associated with subcutaneous fat necrosis.

Babesiosis in pregnancy.

Babesiosis is a malaria-like illness due to intraerythrocytic protozoan parasites. To the authors' knowledge, this unusual disease has not previously been described in a pregnant woman. Herein is reported the case of a gravid woman with an intact spleen who developed infection with Babesia microti in the fifth month of gestation. Her illness resolved following supportive care only, and evidence of transmission of disease to the fetus was not found.

Quantitative blood cultures in the evaluation of septicemia in children with Broviac catheters.

We applied quantitative methods of analysis to all blood cultures drawn during the course of treatment in 28 children with Broviac catheters in a central vein. Thirty febrile episodes in 14 of these patients were evaluated. Samples of blood obtained from a peripheral vein and through the central catheter were cultured quantitatively on agar plates and nonquantitatively in standard broth media. Catheters were judged to be a source of septicemia nine times in seven children. In all nine positive catheter samples, the concentration of pathogens was 10 times as great as that observed in the peripheral venous sample. The blood drawn through the Broviac catheter contained greater than or equal to 2000 colony-forming units per milliliter in six cases. Quantitative cultures in two patients with septicemia not attributable to the catheter yielded low colony counts in the catheter sample. Cultures of blood samples drawn through the catheter when a child was well were not helpful in predicting subsequent septicemia. The technique of inoculating blood directly onto agar plates is easily performed and superior to standard broth cultures, because it detected pathogens within 16 hours and identified infections with multiple organisms.

New issues in the prevention and treatment of ophthalmia neonatorum.

We have recently seen two cases of ophthalmia neonatorum (ON) that illustrate a changing picture of this disease and raise a number of questions concerning optimal prophylaxis and treatment. Silver nitrate, which is the most widely used method for prevention of gonococcal ON, fails to prevent neonatal eye disease due to chlamydia. In addition, strains of gonococci which produce a penicillinase and are resistant to penicillin are becoming common in parts of the United States and Europe. Thus all gonococcal isolates must be tested for penicillinase production. The emergence of Chlamydia trachomatis as the most frequent cause of ON and the appearance of penicillin-resistant gonococci has led to new regimens for prophylaxis and therapy of neonatal ophthalmia. At our institution, we now use intramuscular penicillin and topical tetracycline ointment (1%) for eye prophylaxis. For initial therapy of gonococcal ON we recommend penicillin (systemic and topical) plus another antimicrobial with greater stability against the penicillinase of Neisseria gonorrhoeae.

Treatment of Salmonella gastroenteritis in infants. The significance of bacteremia.

During 1981, we treated 20 infants, less than 24 months old, for nontyphoid Salmonella (NTSal) gastroenteritis (GE). Blood cultures were obtained in 17 cases, and Salmonella bacteremia was demonstrated in 8 (47%). Of the 13 children 3 to 24 months of age, 7 (54%) had positive blood cultures. One child (8 months old) appeared septic. The patients with bacteremia were treated with parenteral ampicillin. All 20 infants recovered, and no focal infectious complications occurred. The incidence of bacteremia in NTSal GE is highest in children under 2 years of age. Previous reports have shown that the peak incidence occurs among infants less than 3 months of age. An infant with Salmonella bacteremia may be afebrile and show no symptoms of sepsis. In most cases, bacteremia is transient and does not alter the course of NTSal GE, but it may result in life-threatening complications such as septicemia and meningitis. Therefore we believe an infant with NTSal GE under 3 months old should have a blood culture and receive antibiotic treatment.

Transplancental cardioversion of intrauterine supraventricular tachycardia with digitalis.

Intrauterine congestive heart-failure caused by a supraventricular tachyarrhythmia was diagnosed in a fetus at 29-30 weeks' gestation. Major congenital malformations were excluded by sonography, amniocentesis, and fetal abdominal paracentesis, and those of the heart by intrauterine fetal echocardiography. The mother was given digoxin and the fetal tachycardia converted to sinus rhythm.