Radiographic presentation of pulmonary tuberculosis in young children

Ten cases of pulmonary tuberculosis (TB) with the isolation of Mycobacterium tuberculosis in patients under 6 years of age occurring between July 1994 and June 1998 were retrospectively reviewed. Radiographs showed air-space consolidation (n = 4), micronodular (n = 3) and miliary lesions (n = 1). Two patients showed non-specific bronchopneumonic infiltrations. Other uncommon radiographic findings include pneumatocele formation and pleural effusion. Lymphadenopathies were detected in 6 (60%) cases using chest radiographs or computed tomography (CT), commonly with involvement of the paratracheal and hilar lymph nodes. However, most lymph node enlargement was not noted in routine postero-anterior (PA) radiographs and usually required a chest CT scan for confirmation. Since lymphadenopathy is common in children with pulmonary TB in Taiwan, we suggest using chest CT scans to detect such pathology in cases of suspected TB if other diagnostic tests are not conclusive.

Pregnancy with primary tubal placental site trophoblastic tumor--A case report and literature review

Placental site trophoblastic tumor (PSTT) is a rare trophoblastic neoplasm with malignant potential. The diagnosis and prognosis of this rare disease remain difficult. A case of tubal PSTT with the primary manifestation of internal bleeding at 30 weeks' gestation is presented. Emergency exploratory laparotomy and right partial salpingectomy were performed initially. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy were done immediately after cesarean section at 34 weeks' gestation. No further adjuvant therapy was given after surgery. No evidence of tumor recurrence or signs of metastasis were noted during 12 months of follow-up. Heterotopic pregnancy, one with intrauterine normal pregnancy and the other with implanting in the right fallopian tube and placental site trophoblastic tumor transformation, was proposed. To our knowledge, this is the first such case in the English literature.

Diagnosis of necrotizing fasciitis in children

Necrotizing fasciitis is a rare but progressive soft tissue infection. This condition is difficult to recognize in the early phase, when it is often confused with cellulitis. We report the cases of four children with necrotizing fasciitis. The initial presentation in these cases was cellulitis. Fever and soft tissue swelling occurred within 24 h and spreading erythema within 4 to 12 h. Radiologic studies of the lesions showed soft tissue thickening. Ultrasonography of the lesions demonstrated distorted, thickened fascia with fluid accumulation. Well-defined, loculated abscesses were demonstrated in two cases. Although typical dusky skin and purplish patches were not found in our cases, necrotizing fasciitis was strongly suspected on the basis of the clinical course and sonographic findings. Ultrasonography also was used as a guide for aspiration of pus. Gram-stained smears and bacterial cultures yielded the pathogens. The choice of antibiotic therapy was made on the results of smears and culture. All patients survived after immediate surgical debridement, intensive antibiotic therapy, and aggressive wound care. In conclusion, ultrasonography provides a rapid and valuable diagnostic modality for necrotizing fasciitis. The pus obtained through sonographically guided aspiration for bacterial culture can allow identification of the pathogenic organisms.

Predictors for extraintestinal infection of non-typhoidal Salmonella in patients without AIDS

To identify the risks and predictors for extraintestinal infection (EII) in patients with non-typhoidal salmonellosis, we undertook a study of 398 patients with cultures positive for non-typhoidal Salmonella seen at Chang Gung Memorial Hospital and Chang Gung Children's Hospital between November 1993 and October 1994. Salmonella choleraesuis was the most invasive serotype observed. S. panama, S. typhimurium and S. schwarzengrund were the commonest causes of EII among those serotypes usually causing gastroenteritis. Pre-existing underlying disease, particularly immunosuppressive disease, was the most important risk factor that may have predisposed adult patients to have EII. Old age (> or = 60 years) and isolation of invasive serotypes were also frequently associated with EII in adult patients. The characteristics of paediatric patients with a high probability of having EII were: < 3 years of age, abnormal blood test results (a leucocyte count > or = 15,000/mm3 or < 5000/mm3, immature leucocytes > or = 10% of total leucocytes, and a C-reactive protein concentration > or = 50 mg/l); and isolation of invasive serotypes. This information can be an aid to early diagnosis and treatment of EII caused by non-typhoidal Salmonella.

Outbreak of Candida parapsilosis fungemia in neonatal intensive care units: clinical implications and genotyping analysis

During a 5-month period, 17 infants hospitalized in neonatal intensive care units of a medical center and a branch hospital developed 18 episodes of Candida parapsilosis fungemia. The mean age at onset was 35 days. Prior to fungemia, all the infants had received hyperalimentation and antibiotics, and 15 infants had had central venous catheters. The presenting symptoms were variable but only vague in 40% of the episodes. Despite administration of antifungal agents, subsequent eradication of fungemia was achieved in only two-thirds of the episodes. None of the environmental samples was positive for C. parapsilosis, while 20% of hand-washing samples of staff working in both units yielded this microorganism. Four genotypes with two main types were identified from 14 outbreak strains and eight genotypes from 14 hand-washing strains, with one type predominant. The results suggest that C. parapsilosis fungemia increases the morbidity and mortality of neonates but does not cause acute lethal events. The outbreak was caused by two main genotypes, possibly via cross-infection by the hands of health care workers.

Prompt recognition of necrotizing fasciitis in a newborn

We report a 13-day-old female neonate with necrotizing fasciitis, who presented with fever and erythema on her back. Rapidly progressive extension of the erythema to the abdominal wall occurred within 12 hours. Sonography for the lesion showed extensive fascial thickening with fluid accumulation. An abscess was also demonstrated. Necrotizing fasciitis was highly suspected. Under sonographic guidance, pus was aspirated from the abscess. A smear for the aspirated pus revealed a large number of neutrophils and abundant gram-positive cocci. Immediate surgical debridement was done. Cultures from the pus and blood revealed Staphylococcus aureus. The patient was free of symptoms after surgical debridement and aggressive antibiotic therapy. She had skin grafting to reconstruct the debrided wound on the 20th hospital day and was discharged shortly after the debridement of wound.

Congenital tracheobronchial stenosis in monozygotic twins

A pair of monozygotic twins suffering from noisy respirations and recurrent wheezes since early infancy were referred for evaluation. Using direct coronal CT and 3-dimensional reconstruction of the airway, congenital tracheobronchial stenosis was found in both twin babies, later confirmed by fibre optic bronchoscopy. The cause of congenital tracheobronchial stenosis remains obscure, but even in monozygotic twins an unidentified environmental factor cannot be excluded and may be responsible for discordant bronchopulmonary abnormalities.

CONCLUSION

This case report shows that tracheobronchial stenosis may present in monozygotic twins. The pattern of malformation in twins differs from cases described previously.

Activating a zymogen without proteolytic processing: mutation of Lys15 and Asn194 activates trypsinogen

The zymogen and mature enzyme forms of trypsin-like serine proteases exhibit a wide range of activities. The prototypical trypsinogen-trypsin system is an example of a minimally active zymogen and a maximally active mature protease. The present work identifies several features of trypsinogen which govern its activity. Our results indicate that rat trypsin is 10(8)-fold more active than rat trypsinogen. Rat trypsinogen appears to be less active than bovine trypsinogen. His40 is believed to be an important determinant of zymogen activity. We are unable to verify this role for His40 in trypsinogen since the mutation of His40 to Phe appears to change the trypsin-substrate interface. Deletion of the N-terminal Ile16 from trypsin is expected to produce a trypsinogen-like protein since the Ile16-Asp194 salt bridge cannot form. Such mutants have higher activity and BPTI affinity than trypsinogen, which indicates that the activation peptide stabilizes the inactive trypsinogen conformation. The mutation of Lys15 to Ala increases the BPTI affinity and activity of trypsinogen to an even greater extent; thus, removal of Lys15 can account for the effect of the loss of the activation peptide. These results suggest that Lys15 is an important determinant of zymogen activity. The mutation of Asp194 to Asn also increases the BPTI affinity and activity of trypsinogen. This result suggests that in addition to stabilizing the active conformation of trypsin via the Ile16-Asp194 salt bridge, Asp194 also maintains the inactive conformation of trypsinogen. A correlation exists between the values of kcat/Km and BPTI affinity of mutant trypsinogens and trypsins. However, the slope of this correlation is 0.64, which indicates that different "active" conformations are involved in BPTI binding and substrate hydrolysis. DeltaI16V17 trypsinogen is the lone outlier; its BPTI affinity is higher than would be expected based on the value of kcat/Km. We show that the rate of BPTI association is slower for DeltaI16V17 trypsinogen than for a mutant trypsinogen with a similar BPTI affinity. This observation suggests that BPTI binds to an "active" trypsinogen conformation that is not kinetically accessible to substrates.

Outbreak of Candida albicans fungaemia in a neonatal intensive care unit

During a 4-month period, 9 premature infants hospitalized in a neonatal intensive care unit (NICU) developed Candida albicans fungaemia. All 9 infants received antifungal agents. Fluconazole was administered in 7 patients and successfully eradicated this organism in 6 with no adverse effects. For epidemiological investigation, 64 environmental specimens and hand-washings of all 54 staff members involved in the NICU were examined for the presence of this organism. No C. albicans could be identified from environmental sources, while the hand-washing of 1 nurse was C. albicans-positive. Two genotyping methods, including electrophoretic karyotyping using contour-clamped homogeneous electric field gel electrophoresis and polymerase chain reaction-based direct sequencing of rRNA gene, were used in the analysis of the isolates recovered from blood cultures of the infants, the hand-washing of the nurse and 7 control isolates. Both methods yielded comparable results and revealed that all 13 isolates from infected infants as well as the isolate from hand washing of the nurse were of the same genotype while the control isolates were distinct. These results suggest that the outbreak of C. albicans fungaemia was caused by a particular strain and possibly via cross-infection. In addition, we showed that fluconazole seemed to be safe and effective in treating C. albicans fungaemia in neonates, although the data were limited.

Association of fungal colonization and invasive disease in very low birth weight infants

BACKGROUND

Fungi are common pathogens of nosocomial infections in the very low birth weight (VLBW) infants. The purpose of this study was to investigate the fungal colonization rate in VLBW infants and the association between fungal colonization and systemic fungal diseases.

MATERIALS

Between January 1, 1996, and December 31, 1996, 116 infants with birth weight < 1500 g admitted to the neonatal intensive care unit of Chang Gung Children's Hospital in the first day of life were included in this prospective study.

METHODS

Cultures from oropharynx, rectum, skin (groin and axilla), bag urine and endotracheal aspirates were obtained in the first 24 h after birth and weekly thereafter throughout their neonatal intensive care unit stay. Medical records were reviewed weekly.

RESULTS

Fungal colonization was detected in 25 infants, among whom 17 infants developed colonization by 2 weeks of life. Candida albicans (61%) and Candida parapsilosis (29%) were the 2 most common organisms. The rectum (76%) was the most frequent site of colonization. Factors significantly associated with colonization were prolonged administration of antibiotic therapy, parenteral nutrition and intralipid emulsion. Three of 116 infants developed fungemia. The association between colonization and subsequent fungemia was demonstrated in 1 infant, representing 4% of colonized infants.

CONCLUSION

Fungal colonization was detected in one-fifth of VLBW infants and represents a risk factor for fungemia. Because disease occurred in the absence of apparent colonization, factors other than colonization may contribute to invasive candidiasis.

Antimicrobial susceptibilities of Campylobacter jejuni and coli by using E-test in Taiwan

To report the in vitro antibiotic susceptibility of Campylobacter species, we determined the MICs of 6 antibiotics by E-test for 93 human clinical strains and 35 chicken strains. The 6 antimicrobial agents tested were gentamicin, erythromycin, clindamycin, tetracycline, ciprofloxacin, and nalidixic acid. Isolates from humans were significantly more susceptible than chicken strains to erythromycin, clindamycin and ciprofloxacin. Nearly all of the human and chicken strains were susceptible to gentamicin. Among human isolates of C. jejuni, cross-resistance between nalidixic acid and ciprofloxacin was found in 66% of the strains, but none of the nalidixic acid-susceptible strains was resistant to ciprofloxacin. The higher prevalence of ciprofloxacin resistance in this area may be attributable to the large amount use of quinolones in poultry. Because of the high resistance rates of chicken isolates to the commonly used antimicrobial agents, it is necessary to create innovative methods to limit the inappropriate use of antibiotics in poultry in order to prevent the spread of the drug-resistant strains to humans.

Characterization and functional analysis of the porcine lactoferrin gene promoter

Lactoferrin, a ferric binding glycoprotein found in milk, can possibly prevent microbial infection of the mammary gland and gastrointestinal tract. To define the regulation of the porcine lactoferrin gene (pLTF), we cloned its 5'-flanking region from a porcine liver genomic library and analyzed the 5' upstream region of approx. 4kb, two exons, and an intron. The transcription start site was localized by primer extension to residue G, which is 41 nucleotides upstream from the ATG start codon. The pLTF 5'-flanking region possesses several putative cis-acting regulatory elements found in both housekeeping and inducible genes; to define their function, they were inserted into a chloramphenicol acetyltransferase reporter construct. The region up to -156 sufficed for basic promoter activity, whereas the region up to -780 was required for maximal promoter activity in porcine testis cells (STcells), kidney cells (PK15 cells) and human mammary epithelial cells (HBL-100 cells). Detailed analysis of this proximal region by DNase I footprinting and electrophoretic mobility shift assays reveals that the ubiquitous factors SP1, AP2 and the mammary gland-specific factor (MGF) might play significant roles in regulating the transcription of the pLTF gene.

Spontaneous resolution of an intratracheal mass: report of one case

A 14 year-old boy was investigated for a slowly resolving right upper lobe consolidation persisting for 3 months after a pneumonic episode. A flexible bronchoscopy showed a polypoid mass in the carina with extension to the right proximal bronchus. The bronchial washings study for fungus, acid-fast bacilli and polymerase chain reaction for mycobacterium were negative. A reported bronchoscopic examination 8 months later revealed no tracheal mass or subsequent stenosis. A tracheal mass in an asymptomatic and non-progressive child may be managed alternatively by repeated bronchoscopic examinations at intervals instead of immediate bronchoscopic excision or thoracotomy.

Swyer James syndrome following Mycoplasma pneumoniae pneumonia: report of one case

A previous healthy 5 year-old girl developed a right hyperlucent lung following Mycoplasma pneumoniae pneumonia 14 months before admission. Serial chest radiographs revealed a persistent right upper lobe atelectasis and gradual development of the right hyperlucent lung associated with frequent bouts of wheezing and exertional dyspnea. Physical examination showed markedly decreased breathing sounds in the right hemithorax with fine inspiratory crackles and expiratory wheezes. A diagnosis of Swyer James syndrome was confirmed by the exclusion of other causes of unilateral hyperlucent lung using computed tomographic scans of chest, fiberoptic bronchoscopy and lung perfusion scintigraphy. She has been followed up at our hospital using anti-asthmatic medication.

Schizophrenia: conceptual change in modern psychiatry

Schizophrenia is perhaps the most devastating mental illness that psychiatrists must treat. Its chronic course with deteriorating consequences has been the focus of study throughout this century. This paper reviews the concept of schizophrenia, from fundamental Kraepelinian theory of 'dementia praecox' to biological correlates and explanation. Its causes, however, remain obscure and there were no appreciable changes in its treatment modality. A 'bio-psycho-social' model of care is emphasized, aiming at the prevention of deterioration of symptoms, functional impairment, disability and social handicap.

Hair growth cycle affects hair follicle destruction by ruby laser pulses

It has been shown that normal mode ruby laser pulses (694 nm) are effective in selectively destroying brown or black pigmented hair follicles in adult Caucasians. This study investigated how the various stages of the hair follicle growth cycle influence follicle destruction by ruby laser treatment, using a model of predictable synchronous hair growth cycles in the infantile and adolescent mice. A range of ruby laser pulse fluences was delivered during different stages of the hair growth cycle, followed by histologic and gross observations of the injury and regrowth of hair. Actively growing and pigmented anagen stage hair follicles were sensitive to hair removal by normal mode ruby laser exposure, whereas catagen and telogen stage hair follicles were resistant to laser irradiation. Selective thermal injury to follicles was observed histologically, and hair regrowth was fluence dependent. In animals exposed during anagen, intermediate fluences induced nonscarring alopecia, whereas high fluences induced scarring alopecia. The findings of this study suggest treatment strategies for optimal laser hair removal.

Downregulation and subcellular redistribution of the gamma-aminobutyric acidA receptor induced by tunicamycin in cultured brain neurons

The significance of N-linked glycosylation and oligosaccharide processing was examined for the expression of gamma-aminobutyric acidA receptor (GABA(A)R) in cultured neurons derived from chick embryo brains. Incubation of cultures with 5 microg/ml of tunicamycin for 24 h blocked the binding of 3H-flunitrazepam and 3H-muscimol, probes for the benzodiazepine and GABA sites on the receptor, by about 20% and 28%, respectively. The loss of ligand binding was due to a reduction in the number of binding sites with no significant changes in receptor affinity. Light microscopic immunocytochemistry also revealed that the treatment reduced approximately 13% of the intensity of GABA(A)R immunoreactivity in the neuronal somata. Furthermore, the fraction of intracellular receptors was decreased to 24% from 34% of control in the presence of the agent, as revealed by trypsinization of cells in situ followed by 3H-flunitrazepam binding. The molecular weight of the receptor subunit protein was lowered around 0.5 kDa after tunicamycin treatment, in accordance with that following N-glycosidase F digestion, indicating the blockade of N-linked glycosylation of GABA(A)R by tunicamycin. Moreover, intense inhibitions of 91% and 44%, respectively, were detected to the general galactosylation and mannosylation in the tunicamycin-treated cells, whereas the protein synthesis was hindered by 13%, through assaying the incorporation of 3H-sugars and 3H-leucine. Nevertheless, treatment with castanospermine or swainsonine (10 microg/ml, 24 h), inhibitors to maturation of oligosaccharides, failed to produce significant changes in the ligand binding. In addition, in situ hybridization analysis showed that these three inhibitors did not perturb the mRNA of GABA(A)Ralpha1-subunit. The data suggest that tunicamycin causes the downregulation and subcellular redistribution of GABA(A)R by producing irregularly glycosylated receptors and modifying their localization. Both galactosylation and mannosylation during the process of N-linked glycosylation may be important for the functional expression and intracellular transport of GABA(A)R.

Yeast carriage on hands of hospital personnel working in intensive care units

The frequency and distribution of yeast carriage on the hands of hospital personnel working in intensive care unit (ICUs), was investigated. Hand carriage of yeast and Candida species was 46 and 29%, respectively. Rhodotorula sp. and Candida parapsilosis were most frequently recovered. There was no significant difference in frequency or distribution of yeasts and Candida sp. recovered among the three ICUs. Seventeen C. parapsilosis isolates and three Candida albicans isolates were genotyped by electrophoretic karyotyping using contour-clamped homogenous electric-field gel electrophoresis. Eleven separate types of C. parapsilosis and two types of C. albicans were identified. There was no common genotype among these isolates, even within the same unit. We conclude that yeast carriage on the hands of personnel working in ICU is common, but these yeasts are usually not acquired from a common source in the ICU.

Hypothermia predisposing to Pseudomonas putida sepsis in a child with panhypopituitarism

A 14-year-old boy presented with a 1-week history of hypothermia and obtundation. His medical history included surgical resection of craniopharyngioma with postoperative visual impairment and panhypopituitarism. The patient's rectal temperature remained persistently lower than 35 degrees C during the first 3 days of hospitalization. His blood pressure was 90/56 mmHg on admission. The peripheral blood leukocyte count was 2.7 x 10(10)/L with 18% neutrophils, 19% band forms, 44% metamyelocytes, 3% myelocytes, and 16% lymphocytes. The C-reactive protein concentration was 133.9 mg/L. Two separate blood cultures both yielded Pseudomonas putida. The patient was treated with amikacin and ceftazidime along with aggressive fluid therapy. Replacement therapy directed at his hormonal deficiencies was initiated as soon as his hemodynamic status was stabilized. The patient responded well to therapy with a gradual rise in body temperature and improvement in general activity. A growth experiment carried out on the P. putida isolate showed that the bacteria grew more rapidly at 30 degrees C than at 37 degrees C. The clinical course of the patient, as well as the results of the laboratory study, suggest that hypothermia may predispose human infection with P. putida.

Hemoptysis in children

BACKGROUND

Hemoptysis is rare in children, yet is one of the most frightening manifestations of cardiopulmonary disease. A wide spectrum of diseases has been reported to cause hemoptysis in children, but the search for a specific cause can be tedious and unrewarding. Early diagnosis and interventions of hemoptysis are extremely important for the successful management of this potentially lethal process in children.

METHODS

From July 1994 to June 1996, 15 pediatric patients ranging from 1 month to 15 years of age were admitted to the Pulmonology division for the investigation of hemoptysis. We retrospectively reviewed the clinical records and diagnostic evaluations of these patients.

RESULTS

Six (40%) of the patients investigated were infectious in origin, only one patient had tuberculous infection. Three patients had a traumatic cause and 2 patients had foreign bodies in the airway. Two cases had no obvious contributing cause of hemoptysis despite extensive investigations. One patient had hematemesis because bleeding from esophageal ulcerations was misinterpreted as hemoptysis. One patient had varicosed tracheal and bronchial collaterals causing massive hemoptysis due to portal vein obstruction and hypertension.

CONCLUSION

Pulmonary infection was the leading cause of hemoptysis in the 15 children we studied, but Mycobacterium tuberculosis is an uncommon causative agent. Bronchoscopy is an extremely useful tool for the diagnosis and localization of hemoptysis. Hematemesis may be misinterpreted as hemoptysis, particularly when an accurate history is not possible in children, therefore, bleeding from the upper aerodigestive tract should be studied meticulously and excluded adequately using endoscopy.

Pneumonia with pneumatocele formation caused by Mycobacterium tuberculosis: report of one case

Pneumatoceles are usually characteristic of staphylococcal pneumonia. They are rarely formed as one of the complications of Mycobacterium tuberculosis pneumonia. We report a 1-year-and-5-month old male child with pneumonia who was confirmed to have the rare complication, pneumatocele formation, by chest radiography and computed tomography. Since the patient did not respond to empiric antibiotic therapy, gastric larvage through a nasogastric tube was performed on three consecutive mornings and, as a result, acid fast rods were found on the three specimens. The cultures subsequently yielded M. tuberculosis. He was finally cured with a 6-month course of antituberculous chemotherapy. We conclude that tuberculosis should be considered in infants or young children with pneumonia that presents radiologically as pneumatocele formation, especially in whom there has been no response to empiric antibiotic therapy.

Oral acyclovir prophylaxis of varicella after intimate contact

OBJECTIVES

Whether oral acyclovir (ACV) given in late incubation can prevent clinical varicella or not.

MATERIALS AND METHODS

Twenty-seven healthy infants and children susceptible to varicella received oral ACV (40 mg/kg daily in four divided doses) for 5 days, starting 9 or 11 days after exposure from the index case in the family (2 in the classroom). The clinical features were compared with 13 control children who did not receive ACV. Enzyme-linked immunoassay was used to detect varicella-zoster virus (VZV) antibody and, in follow-up immunologic studies, lymphocyte proliferative response was added. In some cases, blood culture and polymerase chain reaction with Southern hybridization were used for detection of viremia.

RESULTS

Among the 27 children in the treatment group, two (7.4%) developed the disease and seroconversion was observed in 17 subjects (63%). Follow-up immunologic studies in 12 of these 17 seroconverted subjects 30 months later showed persistent cellular and/or humoral immunity to VZV. Only one subject, bled 11 days after exposure, had positive VZV DNA and blood culture for VZV. On the other hand 10 of 13 (77%) control subjects developed clinical varicella.

CONCLUSIONS

Oral ACV administration to healthy susceptible subjects at the beginning of secondary viremia in the late incubation period (9 days after exposure) can effectively prevent or modify clinical varicella.

Specific immune response in adult medical personnel immunized with acellular pertussis vaccine with special emphasis on T helper cell response

Recent epidemiologic data have indicated that adults are the most important reservoir that transmit pertussis to children. However, conventional whole cell pertussis vaccine is contraindicated in adults and children over 7 years of age because of the unacceptably high rate of adverse reactions. The aim of this study is to evaluate the specific cellular immune responses and adverse reactions to a less reactogenic acellular pertussis vaccine in adult volunteers. Eighty healthy medical personnel in Chang Gung Children's Hospital were enrolled. Volunteers in each group received: (1) Td + full strength acellular pertussis vaccine (PT, 1 microgram/0.5 ml; FHA, 4 micrograms/0.5 ml); (2) Td + half strength acellular pertussis vaccine; (3) Td alone. Lymphocyte phenotypic analysis, antigen-specific antibody titers, antigen-specific proliferative response and cytokine levels were evaluated before and 1 month after vaccination. Our data revealed: (1) the adverse reactions were minimal; (2) phenotypic analysis showed no non-specific activation of helper T or memory T cell after vaccination; (3) both PT and FHA-specific antibody titers increased significantly after vaccination, (4) PT antigens had a mitogenic effect on cord blood mononuclear cells and peripheral blood mononuclear cells of the adult volunteers; (5) FHA-specific T cell proliferative responses significantly increased after vaccination; (6) the cytokine production pattern showed predominant activation of Th 1 cells as reflected in increased production of gamma-IFN after vaccination. Acellular pertussis vaccine can effectively induce both humoral and cellular immune response in adults.

Acetaminophen overdose in children and adolescents

From 1982 to 1997, 12 Chinese children were admitted to Chang Gung Memorial Hospital with acetaminophen overdose. Six subjects (one young child, and five adolescents) developed liver damage which was severe in three cases (AST > 1000 IU/L). Acetaminophen-induced liver function abnormalities were characterized by elevation of transaminase levels with ALT higher than AST(6/6), coagulopathy(5/6), thrombocytopenia (1/6), but absence of jaundice(6/6). Fortunately, none of the six patients with liver damage developed fulminant liver failure, and all recovered completely. Acetaminophen overdose can cause significant morbidity in children and adolescents. Caretakers should be well instructed to give the drug correctly. So far, acetaminophen is still considered as the drug-of-choice for antipyresis in pediatric practice. However, multicentered collaborative study is necessary to determine whether acetaminophen intoxication causes less hepatic failure in Chinese children than in Western children.

Isolation and expression of a porcine lactoferrin gene

OBJECTIVE

To elucidate the spatial and temporal expression of a porcine lactoferrin (LTF) gene.

ANIMALS

4 female and 4 male Large White pigs.

PROCEDURES

We examined LTF expression in various organs excised from the pigs, using northern blot hybridization with a porcine LTF cDNA probe. Antibodies against porcine LTF were raised in rabbits and were used along with immunohistochemical staining to localize the LTF protein.

RESULTS

High amounts of porcine LTF mRNA were detected in the secreting mammary gland and epididymis. This distribution is consistent with that of porcine LTF examined by immunohistochemistry. In female pigs, porcine LTF mRNA concentration increased remarkably in the ductal cells of the lactating mammary gland then significantly decreased at day 21 after parturition. Furthermore, specific staining for LTF was observed in the epithelial cells of the gastrointestinal tract of female pigs, but not in the uterus, ovaries, spleen, kidneys, pancreas, muscles, heart, brain, lungs, or liver of postpartum female pigs, or in the testes of male pigs.

CONCLUSIONS

Gene expression of porcine LTF is closely related to lactation in the mammary gland. Distribution of LTF in the epididymis suggests that LTF may have a regulatory role in development of the reproductive tract of male pigs.

Fatal Haemophilus influenzae pneumonia: two cases report

Haemophilus influenzae is a common cause of acute childhood pneumonia. Most Haemophilus pneumonia generally follow a benign course with occasional complications of pleural effusion, pneumothorax or pneumatocele. Deaths following invasive Haemophilus pneumonia have rarely been reported in children older than 3 years of age. We report 2 deaths in children presenting with fulminant pneumonia, complicated by sepsis and adult respiratory distress syndrome despite vigorous antibiotic therapy and full resuscitative measures.

Salmonella typhimurium brain abscess in a six-month-old infant: a case report and review of the literature

We report the case of a six-month-old male infant with brain abscess caused by Salmonella typhimurium. Upon admission, he was suffering from fever, diarrhea, drowsiness and convulsion. Salmonella meningitis was identified by CSF examination. Following failure of antibiotic therapy to control his fever, brain computerized tomography (CT) was ordered 5 days later and revealed a brain abscess. He received surgical excision of the abscess and recovered completely after receiving ceftriaxone therapy for 8 weeks. The case of our patient, together with 11 cases of Salmonella brain abscess from the English literature are reviewed. There was a male preponderance among these patients (male: female = 2.67 : 1) and the majority were less than one year old. Salmonella typhimurium, typhi, and enteritidis occurred most frequently. Fever, seizure, signs and symptoms of increased intracranial pressure and change in mental status were the most common clinical features. Purulent meningitis was a major predisposing factor. Successful treatment was associated with early identification, prompt surgical intervention, high dose, long-term antibiotic therapy, and close follow-up for possible recurrence and to determine the presence of neurological sequelae.

Hepatitis C and G virus infections in polytransfused children

The prevalence of hepatitis C virus (HCV) and a newly identified hepatitis G virus (HGV) and their clinical significance were studied in 42 polytransfused Taiwanese children. Serological assays for antibodies against HCV (anti-HCV) and polymerase chain reaction for serum HCV ribonucleic acid (RNA) and HGV RNA were performed. The prevalence of anti-HCV and HGV RNA was 17% and 14%, respectively in 42 polytransfused children. Anti-HCV seropositives had a significantly higher mean age, peak serum transaminase level, and longer transfusion duration than seronegatives, while children with HGV infection usually had no or only mild hepatitis activities. The prevalence of anti-HCV dropped sharply after implementation of anti-HCV screening, however the prevalence of HGV viraemia remained unchanged.

CONCLUSIONS

HGV infection is not uncommon in polytransfused Taiwanese children and the virus does not cause significant hepatitis compared to HCV infection. Current blood donor screening for anti-HCV can effectively protect polytransfused children from HCV infection but the impact of additional screening for HGV markers awaits further studies.

Unusual manifestations in children with Kawasaki disease

Between January 1983 and December 1992, the medical records of 187 patients (116 boys and 71 girls) with Kawasaki disease (KD) who were admitted to the hospital in the acute phase were retrospectively reviewed. Of these, 175 patients (93.6%) were under 4 years of age. Among the six principal symptoms of KD, the incidence of cervical lymphadenopathy (41.2%) was relatively low. Additionally, we found some unusual features including intussusception in a 4-month-old female, transient thrombocytopenia in seven children (3.7%) and isolated azotemia in five. KD is a systemic disease of unknown etiology. The diverse associated features make KD puzzling and difficult to diagnose. In caring for children with KD, physicians should be alert to the principal symptoms as well as the unusual associated manifestations.

A pilot study of seven days of ceftriaxone therapy for children with Salmonella enterocolitis

BACKGROUND

The most effective therapy for non-typhoid Salmonella enterocolitis is still unknown. Traditionally, unless extraintestinal complications are present, antimicrobial drugs are not recommended, since earlier trials have shown that antibiotics such as ampicillin, chloramphenicol, or co-trimoxazole, do not shorten the duration of diarrhea and may even prolong convalescent fecal carriage of the bacteria. However, the recently-developed third generation cephalosporin ceftriaxone has been used successfully in the treatment of typhoid fever and other systemic salmonellosis. A controlled, pilot study was therefore undertaken to evaluate the efficacy of intravenous ceftriaxone in the treatment of children with non-typhoid Salmonella enterocolitis.

METHODS

Fifteen children with Salmonella enterocolitis and bacteremia who were eligible for antibiotic therapy were given ceftriaxone intravenously for 7 days and 15 children with enterocolitis but without bacteremia who were admitted for supportive treatment during the study period were selected as the control group. Available stool samples collected on days, 7, 14, and 30 after the completion of the drug therapy were checked for the presence of the bacteria using polymerase chain reaction (PCR) and culture methods.

RESULTS

The result showed that the duration of diarrhea was not significantly affected by ceftriaxone treatment. However, the difference in the rate of clearance of Salmonella from stools, as defined by negative stool cultures and PCR, was statistically significant between the two groups on posttreatment days 7 and 14. Only one patient given ceftriaxone was shown to have recrudescence of the bacteria in feces on day 14. One month after therapy, PCR was positive in two of the ten cases tested and one of these two experienced a relapse of diarrhea, whereas bacterial carriage was maintained in 63% of the control patients.

CONCLUSION

A prompt eradication of Salmonella in feces was observed in most of the patients treated with ceftriaxone in this study. If further studies confirm the efficacy of this therapy and the risk of inducing drug resistance is minimal, the epidemiologic problem created by convalescent fecal bacterial carriage may justify a short-course of ceftriaxone therapy for children with Salmonella enterocolitis.

Endocarditis due to Neisseria sicca: report of one case

Many species of the Neisseria, which are respiratory commensals in humans, have been regarded as being nonpathogenic or as causing disease in only immunocompromised hosts. We report a case in which Neisseria sicca was the cause of infective endocarditis in a child with a ventricular septal defect and review the literature on endocarditis due to N. sicca infection. Most of these patients had an underlying heart disease. Dental caries and poor oral hygiene may be two factors that predispose patients to the infection. N. sicca endocarditis usually results in a subacute onset of symptoms and, if not diagnosed early and treated, is associated with a high rate of embolic complications.

Microbiologic and histologic diagnosis of histoplasmosis in Taiwan

Histoplasmosis is one of the most common opportunistic fungal infections in immunocompromised patients in endemic areas. We report the first two microbiologically documented cases of histoplasmosis in Taiwan. The first patient, with acquired immunodeficiency syndrome and a depleted CD4+ lymphocyte count, presented with a history of prolonged fever, papular skin rashes, pancytopenia and elevation of liver enzymes. He was diagnosed and treated initially for systemic toxoplasmosis, but the microbiologic and pathologic findings of the autopsied specimens disclosed disseminated infection caused by Histoplasma capsulatum. The second patient, an elderly man receiving corticosteroids for adrenal insufficiency, manifested with laryngeal histoplasmosis and was successfully treated with ketoconazole.

Early echo-guided percutaneous aspiration of peripheral lung abscesses in children: report of two cases

A 9 year-old boy and a 7 year-old girl suffered from fever and chest pains before they were brought to Chang Gung Children's Hospital. Chest radiographs and computed tomography scans showed lung abscesses with pleural attachment, and using echo-guidance, percutaneous aspirations were done which confirmed the growth of Fusobacterium sp, and Veillonella parvula respectively, both of which are susceptible to penicillin G. The fever and chest pains subsided within 24 hours after the procedure. We suggest using early percutaneous aspiration of peripheral located lung abscesses soon after admission, rather than after a 10-14 day trial of antibiotic therapy: it can be a safe and cost-effective procedure to shorten the duration of the parenteral antibiotic treatment and hospitalization.

Tuberculosis of the long bone in children

From 1985 to 1994, there were 24 cases of long bone solitary tuberculosis. They were 18 boys and 6 girls with an average age of 18 months. All of the patients were treated by open biopsy and curettage and antituberculosis therapy (isoniazid and rifampin) for 6 months. Two patients had incomplete administration of the drug therapy. The lesions were in the metaphysis. Epiphyseal involvement was not significant. The tuberculin skin test was negative in 3 children and the culture was negative in 17 cases. After 2 years and 8 months' followup, there was radiographic evidence of good bone remodeling. Although there uncommonly is not a delay in diagnosis of skeletal tuberculosis despite prolonged symptoms, diagnostic biopsy with curettage of the lesion is indicated for isolated lesions, especially when the diagnosis is in doubt. It is significant that surgical debridement can shorten the duration of antituberculosis therapy and lead to improved results.

The arc index in evaluation of Class III malocclusion

Lateral cephalometric radiographs were obtained for 46 individuals (18 men and 28 women) aged 20 to 30 years. The sample consisted of Taiwanese with Class III malocclusions and prognathic facial profiles. A modification of the Sassouni arch analysis was used to evaluate this group. All parameters were compared with the norms for adult Taiwanese. The facial pattern of the Class III group was similar to that reported in other studies. The maxilla was in a retrusive position; the lengths of the maxilla and the mandible were significantly different from those in the normal group; the mandibular central incisor was retroinclined; and the total gonial angle, upper gonial angle, and lower gonial angle in the Class III group were significantly different from those angles in the normal group in both sexes. The arc index represented the maxillomandibular positional relationship. There was a statistically significant difference between the mean arc indexes of the Class III and the normal groups. The results indicated that the more negative the arc index, the greater the Class III tendency.

Double-blind placebo-controlled study of oxatomide in the treatment of childhood asthma

Oxatomide is an orally active H1-histamine receptor antagonist. It has been demonstrated to have therapeutic efficacy in the treatment of allergic diseases in adults. The aim of this study was to evaluate the efficacy and safety of oxatomide in the treatment of asthma in children. Sixty-four asthmatic children of both sexes, aged between 5 and 16 years, were enrolled in this double-blind, placebo-controlled trial with a duration of 4 months. Patients were randomized chosen to receive either oxatomide with a daily dose of 1 to 2 mg/kg body weight or a placebo twice daily. Clinical evaluations including pulmonary function tests and immunological studies. The patients' impression on the effect of treatment also were recorded during the study. The effects of bronchodilatation and normalizing pulmonary function were observed 2 months after oxatomide treatment. The levels of eosinophil cationic protein and total asthma symptom scores were significantly reduced during treatment with oxatomide. There was no significant change in total IgE or IgG4 before or after treatment in either the treatment or control groups. During the study, two (5.8%) oxatomide treated patients reported slight drowsiness and one (2.9%) reported body weight gain. Routine laboratory tests showed no significant alterations. In conclusion, oxatomide was generally well tolerated in this study and may have the potential of being an effective treatment for childhood asthma.

Identification of febrile neonates unlikely to have bacterial infections

OBJECTIVE

A prospective study was undertaken to evaluate the usefulness of low risk criteria for identifying febrile neonates unlikely to have bacterial infections, particularly bacteremia and meningitis. Using these criteria we wished to check whether these low risk neonates can be safely managed as inpatients under close observation but without receiving empiric antibiotic therapy.

STUDY DESIGN

We conducted a prospective study of 250 consecutive infants 28 days of age or less (range, 4 to 28 days) who had rectal temperatures of at least 38 degrees C. After a complete history, physical examination and sepsis workup, the 131 febrile neonates with clinical and laboratory findings indicating low risk for bacterial infections were hospitalized, closely observed and not given antibiotics. The low risk criteria used to identify these neonates included well appearance; absence of physical signs of an ear, eye or soft tissue infection; a white blood cell count of 5000 to 15,000/mm3, a neutrophil band form count of < 1500/mm3, a spun urine specimen that had < 10 white blood cells per high power field on microscopy and a C-reactive protein value of < 20 mg/l. The remaining 119 febrile neonates who did not meet the low risk criteria were hospitalized and given empiric antibiotics pending culture results.

RESULTS

The overall incidence of bacterial infections in the 250 febrile neonates was 16.4% (41 neonates) with bacteremia and/or meningitis occurring in 4.4% (11 neonates). Of the 131 low risk neonates only one (0.8%) had a bacterial infection (urinary tract infection) compared with 40 (33.6%) among the 119 who did not meet the criteria (P < 0.05). The negative predictive value of these criteria for excluding bacterial infections was 99.2% (95% confidence interval, 97.7% to 100%). For bacteremia and meningitis this figure became 100%. However, the positive predictive value and specificity of the criteria were too low to identify all febrile neonates with bacterial infections. Among the low risk group 58 (44.3%) were reclassified on the second or third hospital day, because of continued fever (35), poor activity (14) and white blood cell count > 15000/mm3 on a repeat blood test (9). They were given antibiotics, but only 1 had a urinary tract infection. This patient was then treated with a 7-day course of antibiotics. All low risk neonates recovered uneventfully with no relapses observed during their hospital stay or at the time of minimum 1-week outpatient follow-up visits.

CONCLUSION

By the low risk criteria a substantial number of febrile neonates at low risk for bacterial infections can be identified and managed safely as inpatients without antibiotic therapy.

Ileal perforation caused by congenital or perinatal cytomegalovirus infection

Enteritis developed in a 42-day-old female infant, and during hospitalization ileal perforation occurred unexpectedly. Serologic data, urinary viral culture, and pathologic studies of the resected ileal segment all suggested cytomegalovirus infection. Gastrointestinal involvement in congenital or perinatal infection with this virus may be relatively more common than previously recognized.

Invasive Haemophilus influenzae diseases and purulent meningitis in Taiwan

We conducted a 3-year Taiwan-wide hospital-based survey of invasive Haemophilus influenzae infections in children less than 15 years of age. From January 1992 to December 1994, 105 cases (57 boys, 48 girls) were reported. Seventy-three patients (69.5%) had meningitis and 32 patients had other diseases (12 pneumonia, 10 sepsis, 7 cellulitis, 3 arthritis). Fourteen patients (13%) died, all of whom had meningitis or sepsis. Among the 63 patients who survived meningitis, 17 (27%) had neurologic sequelae and eight (47%) had hearing impairment. The number of cases of H. influenzae meningitis (30%) and other H. influenzae diseases (29%) peaked in children between 6 and 12 months of age. Patients with invasive infections (82%) and meningitis (73%) were younger than 24 months of age. Only 12 patients (11%) were older than 5 years of age and four had underlying diseases. The annual incidence of invasive H. influenzae infections in children less than 5 years old was 1.9 per 100,000 per year. During the same period a survey of purulent meningitis in children younger than 15 years of age was also conducted in 20 hospitals. A total of 198 patients, in whom the causative organisms were identified, were included; 94 patients were 2 months of age or under and the most frequent pathogen was group B streptococci (35 cases, 37%). Among the 104 patients who were older than 2 months of age, H. influenzae was the leading cause (38 cases, 37%). In conclusion, invasive H. influenzae type b (Hib) diseases exist in Taiwan but have an incidence lower than in Western countries. Hib meningitis is still the most common cause of purulent meningitis in children in Taiwan and is an important cause of mortality and morbidity. Continuous active surveillance of invasive H. influenzae infections is suggested to determine the best time to introduce an Hib conjugate vaccine in Taiwan.

Diagnostic value of C-reactive protein in children with perforated appendicitis

The diagnostic value of serum C-reactive protein (CRP) levels in children with perforated appendicitis was prospectively studied in 78 consecutive patients with histologically confirmed appendicitis. The patients were divided into two groups: group A included 56 patients with perforated appendicitis and group B consisted of 22 patients with simple appendicitis. Serum CRP level and leucocyte count were assayed in all and abdominal ultrasonography was performed in 75. The mean age group A patient was significantly lower than that of group B patients (7.5 vs. 10.4 years, P < 0.001). Group A patients had a significantly higher mean serum CRP levels than group B patients (92 vs. 31 mg/l, P < 0.001), while the mean leucocyte count was comparable in the two groups. Of 75 examined patients, 73 (97%) had a pre-operative sonographic diagnosis of appendicitis.

CONCLUSION

Perforation is a common complication in children with appendicitis, especially in those of young age and with prolonged pain duration. Greatly increased serum CRP levels (> or = 50 mg/l) and abdominal ultrasonography are important diagnostic aids in such patients.

Responses to primary and a booster dose of acellular, component, and whole-cell pertussis vaccines initiated at 2 months of age

A second generation acellular pertussis vaccine (component pertussis vaccine) containing purified pertussis toxin (PT) and filamentous hemagglutinin (FHA) was tested for its immunogenicity and safety in 2-month-old infants in comparison with first-generation acellular and whole-cell pertussis vaccines. At the ages of 2, 4, 6, and 18 months, respectively, 350 subjects were inoculated one dose of pertussis vaccine, which was combined with diphtheria and tetanus toxoids. Both acellular and component vaccines elicited significantly much fewer local and systemic reactions than whole-cell vaccine did. Besides, although not reaching statistical significance, the component vaccine was less reactogenic than the acellular vaccine. After each dose of the primary immunization, antibodies against PT and FHA were much higher in acellular and component pertussis vaccinees than in whole-cell vaccinees. However, at 18 months of age, just before the booster dose, both anti-PT and anti-FHA declined very close to, or even lower than, the prevaccination levels in all three groups and then responded rapidly to a booster dose to attain high levels. The booster responses were also significantly higher (P < 0.01) in acellular and component groups than in whole-cell group. Component and acellular vaccines induced similar levels of anti-FHA but the former induced higher anti-PT than the latter (P < 0.01). Our results indicate that both in primary immunization and as a booster, acellular and component pertussis vaccines are much more immunogenic for PT and FHA and much less reactogenic than whole-cell vaccine. However, the persistence of anti-PT and anti-FHA was not as good as one can expect from other protein antigens without giving a booster dose. A long-term follow-up of the vaccinees has been underway to understand the persistence of these antibodies after the first booster.

The structure and expression of an hsc70 gene from Lycopersicon esculentum

A tomato hsc70 genomic clone (Lehsc70-3; Lycopersicon esculentum heat-shock cognate 70-3) was obtained by screening a genomic library with the tomato Lehsc70-2 cDNA. Two restriction fragments of 2.6 and 5 kb, which compose the Lehsc70-3 gene, were subcloned into pBluescriptIIKS+ and analyzed. Transcript mapping reveals that the mature Lehsc70-3 mRNA contains a 122-nt 5' untranslated region (UTR), a coding region of 1956 nt corresponding to a polypeptide of 651 amino acids, an intron of 717 nt and a 3' UTR. Analysis of genomic DNA indicates that Lehsc70-3 is present as a low-copy-number gene. We note that the sequence upstream from the coding region of Lehsc70-3 shares common features with a number of hsc/hsp genes. High-temperature treatment (37 degrees C) caused a twofold increase in the level of the Lehsc70-3 mRNA. However, Lehsc70-3 has also been expressed at substantial levels in tomato vegetative tissues, suggesting a general function of this hsc70 gene in L. esculentum.

Congenital anomalies following maternal varicella infection during early pregnancy

We report a typical case of congenital varicella syndrome following a maternal varicella infection during the 10th week of pregnancy. The presenting symptoms in the small gestational age baby were: cicatricial skin lesion, Horner's syndrome,dysphagia with resulting aspiration pneumonia and delayed developmental milestones. Serologic studies revealed persistence of varicella zoster virus IgG for at least 10 months. Although congenital varicella syndrome is rare, it should be kept in mind when counseling families where maternal varicella infection has occurred during the first 20 weeks of gestation. A maternal history of varicella infection, typical manifestations and serologic proof are crucial in the diagnosis of congenital varicella syndrome.

Evaluation of chronic atelectasis in children using chest computed tomography and bronchoscopy

A heterogeneous group of 11 children with atelectasis persisting longer than one month were investigated for the causes using chest computed tomography and fiberoptic bronchoscope. Four young infants had right upper lobe (RUL) posterior segmental atelectasis simulating RUL lobar collapse in plain chest films; all had only two visible segmental bronchi by bronchoscopic examination. Intraluminal obstruction in the central airway was not a common cause of pediatric chronic atelectasis in this small series of patients. Only one obstructive atelectasis caused by dilated pulmonary arteries was detected in this study. Two patients with pre-existing neuromuscular diseases showed multiple atelectasis. The atelectatic lobes do not spontaneously re-inflate following flexible bronchoscopy. Investigations involving a larger number of cases are needed to substantiate the etiologies and to guide specific therapy for those children with chronic atelectasis.

Hydrophobic interactions control zymogen activation in the trypsin family of serine proteases

Trypsinogen is converted to trypsin by the removal of a peptide from the N terminus, which permits formation of a salt bridge between the new N-terminal Ile (residue 16) and Asp194. Formation of this salt bridge triggers a conformational change in the "activation domain" of trypsin, creating the S1 binding site and oxyanion hole. Thus, the activation of trypsinogen appears to represent an example of protein folding driven by electrostatic interactions. The following trypsin mutants have been constructed to explore this problem: Asp194Asn, Ile16Val, Ile16Ala, and Ile16Gly. The bovine pancreatic trypsin inhibitor (BPTI), benzamidine, and leupeptin affinities and activity and pH-rate profiles of these mutants have been measured. The changes in BPTI and benzamidine affinity measure destabilization of the activation domain. These experiments indicate that hydrophobic interactions of the Ile16 side chain provide 5 kcal/mol of stabilization energy to the activation domain while the salt bridge accounts for 3 kcal/mol. Thus, hydrophobic interactions provide the majority of stabilization energy for the trypsinogen to trypsin conversion. The pH-rate profiles of I16A and I16G are significantly different than the pH-rate profile of trypsin, further confirming that the activation domain has been destabilized. Moreover, these mutations decrease kcat/Km and leupeptin affinity in parallel with the decrease in stability of the activation domain. Acylation is selectively decreased, while substrate binding and deacylation are not affected. Together these observations indicate that the stability of protein structure is an important component of transition state stabilization in enzyme catalysis. These results also suggest that active zymogens can be created without providing a counterion for Asp194, and thus have important implications for the elucidation of the structural features which account for the zymogen activity of tissue plasminogen activator and urokinase.