Emergence of multiresistant methicillin-resistant Staphylococcus aureus in two patients with atopic dermatitis requiring linezolid treatment.

We report two patients with atopic dermatitis who developed methicillin-resistant Staphylococcus aureus (MRSA) skin infections resistant to clindamycin and trimethoprim-sulfamethoxazole requiring repeated linezolid treatment. For one patient and family members who received an aggressive regimen of staphylococcal decolonization, including intranasal mupirocin, dilute bleach baths, and bleach cleansing of household items and surfaces, subsequent culture results demonstrated methicillin-susceptible S. aureus colonization and infection. These findings underscore the challenges presented by multiresistant MRSA infections in children with atopic dermatitis.

An upsurge in pertussis: epidemiology and trends.

OBJECTIVE: The objective of the study was to review the 2010 pertussis upsurge occurring within California and recent experiences at a large tertiary care children's hospital within California. METHODS: A retrospective review of all specimens submitted for Bordetella pertussis polymerase chain reaction assay from the emergency department at a large tertiary care children's hospital from January 2009 to August 2010. Outcome measures were the number of specimens submitted, the number of positive specimens, and the percentage of positive specimens. RESULTS: The last peak incidence of pertussis, in the Unite States, was seen in 2005 with an annual incidence of 25,616 reported cases. Comparing 2010 with 2009 during the same period, the total number of positive cases increased from 13 to 94, a 723% increase at our institution. The median monthly number of positive specimen was 1.5 for 2009 and 6.5 for 2010 (P = 0.0169). CONCLUSIONS: Hospitals, private practitioners, and the California Department of Public Health need to emphasize prompt diagnosis and treatment of this contagious infection to limit the spread to susceptible individuals. A more widespread safe and effective vaccination program will hopefully enhance protection against pertussis infection.

Increased incidence of sacroiliac joint infection at a children's hospital.

BACKGROUND: Pyogenic sacroiliitis (PSI) is an uncommon type of osteoarticular infection. A study is undertaken to confirm an observed increase in incidence of PSI at our pediatric institution and to evaluate any associations with increasing incidence of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infection and other factors. METHODS: All inpatients with osteoarticular infection were identified from the periods of 1992 to 1996 and 2004 to 2007. Patients with surgical site infection, immunologic deficits, decubiti, or other predisposing factors were excluded. Demographic, microbiologic, and clinical factors were analyzed for comparison. RESULTS: Overall 362 cases were included: 205 with osteomyelitis alone and 157 with pyarthrosis, of which 15 were PSI cases. The incidence of PSI increased from the periods of 1992 to 1996 and 2004 to 2007 (0.8 vs. 2.8 cases/y, P=0.03), along with osteomyelitis at pelvic and spinal sites (ie, axial sites; 1.6 vs. 5.0 cases/y; P=0.03), whereas the incidence of osteoarticular infection at other sites remained stable. CA-MRSA was isolated in 1 (6.7%) PSI case. In the second time period, CA-MRSA did not form a higher proportion of S. aureus isolates at sacroiliac or other axial sites (CA-MRSA: 17% of S. aureus in PSI and axial osteomyelitis vs. 45% of S. aureus at nonaxial sites, P=0.08). Patients were older in the second time period (4.5 y vs. 7 y; P<0.0001), and patients with PSI (10.5 y) and axial osteomyelitis (8.5 y) were older than those with osteoarticular infection at other sites (5.3 y; P<0.0001). CONCLUSIONS: The emergence of CA-MRSA does not explain the increasing incidence of PSI. The incidence of PSI and osteomyelitis involving the axial skeleton are increasing, predominantly in older patients. These trends should be prospectively investigated. LEVEL OF EVIDENCE: III, Prognostic Study.

Raoultella ornithinolytica bacteremia in an infant with visceral heterotaxy.

A case of Raoultella ornithinolytica bacteremia in an infant with visceral heterotaxy is reported. Physical examination was remarkable for markedly red skin flushing, not unlike that seen during histamine fish poisoning. R. ornithinolytica is a histamine-producing bacterium recently elucidated as a major cause of histamine fish poisoning. Only 2 other cases of human infection by R. ornithinolytica have been reported.

Prospective monitoring for invasive aspergillosis using galactomannan and polymerase chain reaction in high risk pediatric patients.

BACKGROUND: The diagnosis of invasive aspergillus remains a challenge in the care of high-risk patients. Outcomes are improved when invasive aspergillus is diagnosed early, prompting the initiation of appropriate antifungal therapy. We evaluated the utility of prospective monitoring for invasive aspergillosis (IA) using biomarkers such as serum galactomannan (GM) and/or blood polymerase chain reaction (PCR) in high-risk pediatric patients. METHODS: Patients with high-risk leukemia (HRL) or allogenic hematopoietic cell transplant (HCT) recipients were prospectively monitored twice weekly for IA using GM and PCR for Aspergillus species. RESULTS: Sixty-eight patients had collected >or=2 specimens. The 1086 specimens were collected; 627 from HRL (58%) and 459 (42%) from HCT recipients. Median specimens/patient was 11.0 (2 to 58), and median follow-up/patient was 98.5 days (14 to 437). Fifty-six percent of samples were obtained from patients receiving mold-active agents; 32% HRL and 89% HCT. There were no proven, 3 probable, and 20 possible episodes of IA. Thirteen specimens (1.2%) from 4 patients (5%) were GM+. None were positive by PCR. CONCLUSIONS: The prospective use of GM and PCR in this high-risk pediatric population did not identify cases of proven IA. A high false positive rate was not detected. It is speculated that changes in clinical practice, such as early use of empiric and/or prophylactic mold-active agent and frequent imaging studies have impacted the epidemiology of IA. In a population with low incidence of IA, the use of these assays as a screening device on blood may not further enhance current outcomes.

The role of bronchoalveolar lavage galactomannan in the diagnosis of pediatric invasive aspergillosis.

BACKGROUND: : Molecular biomarkers such as the galactomannan assay are of increasing interest in clinical settings for diagnosis of invasive aspergillosis (IA). The use of bronchoalveolar lavage galactomannan (BAL GM) is being validated in adult populations, but has not been systematically evaluated in pediatric patients. METHODS: : A retrospective analysis was performed of patients for whom GM assays from BAL were submitted between November 1, 2006 and November14, 2007 at Childrens Hospital Los Angeles. Medical charts were reviewed and patients were categorized as having no, possible, probable, and proven IA, per established definitions. RESULTS: : Of 85 pediatric patients who had a BAL GM submitted during the study, 59 were immunocompromised. Three patients were identified as having proven IA, 6 had probable IA, 37 had possible IA, and 39 had no evidence of IA; 38 had a concurrent serum GM performed. A positive, linear correlation was established between BAL and serum GM, using OD index values (rho = 0.48, P = 0.002). Among immunocompromised patients, receiver operating characteristic curves demonstrated an optimal BAL GM OD cut-off value of 0.87, that yielded a sensitivity for probable/proven IA of 78% and a specificity of 100%. At 0.87, the positive and negative predictive values among immunocompromised patients were 58% and 96%, respectively. CONCLUSIONS: : We found a correlation between BAL GM values and a diagnosis of IA. We also noted a linear relationship between serum and BAL GM values. Receiver operating characteristic curves obtained from our pediatric data validate the current cut off for serum and suggest a possible cut off for BAL specimens.

Right atrial mass in a child with disseminated coccidioidomycosis.

A 10-year-old patient with known coccidioidomycosis relapsed and had dysrrhythmias and a right atrial mass. Histopathology and culture after surgical removal revealed that this was a vegetative mass infected with Coccidioides spp. We believe that this is the first case of coccidioidal endocarditis to be reported.

Variable presentation of disseminated nontuberculous mycobacterial infections in a family with an interferon-gamma receptor mutation.

A previously healthy 13-year-old child who had disseminated Mycobacterium avium infection is described. Further history revealed disseminated mycobacterial infections in the patient's father and uncle, starting at 9 years old and 1 year old, respectively. Autosomal dominant interferon- gamma receptor mutation was subsequently identified. Clinical variability among the affected members of the same family is consistent with previous reports suggesting substantial variability in the clinical course of this disorder.

Bordetella bronchiseptica infection in pediatric lung transplant recipients.

Bordetella bronchiseptica are small, pleomorphic Gram-negative coccobacilli which are commensal organisms in the upper respiratory tract of many wild and domestic animals ('kennel cough' in dogs). While it is common for health care providers to ask about exposure to ill family/friends, most do not routinely inquire about the health or immunization status of household pets. We report two cases of B. bronchiseptica pneumonia in lung transplant recipients [cystic fibrosis (CF); ages 10 and 15 yr; one male] who contracted B. bronchiseptica from pet dogs. We compared their course and outcome to four children (two CF, one congenital heart disease and one Duchenne's muscular dystrophy; four males, age range 6 months to 14 yr) with B. bronchiseptica cultured from the respiratory tract. Two of the four patients also acquired their illnesses from pet dogs and two from unknown sources. One lung transplant recipient expired from progressive respiratory failure. We conclude that B. bronchiseptica can cause serious infections in both immunosuppressed and immunocompetent children. We speculate that a detailed history of exposure to ill pets (particularly dogs), and the immunization status of all pets should be included in the routine evaluation of all pediatric transplant recipients.