[Erythema migrans disease. A contribution to its clinical features and relation to Lyme disease]

A largely prospective study averaging 33 months was undertaken in 30 patients with and one without (chronic) erythema migrans. In one case erythema migrans disappeared spontaneously, in the 29 others it persisted up to six months, but quickly responded to antibiotic treatment. Measured from the tick bite in 9 patients or from onset of the erythema migrans, arthritis and arthralgia appeared in ten patients on average 6.5 months (0.7-36), and persisted for eight months (0.2-42). In seven of these patients sensory disturbances appeared three weeks (1-10) later and (or) signs of meningitis which lasted for four months (0.5-16), while in three patients cardiac symptoms appeared a few weeks later, persisting for 4.5 months (0.3-12). In one patient tracheolaryngitis developed two months later, persisting for three months. These manifestations occurred in seven patients despite antibiotic treatment. Extradermal manifestations in two patients were successfully treated with high parenteral penicillin doses, in one instance followed by tetracyclin. "Erythema migrans disease", differing from Lyme disease described in the U.S.A. in only a few aspects, apparently cannot be successfully treated with low oral doses of penicillin, but can in certain circumstances be favourably influenced by high parenteral doses of penicillin G.

Bacterial tracheitis

During a two-year period, 17 children were brought to the St Paul Children's Hospital with the clinical features of croup, unresponsive to conventional therapy; 12 of these were seen during a two-month outbreak of parainfluenza virus type 1 that occurred in the community. Bronchoscopy showed copious purulent tracheal secretions. Cultures of transbronchoscopic aspirates were positive for bacterial organisms, the most common being Staphylococcus aureus (six of 17) and alpha-hemolytic Streptococcus (seven of 17). Four of these children, all treated conservatively with observation and/or endotracheal intubation, suffered a cardiorespiratory arrest, and two of them died. In contrast, one of 13 children who underwent tracheostomy died. Bacterial tracheitis clinically resembles viral croup, but carries a significant morbidity and mortality. Bronchoscopy documenting the presence of copious endotracheal pus and prompt tracheostomy may reduce the complications of this disease.

[Microbiological diagnosis of epiglottitis]

Forty patients, between July 1977 and April 1982, with clinical diagnosis of epiglottitis were studied for the presence of capsular antigen by counter-immunoelectrophoresis (CIE) and for positive blood culture. Blood culture was positive, for Haemophilus influenzae only, in 15 patients. Haemophilus influenzae type b antigen was present in blood and/or urine of 25 patients (blood 14 patients, urine 18 patients). CIE associated with blood culture give conclusive proofs of Haemophilus influenzae etiology in 30 patients.

Respiratory tract lesions from infectious laryngotracheitis virus of low virulence

The pathogenicity of the A4557-5 strain of infectious laryngotracheitis virus for eight-week-old chickens was investigated by aerosol route of infection; chickens were necropsied five days after infection. The virus caused mild catarrhal tracheitis, peribronchial lymphoid infiltration, and focal lymphocytic infiltration in the lung and focal lymphocytic infiltration in the air sacs of some chickens. Chickens infected with this virus developed low levels of humoral antibody and were resistant to intratracheal challenge with the virulent V154 strain. By comparison, aerosol infection with a similar dose of virulent V154 strain caused severe necrotizing laryngotracheitis with marked suppurative bronchopneumonia and airsacculitis.

Spasmodic croup in the adult

Recurrent inspiratory stridor, for which there appears to be no organic basis, can present a serious medical problem. We measured the changes in cross-sectional area of the glottic aperture during the respiratory cycle in a patient with recurrent inspiratory stridor when she was well, during a spontaneous attack, and during one induced with histamine aerosol. The glottis was visualized using a fiberoptic bronchoscope passed transnasally and attached to a video camera and tape recorder. During stridor there was marked constriction of the glottis on inspiration and phase reversal of the normal movements of the vocal cords with respect to respiration. Intermittent positive pressure ventilation (IPPV) and continuous positive airway pressure (CPAP) applied during stridor, in the absence of inspiratory effort, reversed the glottic narrowing. Pulmonary resistance (RL) on inspiration was elevated during stridor and returned to normal during IPPV and CPAP. Expiratory RL was normal throughout. Our results show that stridor in this patient was due to dynamic inspiratory constriction of the vocal cords. Glottic constriction could be induced by histamine aerosol and reversed when lung inflation was unaccompanied by inspiratory effort during IPPV and CPAP. Recognition and appropriate management of this condition may avoid potentially dangerous therapeutic interventions.

Aspergillus epiglottitis

A 21-year-old woman with acute lymphocytic leukemia developed clinical and radiographic signs of epiglottitis. Premortem and postmortem histologic studies showed invasive aspergillosis; Aspergillus flavus was grown in culture. The necrotizing nature of this infection is explained by the predilection of Aspergillus sp. for invasion of blood vessels. The usual causative agents of epiglottitis are bacteria; the association with fungal infection has not been previously described.

Immunobiological aspects of acute subglottic laryngitis in children

In the pathogenetic evaluation of acute subglottic laryngitis (ASL) the anatomy of the child's larynx should be taken into consideration: its absolute size need not necessarily be smaller than that of the adult, but its relative size with respect to the developmental stage of other organs, is. The most frequently seen anaphylactic reaction of the larynx in ASL is edema. Since 1975, 284 children with ASL have been treated in our Department of Otorhinolaryngology. They have been divided into the following groups: Group A--196 children with diseases of unknown etiology; Group B--20 children with identified viral infections; and Group C--68 children with allergic reactions. All children had their histories taken and they were all submitted to clinical examination, endoscopy, laboratory tests and allergy tests. Immunological and serological determinations, as well as lung function tests markedly facilitate the identification of etiologic factors in ASL and are of considerable help in planning a therapy and preventing any relapse of the disease.

Croup: pathogenesis and management

Croup syndromes are common in children, most frequently being infectious in origin. Children present with a slow progression of inspiratory and expiratory stridor and a croupy, "barking seal" cough. Children are variably febrile and with progression of disease, exhaustion, agitation, cyanosis and air hunger may develop. The evaluation of the patient must focus on the degree of respiratory distress and associated findings. Epiglottitis and foreign body aspiration must be excluded. Management is primarily dependent upon administration of humidified air. Children with moderate to severe croup benefit from racemic epinephrine and steroids. Admission is indicated in children with stridor at rest, evidence of exhaustion, toxicity or respiratory distress. Active airway intervention is rarely required but may be life saving if obstruction develops.

Epiglottitis

Epiglottitis is a life-threatening infection due to Hemophilus influenzae causing respiratory obstruction. Commonly presenting in children under 5 years of age, the obstruction progresses rapidly with associated inspiratory stridor, muffled voice, fever and systemic toxicity. The epiglottis is markedly enlarged on lateral neck X-ray. Once the diagnosis is considered, the patient should always be accompanied by a clinician skilled in airway management, prepared to intervene should acute obstruction occur. Optimally, patients are intubated electively in the operating room by a team of specialized physicians. Nasal or oral tracheal intubation is commonly utilized although a tracheostomy is an alternative means of securing the airway. Positive pressure ventilation may be successful as a temporizing measure if obstruction occurs until the airway is stabilized. Chloramphenicol should be initiated once airway stabilization has been achieved.

Lupus tumidus involving facial skin, nasal cavity, throat and eye (with 1 color plate)

A case of tuberculosis involving facial skin, nasal cavity, throat and eyes was found in a young Korean girl. We report the case because of its unusual clinical picture and to recall the morbidity of cutaneous tuberculosis in the present dermatological field.

Pneumococcal epiglottitis in systemic lupus erythematosus on high-dose corticosteroids

A patient with systemic lupus erythematosus who developed pneumococcal epiglottitis is described and the literature reviewed. This infection is extremely rare in adults, and only 10 cases, none of them with SLE, have so far been reported. Epiglottitis is usually caused by Haemophilus influenzae. However, in immunocompromised hosts the probability of Streptococcus pneumoniae as the infecting agent is considerable. Penicillin should therefore be part of the antimicrobial regimen in such patients.

Observations on the pathogenesis of chronic non-specific pharyngitis and laryngitis

Repeated analysis of cinephotographic and cinefluorographic studies, correlated with clinical observations, have provided insight into the physiopathology of many cases of chronic non-specific pharyngitis, laryngitis, contact ulcers, granulomas, and pachylaryngitis. Hiatal hernia and gastro-esophageal-pharyngeal reflux appear to be the cause of local irritation. Chronic coughing and habitual harsh throat clearing initiate the contact ulcers and granuloma formation. the successful treatment of this entire family of lesions is dependent upon elimination of vocal abuse and control of the factors that are responsible for the chronic irritations.

Acute epiglottitis and bacteremia with ampicillin-resistant Haemophilus influenzae

Acute epiglottitis in adults occurs more frequently than generally realized. Haemophilus influenzae type b is the major causative agent. While H influenzae resistant to ampicillin sodium has been associated with epiglottitis in children, no adult cases have been reported. We describe a 48-year-old woman with epiglottitis and associated typical rapid onset of sore throat, fever, respiratory distress, and swollen, red supraglottic structures. Blood cultures were positive for beta-lactamase-producing, ampicillin-resistant H influenzae. We conclude that H influenzae resistant to ampicillin should be considered when diagnosing and treating adult epiglottitis.

Systemic Haemophilus influenzae infection in childhood

Forty-nine children who had systemic Haemophilus infection and were treated at the Westmead Centre, Sydney, over a two-year period are described. The majority (29 of 49 children) were aged two years or less. Epiglottis and meningitis accounted for 77% of these infections. All H. influenzae isolates associated with clinical disease were of the capsular type b. Eight per cent (four of 50) of H. influenzae infections were caused by beta-lactamase producing strains. There was no geographic clustering or seasonal variation. There was no mortality. Major morbidity included two patients who had epiglottis and required tracheostomy, and two patients who had meningitis developed bilateral profound sensorineural deafness. No secondary cases were detected in household contacts of 21 patients with H. influenzae meningitis during the study period. Epiglottis frequently occurs in very young children. The rapid response to antibiotic treatment suggests that early cases of epiglottis may be undiagnosed, but treated with antibiotic agents in the community.

[Acute epiglottitis. Diagnosis and treatment in eight cases (author's transl)]

A revision of acute epiglottitis is carried out with reference to eight cases recorded from 1973 to 1981. The ages of the patients varied from 12 to 35 months, with a female predominance (7:1) and a seasonal pattern occurring in winter months. Authors establish the attitude to be taken when faced to a patient clinically suspected of having acute epiglottitis, its' diagnosis and therapeutic protocol. The use of nasotracheal intubation instead of tracheostomy as the best way of obtaining a free airway in these patients at risk of sudden airway obstruction, is specially stressed.