[Kawasaki disease complicated with hemorrhagic enteritis mimicking intestinal obstruction: report of one case]

A 6-month-old little boy presented with fever and cervical lymphadenopathy for four days. On admission, he was found to have conjunctival congestion of both eyes, reddened and fissured lips, straw-berry tongue, macular rash at the trunk and erythematous change on the BCG injection site. The diagnosis of Kawasaki disease was made and aspirin therapy (100 mg/kg/day) was started. On the 3rd hospital day, he developed abdominal distention, jaundice, poor activity and tachypnea. Bowel sound was silent on auscultation. Nasogastric tube was inserted for decompression and bilious material was drained out continuously. In addition, bloody, mucoid stool passage was noted. An abdominal radiography revealed dilatation of the small bowel and paucity of the colon gases. On the abdominal ultrasound, hydrops of gallbladder, marked ascites and silent and dilated bowel loops were found. Despite of supportive care, abdominal symptoms persisted and condition deteriorated. Laparotomy was done on the following day. At operation, it was found that the patient developed severe petechia on the long segment of small intestine from 15cm distal to the Treitz ligament to ileocecal valve and some fibrin plagues on the terminal ileum at 25cm proximal to the ileocecal valve were also found.

Genetic variance and heritability of serum cholesterol and triglycerides among Chinese twin neonates

In order to examine the genetic variance and heritability of serum total cholesterol, high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and triglycerides, a total of 349 pairs of same-sexed twin neonates born in four major general teaching hospitals in Taipei City were studied. Based on the placental pattern and 12 red blood cell antigens, 271 monozygotic (MZ) and 78 dizygotic (DZ) twin pairs were identified. There was a significant genetic variance for total cholesterol, HDL-C, LDL-C, and triglycerides both unadjusted and adjusted for sex, gestational age and placentation. The unadjusted heritability of total cholesterol, HDL-C, LDL-C, and triglycerides was 0.59, 0.30, 0.25 and 0.75, respectively; while the corresponding adjusted heritability was 0.74, 0.38, 0.31, and 0.49, respectively. Intrapair variance of serum lipids was not significantly different between monochorionic and dichorionic MZ twins.

Membranous nephropathy in 52 hepatitis B surface antigen (HBsAg) carrier children in Taiwan

To elucidate the prognosis and the causative viral antigens of hepatitis B virus (HBV)-associated childhood membranous nephropathy (MN), the clinical course and glomerular HBV antigens were studied in 52 HBsAg carrier children with MN (40 boys, 12 girls). With Fab fragments of monoclonal antibodies, hepatitis Be antigen (HBeAg) was detected in the glomerular deposits in 41 (95%) of 43 cases but HBsAg and hepatitis B core antigen (HBcAg) in none. HBeAg was detected in sera from 43 (93%) of 46 children examined. These results suggest that HBeAg plays an important role in the development of MN in HBsAg carrier children. During the follow-up period (mean, 4 years), complete remission was found in 64% and 92% of the patients followed for one and seven years, respectively; only one child had mild renal function impairment. These findings suggest a favorable outcome of HBsAg-associated childhood MN. The patient's age, disease duration, amount of glomerular deposit, focal sclerosis and disease stage appeared to affect the clinical course. HBsAg seroconversion to HBsAg-negative occurred in seven cases, and all (100%) had quick remission in two years. In patients with persistent HBsAg carriage, serum HBeAg status alone did not correlate with remission rate and remission occurred usually before the HBeAg seroconversion to anti-HBe. These findings, together with the predominant horizontal infection in these children in contrast to the frequent vertical (perinatal) transmission from HBsAg carrier mothers in HBsAg carriers in Taiwan, suggest that factors other than HBeAg per se may also play important roles.

[Congenital megacolon presented as fecaloma and urinary tract infection. Report of one case]

A 5-month old boy was admitted with urinary tract infection. While doing the voiding cystogram, the bladder was found to be pushed to the right side by a soft tissue mass. Through CT scan examination, the mass revealed to be a fecaloma. Through rectal suction biopsy and barium enema study for megacolon, it was proved to be a case of congenital megacolon. A pull-through operation for megacolon was carried out. He recovered quickly, and was discharged 10 days later. We make this report in order to discuss this rare presentation which may occur in congenital megacolon.

Urinary tract infections in children

From January 1981 to December 1987, 346 children with urinary tract infections, proved by urine culture, were admitted to the Department of Pediatrics, Mackay Memorial Hospital. The ratio of male to female was 3.0 in children below 2 years, and 0.8 in children above 2 years, of age. The urine specimens were collected from suprapubic punctures in 281 cases (81.2%). Fever was the most common clinical manifestation. In children below two years old, other common symptoms and signs were body weight loss or poor gain, feeding problems, diarrhea, irritability, jaundice, and abdominal distension. In older children, urinary frequency, dysuria, enuresis, loin and abdominal pain were frequently found. Hematuria and edema were occasionally noted in all age groups. Microscopic examination of 329 centrifuged urine specimens revealed: 256 cases (77.8%) had more than 5 leukocytes per high power field, 233 cases (70.8%) had more than 10 leukocytes. Three hundred and seventy positive urine cultures were obtained from these patients. E. coli was isolated in 273 cases (73.6%), followed by Klebsiella spp., 34 cases (9.2%); Proteus spp., 27 cases (7.3%); Enterococcus, 21 cases (5.7%); Enterobacter spp., 9 cases (2.4%); Pseudomonas aeruginosa, 8 cases (2.2%); Citrobacter spp., 7 cases (1.9%); Morganella morganii, 6 cases (1.6%); Acinetobacter spp., 6 cases (1.6%); etc. Candida albicans was isolated from three patients. Two organisms were isolated in 26 cultures; 3 organisms, in 3, and 4 in 1.

[Dose-response of intrathecal morphine for post-cesarean analgesia]

Intrathecal morphine for post-operative analgesia is famous for its quality and safety, but its role in post-Cesarean analgesia is not well established. In this study, we investigate its analgesic effect, complication rate and neonatal outcome under various dosages of morphine. The parturients divided into five groups according to morphine dosage: 0, 0.1, 0.25, 0.5, 1.0 mg respectively. The duration of analgesic effect was 19.1 h in 0.1 mg group, 23.6 h in 0.25 mg group, 28.1 h in 0.5 mg group, 30.5 h in 1.0 mg group. Complication rate increased markedly as more than 0.5 mg morphine was injected. Respiratory inhibition (respiratory rate less than 10/min) that required naloxone treatment had occurred twice in 0.5 and 1.0 mg group respectively. Neonatal outcome did not bear any difference among the five groups. In conclusion, adding 0.1 to 0.25 mg morphine to intrathecal anesthetics can be effectively and safely extended into post-Cesarean analgesia.

Sonographic finding of ventricular asymmetry in neonatal brain

One thousand normal Chinese full term neonates underwent prospective ultrasonography examination. Asymmetry of size between the right and left lateral ventricle was observed in a similar proportion of boys: 257/551 (47%) and girls: 183/449 (41%). The mode of delivery did not significantly influence the occurrence of ventricular asymmetry. We propose four different patterns of asymmetry.

Cardiac transplantation at National Taiwan University Hospital: a review from the anesthesiologist's standpoint

We report our initial experience with three patients who underwent heart transplantations at National Taiwan University Hospital. Two had idiopathic dilated cardiomyopathy. One had ischemic heart disease. Anesthesia was induced with fentanyl, ketamine, etomidate and pancuronium. In addition to regular maintenance with fentanyl, diazepam and pancuronium, low doses of isoflurane were added for skin incision and sternotomy. The anesthetic courses were uneventful. Mild hypotension was noted in the first case after cardiopulmonary bypass, and was immediately corrected by increasing the preload and dosage of inotropes. Sinus tachycardia from the donor SA node was the predominant rhythm after cardiopulmonary bypass. Our experience agrees with other reports that anesthesia for cardiac transplantation is a relatively safe procedure under careful hemodynamic monitoring and pharmacological support. Aseptic techniques, adequate preload and hemostatic agents supply are the major concerns for anesthetists.

Sonographic finding of the bright thalamus

Six of 83 asphyxiated neonates showed a diffuse increase of echodensity in bilateral thalami with or without other lesions in the basal ganglia on sonographic examination. The thalamic image still had a fairly high echogenecity compared with the surrounding brain parenchyma on follow up examination and was hence termed the bright thalamus. These six patients had a poor neurological outcome, including psychomotor retardation, spastic diplegia or quadriplegia, microcephaly, failure to thrive, seizures, and one death. The bright thalamus is not an occasional or an isolated sonographic finding of hypoxic-ischaemic encephalopathy, but it may serve as a landmark of severe hypoxic brain damage with adverse outcome.

Subependymal cysts in normal neonates

We undertook a prospective ultrasound study of subependymal cyst formation in normal neonates. Twenty five of 500 normal Chinese neonates (5%) were found to have subependymal cysts. Most of these (18 of 25) showed no obvious perinatal insult. This study suggests a rather high incidence of concealed intrauterine subependymal haemorrhage in normal term neonates.

Prevention of perinatally transmitted hepatitis B virus infections with hepatitis B immune globulin and hepatitis B vaccine

A randomised blind controlled trial of hepatitis B immune globulin (HBIG) plus hepatitis B vaccine for the prevention of the perinatally transmitted HBsAg carrier state was conducted in Taipei. Infants of e-antigen-positive HBsAg carrier mothers were given HBIG immediately after birth, and then one of three schedules of vaccination. There was no difference in efficacy between the three schedules; the combined efficacy was 94%, compared with that of HBIG alone (71%) or of vaccination alone (75%). Persistent HBs antigenaemia developed in only 9 (6%) of the 159 infants receiving prophylaxis, but in 88% of the controls. Antibodies developed in all those who did not become antigenaemic and presumably will provide long-term protection from hepatitis B virus infection. HBIG should be given as soon as possible after birth and need not be given again if the infant is subsequently vaccinated. With HBIG coverage from birth, the timing of the start of vaccination does not seem to be of importance within the first month of life, but to maximise compliance and minimise costs hepatitis B vaccination should be initiated during the confinement.

Report of a case of Nezelof syndrome

In this report, we present a 5 months old male baby, who suffered from watery diarrhea since 4 days old. From then on, he had been admitted 3 times in 3 different hospitals but the symptoms still bothered him off and on. During the days of hospitalization, sepsis with positive blood culture of Klebsiella was noted. The patient expired at 5 months of age. The T cell count was 20% active T was 0. Delayed hypersensitivity skin tests including Candida (10 X), PHA (10 micrograms), PHA (1 microgram), SK/SD (50 units) were negative. The granulocyte function study showed normal. Immunoglobulin analysis revealed IgG: 1320 mg%, IgA: 120 mg%, IgM: 100 mg%. Agenesis of thymus, failure of lymphoid differentiation and abnormal lymphoid architecture with absence of germinal centers were noted at autopsy. Combined immunodeficiency with normal immunoglobulins (Nezelof syndrome) is a disease of primary immunodeficiency characterized by recurrent infections, failure to thrive, lymphopenia, diminished lymphoid tissue, abnormal structure or agenesis of the thymus, and presence of normal or increased levels of one or more of the major immunoglobulin classes, but with impaired antibody synthesis. Since its original description by Nezelof and associates in 1964, it has been reported on the subsequent occasion. In this report, we present our one experience and review the clinical and laboratory data in 33 reported cases.