Does the cranio-cerebello-cardiac syndrome (3C syndrome) include abdominal malformations?

We report two children of nonconsanguineous parents, with hypotonia, severe psychomotor retardation, short stature, a prominent forehead, ptosis, a wide flat nasal bridge, broad nasal tip, a high arched palate, bilateral small cerebellar hemispheres, vermis hypoplasia, a large cisterna magna, and an atrial septal defect and a duodenal stenosis in one case. These features are part of the 3C syndrome. The duodenal stenosis present in one of our sibs has not been reported before in this syndrome.

Penicillin-nonsusceptible pneumococcus in acute otitis media in New York City

OBJECTIVE

To determine the proportion of children with acute otitis media (AOM) presenting in our catchment area in New York City who were infected with nonsusceptible Streptococcus pneumoniae and to determine the susceptibility of these organisms to penicillins and other antibiotics commonly used to treat AOM.

SETTING

Ambulatory clinics and the emergency department of a tertiary care, inner-city medical center.

PATIENTS

During a 2-year period from 1993 to 1995, 115 children (aged 6 months to 12 years) with AOM underwent tympanocentesis. Patients did not receive antibiotics for at least 1 week before tympanocentesis.

RESULTS

Thirty-one children were infected with S pneumoniae, and 83.9% of isolates were susceptible to penicillin. Of the 16.1% strains that were nonsusceptible, most (4 of 5 strains) were intermediately resistant, and only 1 exhibited high-level resistance to penicillin. Of all the cephalosporins tested, only cefotaxime had consistent activity against the intermediately resistant strains. Notably, all nonsusceptible pneumococci were inhibited by macrolides.

CONCLUSIONS

This study provides unique reference data for nonsusceptible Streptococcus pneumoniae in children with AOM and documents that newer cephalosporin agents are not active against all of these strains.

Lipid peroxides in middle ear fluid after acute otitis media in guinea pigs

Oxygen free radical damage has been demonstrated in the middle ear mucosa of a guinea pig model of acute otitis media (AOM). Potential sources of free radicals include both neutrophils responding to infection and Streptococcus pneumoniae, a common AOM pathogen. This project was conducted to examine the middle ear fluid in a guinea pig model of AOM for evidence of elevated lipid peroxide (LPO) as a marker of free radical damage. Twenty-one guinea pigs were injected transtympanically with bacteria into the left (infected) middle ear cavity and sterile saline into the right (control) middle ear. Middle ear fluid was recovered on postoperative day 5. The fluid was weighed and analyzed for quantity of LPO. Results indicated an increased absolute level of LPO, as well as an increased level of LPO divided by the weight of the fluid recovered. Histologic examination confirmed leukocyte infiltration and mucosal edema that were consistent with mucosal damage. While free radical damage to the middle ear mucosa in a guinea pig model of AOM is well documented, this is the first study to demonstrate evidence of free radical damage in middle ear fluid. These results are relevant because they correlate mucosal damage with lipoperoxidation in fluid. Additionally, this serves as an important precursor to human studies, since middle ear fluid is readily available in patients with otitis media.

Non-quassinoid constituents from the twigs and thorns of Castela polyandra

The structures of two new constituents, a beta-glycoside (1) and a steroid (2), isolated from the twigs and thorns of Castela polyandra, were established by a combination of spectroscopic and single-crystal X-ray analysis.

Evidence of oxygen free radical damage in human otitis media

Recent work with a guinea pig model of otitis media has demonstrated evidence of oxygen free radical damage to the middle ear mucosa. However, the relevance of an animal model to human disease is uncertain. Accordingly, the following pilot study was conducted to examine human middle ear fluid for lipid hydroperoxides as evidence of free radical damage. Thirty-five specimens of middle ear fluid from children with chronic otitis media were collected and described as mucoid (n = 19), purulent (n = 10), or serous (n = 6); specimens were weighed and analyzed for lipid hydroperoxide content. The results demonstrated the presence of lipid hydroperoxide in all 3 types of middle ear fluid. Additionally, there was a statistically significant elevation of total lipid hydroperoxide content in mucoid effusions compared with serous effusions, as well as a significant elevation of lipid hydroperoxide divided by weight of purulent effusions compared with serous effusions. This is the first study to document free radical damage in human otitis media.

Follow-up results of transvenous occlusion of patent ductus arteriosus with the buttoned device

OBJECTIVES

The purpose of this presentation is to document results of buttoned device (BD) occlusion of patent ductus arteriosus (PDA) in a large number of patients with particular emphasis on long-term follow-up in an attempt to provide evidence for feasibility, safety and effectiveness of this method of PDA closure.

BACKGROUND

Immediate and short-term results of BD occlusion of PDA have been documented in a limited number of children.

METHODS

During a six-year period ending August 1996, transcatheter BD closure of PDA was attempted in 284 patients, ages 0.3 to 92 years (median 7) under a protocol approved by the local institutional review boards and FDA with an investigational device exemption in U.S. cases.

RESULTS

The PDAs measured 1 to 15 mm (median 4) at the narrowest diameter; 20 were larger than 8 mm and 10 larger than 10 mm. They were occluded with devices measuring from 15 to 35 mm delivered via 7F (N = 140) or 8F (N = 144) sheaths. Successful implantation of the device was accomplished in 278 (98%) of 284 patients. The Qp:Qs decreased from 1.8+/-0.6 (mean+/-SD) to 1.09+/-0.19 (p < 0.001). Effective occlusion defined as no (N = 167 [60%]) or trivial (N = 79 [28%]) residual shunt was achieved in 246 (88%) patients. All types of PDAs, irrespective of the shape (conical, tubular or short), size (small or large) or length (short or long) of the PDA and previously implanted Rashkind devices, could be occluded. Follow-up data, 1 to 60 months (median 24) after device implantation, were available in 234 (84%) patients. Seven (3%) patients required reintervention to treat residual shunt with (N = 2) or without (N = 5) hemolysis. Actuarial reintervention-free rates were 95% at 1 and 5 years. There was gradual reduction of actuarial residual shunts and were 40%, 28%, 21%, 14%, 11%, 10%, 6% and 0% respectively at 1 day, 1, 6, 12, 24, 36, 48 and 60 months after device implantation. Incorporation of folding plug over the button loop in 10 additional patients produced immediate and complete occlusion of PDA.

CONCLUSIONS

This large multiinstitutional experience confirms the feasibility, safety and effectiveness of buttoned device closure of PDAs. All types of PDAs irrespective of the shape, length and diameter can be effectively occluded. Incorporation of folding plug over the button loop produces complete PDA occlusion at the time of device implantation.

Quassinoids from the twigs and thorns of Castela polyandra

The structures of six new C20 quassinoids and one new C19 quassinoid, all isolated from the twigs and thorns of Castela polyandra, were established by a combination of spectroscopic and single-crystal X-ray analysis. Five known quassinoids and one known sterol were also identified.

Pervasive developmental delay in children presenting as possible hearing loss

OBJECTIVE/HYPOTHESIS

Children who fail to develop adequate language skills and/or appropriate social skills by age 2 years often are referred to the department of otolaryngology for otolaryngologic examination and evaluation of possible hearing deficits. Discovering a gross disparity between hearing function and language ability often uncovers an underlying developmental disorder satisfying criteria for diagnosis on the spectrum of autism and pervasive developmental delay (PDD). The otolaryngologist has a unique opportunity to identify these autistic children and initiate their evaluation and management.

STUDY DESIGN

Retrospective review.

METHODS

Review of charts of children referred over the past 4 years to the Department of Otolaryngology for possible hearing loss identified 15 children who were later diagnosed with PDD.

RESULTS

Fifteen children initially referred for hearing evaluation were subsequently identified with a diagnosis of PDD. Males outnumbered females 4 to 1, with the average age of referral being 2 years. One third of the patients displayed middle ear disease that improved with PE tube placement. One third of the patients showed brainstem conduction dysfunction on auditory brainstem evoked response testing.

CONCLUSIONS

Children with developmental delays, especially higher functioning ones, may present with a myriad of language and communication deficits that are often mistakenly attributed to hearing loss. Otolaryngologists and audiologists can assist in their early identification and appropriate referral for therapy.

Partial left ventriculectomy: preoperative risk factors for perioperative mortality

This study aimed at determining risk factors for perioperative mortality for patients undergoing partial left ventriculectomy. Fourteen patients with end-stage congestive heart failure underwent partial ventriculectomy at our institution from February, 1995 to October, 1997. Mean age was 48+/-11 years, symptoms duration 44+/-34 months, New York Heart Association symptoms score 4+/-0, systolic blood pressure 97.69+/-20.06 mmHg, diastolic blood pressure 65.38+/-13.91 mmHg, heart rate 91+/-15 beats/min, furosemide daily dose 121.66+/-96.65 mg and captopril daily dose 68.75+/-76.76 mg. Seven (50%) patients needed inotropic support for hemodynamic stabilization. On echocardiography, left ventricular diastolic dimension was 81.71+/-11.92 mm. Left ventricular ejection fraction determined by radionuclide ventriculography or echocardiography was 16.71+/-5.13. At heart catheterization, mean right atrial pressure was 12.50+/-7.72 mmHg, mean pulmonary capillary wedge pressure 23.60+/-7.79 mmHg, and mean pulmonary artery pressure 34.10+/-12.81 mmHg. Twelve patients had idiopathic dilated cardiomyopathy and two patients had a globally dilated heart with single vessel coronary artery disease. Aneurysmectomy, mitral valve surgery or coronary artery bypass surgery were not performed in any patient. Four (28%) patients died: three in the operating theatre and one from low output syndrome 2 days after surgery. The proportion of patients operated on with cardiogenic shock was four (100%) in nonsurvivors and 0% in survivors (P=0.001). Inotropic support was necessary in three (30%) survivors and in four (100%) nonsurvivors (P=0.06). Thus, preoperative hemodynamic instability may be associated with perioperative mortality after partial left ventriculectomy.

Incidence and outcome of primary Epstein-Barr virus infection and lymphoproliferative disease in pediatric heart transplant recipients

BACKGROUND

The objective of this study was to assess the relationship between Epstein-Barr virus (EBV) infection and posttransplantation lymphoproliferative disease (PTLD) in pediatric heart transplant recipients. EBV is implicated in the development of PTLD. However, the relationship between primary EBV infection and PTLD is not well understood.

METHODS

Serial EBV titers were determined prospectively in 50 children before and after heart transplantation. Results were correlated with the development of PTLD. The clinical presentation, management, and outcome of PTLD were characterized.

RESULTS

Before transplantation, EBV titers were positive in 19 and negative in 31 patients. After transplantation, all EBV-positive patients remained positive; 1 developed PTLD. Among EBV-negative patients, 12 of 31 remained negative; none developed PTLD. Nineteen patients demonstrated serologic evidence of primary EBV infection after heart transplantation; 12 developed PTLD. Mean follow-up after heart transplantation was 3.3 years (range 0.4 to 8.4 years). Mean time from heart transplantation to histologic confirmation of PTLD was 29 months (range 3 to 72 months). Survival with PTLD was 92%.

CONCLUSIONS

Twelve of 13 pediatric heart transplant recipients who developed PTLD had evidence of primary EBV infection. Serial monitoring of EBV titers may lead to earlier identification and improved treatment of PTLD.

Retropharyngeal abscess and Epstein-Barr virus infection in children

A 6-year retrospective chart review was conducted of all pediatric patients with the diagnosis of retropharyngeal abscess (RPA) at the Columbia-Presbyterian Medical Center. The charts were examined for signs, symptoms, and serologic findings consistent with recent acute Epstein-Barr virus (EBV) infection. Of the 7 patients we studied, 4 had elevated immunoglobulin G antibodies that were consistent with recent acute EBV infection, and 3 patients were not tested. The 4 patients with positive titers also presented with signs typical for acute EBV infection, including fever (3/4), lymphadenopathy (4/4), and pharyngitis (4/4). Of note, the 2 patients who were older than expected for RPA (ages 18 and 11) had the most severe infections. We submit that there may be a role for EBV infection in the pathogenesis of RPA formation in children. Increasing age may correlate with a more severe infection in this setting.

[Fetomaternal hemorrhage: a series of 9 cases]

AIM

This study was designed to stress the importance of early diagnosis of fetomaternal hemorrhage (FMH) in attempt to prevent the subsequent adverse outcome on the fetus and the newborn.

PATIENTS AND METHODS

Nine newborns were admitted because of neonatal anemia to our neonatal unit from October 1989 through September 1995. The diagnosis of FMH was made by the sigma diagnostic fetal hemoglobin that is the Kleihauer test in our hematologic laboratory. Other causes of neonatal anemia have been ruled out.

RESULTS

Seven out of the nine cases have expressed early signs of fetal distress in term of abnormal fetal monitoring and/or thick meconium associated with decreased fetal movements. At birth, a wide clinical spectrum depending on the amount of the hemorrhage was seen, ranging from mild anemia with no symptoms (four cases), hypovolemic shock (one case), respiratory distress syndrome (two cases) and maladjustment to extra-uterine life (one case). There was one death at 48 hours after birth; one infant survived with severe encephalopathy.

CONCLUSION

These results indicate that it is mandatory to carry out a Kleihauer test whenever a high suspicious index of FMH is faced or an unexplained neonatal anemia is found.

Lipoperoxidation as a measure of free radical injury in otitis media

Free radical damage, as evidenced by lipoperoxidation, has previously been demonstrated to contribute to the inflammatory changes associated with acute otitis media. The present study was undertaken to evaluate whether lipoperoxidation continues to be present for a period of time after middle ear infection. Eighty-two 300- to 400-g guinea pigs were injected with Streptococcus pneumoniae in the left ear and sterile saline in the right ear as a control. Animals were examined and sacrificed on day 5, 10, 20, or 30; middle ear mucosa was harvested and assayed for lipid hydroperoxide content. A statistically significant increase in lipoperoxidation was seen at each time point studied, compared with controls. Lipoperoxidation was highest at days 5 and 10; a significant decrease was seen at days 20 and 30. Histologic sections of middle ear mucosa of two animals per group were prepared and evaluated for inflammation. These results demonstrate that lipoperoxidation may contribute to middle ear inflammation for a significant period of time after acute infection; the findings are discussed in light of other work on the role of free radicals in otitis media.

[Heart involvement in systemic amyloidosis. In vivo diagnosis]

This is the case of a 42 year-old male with systemic amyloidosis, probably primary, and heart involvement. Physiopathological and clinical aspects are described as well as the rarity of the diagnosis in vivo. The limited aspects of therapy are also described.

Effects of 21-aminosteroid U-74389G on acute otitis media in a guinea pig model

Free radicals participate in the development of disease under inflammatory conditions. Lipid peroxides such as malondialdehyde are regarded as markers of cell membrane damage by oxidative stresses. Previous work from our laboratory has demonstrated that lipidperoxidation is increased in acute otitis media in guinea pigs, implicating a role for free radicals as contributors to inflammation. In this study we examined the effect of lazaroid U-74389G, a 21-aminosteroid, on acute otitis media in guinea pigs. Streptococcus pneumoniae organisms were inoculated into the right tympanic cavity; sterilized phosphate-buffered saline solution was injected into the left ear to serve as a control. The guinea pigs were given intraperitoneal injections of 40 mg/kg of a lazaroid compound or its vehicle every 12 hours. Middle ear mucosa was collected and used for assay. We quantified lipid peroxide by means of the methylene blue-hemoglobin method and by means of measurement of thiobarbituric acid reactive substance. Lazaroid significantly (p < 0.05) suppressed production of lipid hyproperoxide of the middle ear mucosa of the guinea pigs with acute otitis media for up to 24 hours. These results suggest that lazaroid may reduce lipoperoxidation in the middle ear at an early stage of acute otitis media.

[Juvenile hyaline fibromatosis]

BACKGROUND

Juvenile hyaline fibromatosis (JHF) is rare disease of autosomal recessive inheritance.

CASE REPORT

A 14-year old boy, born to consanguineous parents was admitted because he suffered from multiple tumors since the age of 5 years. These tumors were mobile, painful varying in size, located mainly on the head, the back, and extremities; they were associated with gingival overgrowth. Bone X-rays showed osteolytic lesions. The cognitive development was normal. Biopsy of tumors showed cords of spindle-shaped cells embedded in homogeneous eosinophilic matrix. The child was progressively disabled due to articular changes. Two of his brothers presented the same features.

CONCLUSION

This new case of JHF confirms the severity of prognosis of such a fibromatosis presently considered as a hereditary disorder of collagen metabolism.