The upper limb-cardiovascular syndrome (Holt-Oram syndrome) in a South African family

The upper limb-cardiovascular syndrome is reported for the first time in a South African family. There were 6 affected members in 3 generations. Infradiaphragmatic total anomalous pulmonary venous drainage, with obstruction, was found in 1 child. This rare cardiac abnormality, which constitutes only 8,5% of all cases of total anomalous pulmonary venous drainage, itself an unusual abnormality, has not previously been reported in association with the Holt-Oram syndrome.

Hypertension as the major problem of idiopathic arterial calcification of infancy

We describe two infants with severe hypertension associated with idiopathic arterial calcification of infancy. In both children, blood pressure control was refractory to aggressive antihypertensive therapy. There was radiologic and laboratory evidence of renovascular disease requiring the use of specific renin antagonists and later nephrectomy, resulting in moderate improvement of hypertension. Although on occasion there is a familial incidence, in the vast majority of cases the diagnosis hinges on a high index of suspicion.

Patch graft aortoplasty for repair of coarctation of the aorta in infants under 1 year of age

Patch graft angioplasty for symptomatic coarctation of the aorta was carried out in 34 infants aged from 6 days to 9,5 months (mean 49,4 days). Congestive cardiac failure was present in 32 and severe hypertension alone in 2 patients. Of the 34 children, 21 (61,8%) had significant associated cardiac lesions and 25 (73,5%) were less than 6 weeks of age. Systolic blood pressures were recorded by the Doppler technique before and after the operation. There were 6 hospital deaths (17,6%) and 3 late deaths, giving a total mortality of 26,5%. Pre-operative systolic pressure gradients between upper and lower limbs ranged from 20 to 92 mmHg (mean 54,5 mmHg). Of the 28 early survivors, 1 was lost to follow-up. Duration of follow-up ranged from 3,5 to 62 months (mean 24,5 months). Postoperative residual gradients of less than 20 mmHg were found in 19 of the 27 cases followed up (70,4%), while 8 patients had significant residual gradients (40 - 90 mmHg). Of these 8, 7 had undergone surgery when less than 6 weeks old, and 6 of them have subsequently undergone a second corrective operation. It is concluded that while patch graft angioplasty is a life-saving procedure for the correction of symptomatic coarctation of the aorta in early infancy, a significant proportion of the patients develop a recurrence of coarctation necessitating further surgery later.

Significance of hypertension in children

This article does not consider the secondary causes of high blood pressure in children. Essential hypertension is a major factor in the morbidity and mortality from cardiovascular disease among adult populations throughout the world. The possibility that a raised blood pressure may have its origins in childhood or even in infancy is being extensively explored. Accurate measurement of blood pressure--especially systolic--is now feasible, by the Doppler technique, in very young children. The concept of "tracking" of blood pressure has been investigated. In addition, factors such as familial aggregation, genetic aspects, and the role of obesity in the etiology of hypertension have been considered. The reason for differences in the severity of manifestation of hypertension in black and white populations has not been satisfactorily elucidated, despite a number of childhood population studies. With an increased number of blood pressure measurements more children are being discovered with labile or even essential hypertension. The exact level above which to consider therapy is somewhat controversial. Nevertheless, even with mild persistent elevations, nonpharmacologic measures such as control of obesity, reduction in salt intake, regular exercise, potassium supplementation, and relaxation therapy, seem warranted. These measures should also be seriously considered in the prevention of hypertension in young urban populations.

Infective endocarditis due to non-toxigenic Corynebacterium diphtheriae in a child. A case report

A case of infective endocarditis (IE) in a 5 1/2-year-old boy in whom blood and bone marrow cultures yielded an unusual organism, a non-toxigenic strain of Corynebacterium diphtheriae, is reported. This proved fatal, and at autopsy congenital valvar aortic stenosis was found, but the vegetations occurred on an anatomically normal mitral valve. Organisms such as C. diphtheriae should not be ignored when isolated from blood cultures in suspected cases of IE.

Surgical correction of combined supravalvular and valvular aortic stenosis in homozygous familial hypercholesterolaemia

Although premature coronary atherosclerosis is a well-recognized complication of homozygous familial hypercholesterolaemia, involvement of the aortic root and valve has not been recognized frequently during life. Two cases of supravalvular and valvular aortic stenosis due to familial hypercholesterolaemia are described. Both patients underwent successful surgical correction of these lesions. The importance of relieving left ventricular outflow tract obstruction by a technique of aortic root enhancement and oblique insertion of a prosthesis is stressed.

Hypoplasia or absence of the depressor anguli oris muscle and congenital abnormalities, with special reference to the cardiofacial syndrome

An asymmetrical crying facies due to hypoplasia or absence of the depressor anguli oris muscle (DAOM) was observed in 23 infants and children. The cases were divided into two groups. Group 1 consisted of 12 patients who had associated cardiac abnormalities. In group 2 were 11 patients who either had other non-cardiac abnormalities (6) or no other abnormalities (5). The associated cardiac anomalies recorded in the literature are reviewed and 2 infants in this series are reported with abnormalities not previously described. The results of chromosomal analysis have generally been found to be normal, although a patient in our series was found to have trisomy E (18). The incidence of hypoplasia of the DAOM in newborn infants in a maternity hospital hospital is assessed and was found to be lower than reported in other studies. It is concluded that a detailed and careful examination for congenital abnormalities should be carried out on every child with an asymmetrical crying facies.

Intracranial arteriovenous fistulas in infancy--haemodynamic considerations

The clinical, electrocardiographic and radiological features and cardiac catheterization findings in 3 young infants with large intracranial arteriovenous fistulas are presented. In addition to the congestive cardiac failure, the haemodynamic disturbances which give rise to central cyanosis, pulmonary hypertension and, in some instances, poor peripheral pulses, are discussed. The cyanosis in these children may have been the result of a combination of right-to-left shunting at atrial or ductal level, as well as intrapulmonary shunting in association with pulmonary engorgement. Left ventricular dysfunction, with elevated end-diastolic pressures, appeared to be most marked in those cases in which poor peripheral pulses were present. Increased pulmonary arterial pressures (considerably greater than systemic arterial pressure in 2 of the cases) are considered to be due to a combination of the obligatory left-to-right shunt which results from the fistula, and to the super-added effect of altitude (1765 metres) with resultant pulmonary vasoconstriction.

Choanal atresia and congenital heart disease

The association of congenital heart disease with choanal atresia is described in 6 infants (2 White, 3 Black and 1 Coloured). The literature is reviewed and 46 similar cases are analysed. The combination of choanal atresia and congenital heart abnormality generally carries a poor prognosis.

Arteriohepatic dysplasia: association of liver disease with pulmonary arterial stenosis as well as facial and skeletal abnormalities

The clinical features and course of five children with the recently described syndrome of arteriohepatic dysplasia are presented. All had bilateral pulmonary arterial stenosis, proven at cardiac catheterization, as well as associated liver disease of varying severity. In one of the fatal cases, a hitherto undescribed anomaly was found--stenosis of the right coronary artery ostium. A viral etiology, eg, the congenital rubella syndrome, was considered most likely, but detailed investigations proved to be negative.

Rhabdomyoma of the heart in a newborn infant. Diagnosis by echocardiography

An intracavitary right ventricular tumour was identified echocardiographically before operation in an infant with a rhabdomyoma of the heart. Necropsy showed associated tuberous sclerosis.

Transposition of the great arteries associated with a double left ventricular outflow tract

A case is described in which, at semilunar valve level, the aorta and pulmonary artery arose from inappropriate ventricles. Despite this, the outflow tracts to both vessels originated from the left ventricle. Embryologically, it is speculated that this anomaly is the result of normal rotation of the proximal conus, without concomitant truncal inversion, and excessive leftward shift of the proximal conus and conal septum or anterior and rightward deviation of the anterior segment of the ventricular septum. Surgical repair using a double conduit between the right ventricle and pulmonary artery and left ventricle and aorta, respectively, was unsuccessful.

Significance of intracranial bruits in neonates, infants, and young children

In a control group an intracranial bruit (ICB) was heard in 4 of 13 children aged between 4 months and 3 years, but in none of 43 younger infants between the ages of one day and 4 months. In a group of 70 infants with cardiac murmurs of intensity grade III/VI or more, 19 of 30 aged between 4 months and 3 years had an ICB, compared with 4 of 40 younger infants aged between one day and 4 months (P less than 0.0005). It is concluded that in infants under the age of 4 months, even in the presence of a loud cardiac murmur, an ICB is rarely heard. The presence of an ICB, with or without signs of cardiac failure, strongly suggests an intracranial arteriovenous fistula.

The use of a curved uterine vulsellum for removal of rectal foreign bodies: report of a case

Removal of retained foreign bodies can be a tedious process, requireing considerable skill and ingenuity on the part of the surgeon. Employment of a curved, double-pronged, uterine vulsellum can be useful in simplifying removal of certain of these objects. A method which can be employed on an outpatient basis is described. When this method fails, suitable cooperation by the patient is lacking, or there is evidence of serious rectal injury or perforation, hospitalization for appropriate treatment under general or regional anesthesia is indicated.

Infantile cortical hyperostosis (Caffey's disease): a case report

An infant in hospital unexpectedly developed infantile cortical hyperostosis (Caffey's disease) while under-going treatment for an unrelated illness. The presentation of the disease was classic and there was marked thrombocytosis. The aetiological possibilities are discussed.