Polyarticular septic arthritis

Seven adult patients with nongonococcal polyarticular septic arthritis are presented with a literature review of the clinical features of polyarticular bacterial infection. Polyarticular septic arthritis occurred in 19% of reported cases of septic arthritis in adults. Similar to monoarticular disease, the knee was the most commonly affected joint, and Staphylococcus aureus was the most frequently isolated microorganism. Pneumococcus, group G streptococcus, and Hemophilus influenzae had an increased association with polyarticular infection. Five of our 7 patients had underlying rheumatic diseases and the immediate mortality rate was 57%. Review of the literature yielded an overall mortality of 23% for polyarticular septic arthritis compared to the 9% mortality of septic arthritis in general. The subset of patients with polyarticular infection superimposed on rheumatoid arthritis had a mortality rate of 56%.

Loss of ciliary activity in organ cultures of rat trachea treated with lipo-oligosaccharide from Haemophilus influenzae

Organ culture of rat trachea was used as an experimental model to examine the ability of lipo-oligosaccharide from Haemophilus influenzae to damage respiratory tract mucosal tissue. Lipo-oligosaccharide from two strains of H. influenzae produced a significant decrease in the ciliary activity of tracheal rings observed over a 3-5 day period. No loss of ciliary activity was observed with the lipid-free moiety of the lipo-oligosaccharide.

Association between preadmission oral antibiotic therapy and cerebrospinal fluid findings and sequelae caused by Haemophilus influenzae type b meningitis

The association between the administration of oral antibiotics and cerebrospinal fluid (CSF) findings and sequelae was investigated in 281 children with Haemophilus influenzae type b meningitis from two prospective studies. Ninety-four (33%) children were pretreated; 59% of pretreated children received ampicillin or amoxicillin. Compared with untreated children, in pretreated children significant decreases were noted in the percentage of polymorphonuclear leukocytes in the CSF (P less than 0.03), CSF protein concentration (P less than 0.001) and percentage with a positive CSF Gram stain or culture (P less than 0.05). When adjusted for duration of illness prior to admission, only the CSF protein concentration remained different (P less than 0.01). Children who were pretreated were more likely (P less than 0.05) to have paresis at one or more follow-up visits and sensorineural hearing loss (P less than 0.05), but these differences were diminished when adjusted for duration of illness before admission. The duration of illness prior to admission was significantly (P less than 0.0001) longer for pretreated (median, 3.0 days) than for untreated children (median, 1.0 day). The incidence of deafness did not correlate with duration of illness before admission by multiple logistic regression analysis (P = 0.132), but deafness was significantly (P less than 0.02; relative risk, 5.9) more common when all children who were ill for more than 1 day prior to admission were compared to those children who were ill for 1 day or less.(ABSTRACT TRUNCATED AT 250 WORDS)

Similarity in white blood cell counts between white and black children with bacteremia

The charts of 104 white and 52 black children with bacteremia caused by Streptococcus pneumoniae or Haemophilus influenzae type b were reviewed to determine each patient's white blood cell (WBC) and absolute polymorphonuclear cell (PMN) counts at the time of presentation to the emergency room. Mean WBC and PMN counts were virtually identical for the racial groups, 18,300 vs. 18,700/microliter and 12,900 vs. 13,000/microliter, respectively. Examination of subgroups of white and black children with or without meningitis or other focal infection also revealed no significant differences between races, although significantly lower mean WBC and PMN counts were found in children with, compared to those without, meningitis regardless of race. As an aid to the identification of children at high risk for S. pneumoniae or H. influenzae type b bacteremia, it appears that WBC and PMN counts may be interpreted without regard to race.

Meningitis due to Haemophilus influenzae resistant to ampicillin and chloramphenicol

A case of ampicillin and chloramphenicol resistant Haemophilus influenzae meningitis successfully treated with cefotaxime is described.

Hemophilus influenzae pericarditis in two adults

Images

Pyogenic arthritis in infants and children: a review of 95 cases

The clinical and laboratory findings of 95 children with pyogenic arthritis were reviewed to assess etiologic agents, diagnostic tools and results of therapy. Despite obtaining specimens from multiple sites for culture and using antigen detection tests only 64% of patients had an etiologic agent determined. Haemophilus influenzae type b was the most common causative agent identified and 82% of such cases occurred in children between 6 and 24 months of age. Infection due to Staphylococcus aureus was not confined to any age group. Results of laboratory tests which measure inflammatory response were not always abnormal. Platelet count and sedimentation rate frequently rose as clinical improvement occurred. Roentgenograms and radionuclide studies were of little benefit. Therapy included immediate decompression of the joint space, articular rest and use of antibiotics delivered parenterally. Ninety percent of 70 patients who were followed for 1 month to 5 years (mean, 15.5 months) were cured. Eight children had clinically significant sequelae which affected length of extremity, stability of articulations and range of movement. Development of sequelae was significantly associated with infection at age less than 6 months, delay of 4 or more days in institution of medical or surgery treatment, infection due to S. aureus and most strikingly the involvement of the hip or shoulder with concomitant presence of osteomyelitis.

Nursing home-acquired pneumonia. A case-control study

To determine if there are any unique features of nursing home-acquired pneumonia we carried out a case-control study wherein each patient admitted with nursing home-acquired pneumonia was age- and sex-matched with a patient with community-acquired pneumonia. There were 36 men and 38 women in the nursing home group. The mean age of both groups was 74 years. The mortality rate for nursing home-acquired pneumonia it was 40.5%, whereas for community-acquired pneumonia it was 28% (P = NS). Patients with nursing home-acquired pneumonia had a significantly higher incidence of dementia and cerebrovascular accidents, and patients with community-acquired pneumonia were more likely to be smokers and to have chronic obstructive pulmonary disease. Aspiration pneumonia was more common among patients with nursing home-acquired pneumonia (P less than .001), and Hemophilus influenza pneumonia more common among the patients with community-acquired infection (P less than .01). Sputum for culture could be obtained in only 31 and 39% of the patients--contributory to the high rates of pneumonia of unknown etiology 63.5 and 56.1% for the nursing home group and the control subjects, respectively. Patients with nursing home-acquired pneumonia received cloxacillin and aminoglycosides more frequently than patients with community-acquired pneumonia (P less than .05), and patients with community-acquired pneumonia received erythromycin more frequently than patients with nursing home-acquired pneumonia (P less than .05). Complications were common during the hospital stay of these patients--the most frequent being congestive heart failure, urinary tract infection, renal failure, and respiratory failure.

Bacterial meningitis in infants two to six weeks old

We reviewed our experience with bacterial meningitis in older neonates (2 to 6 weeks of age) during a five-year period. Seventeen patients with bacterial meningitis were diagnosed and treated. Bacteria recovered from the cerebral spinal fluid (CSF) included pneumococci (29%), E. coli and meningococci (23% each), group B streptococci (12%), Enterobacter and H. influenzae (6% each). There were no cases of Listeria monocytogenes. The mean duration of symptoms before admission was 3.1 days. The mortality rate was high (30%), and 36% of the patients had significant neurologic residua. Our study shows that this specific age group is different from newborns or older infants. Therefore, the initial selection of antibiotics for the treatment of meningitis in this age group should include antibiotics that are effective across this spectrum of potential pathogens.

Arthritis associated with Haemophilus influenzae meningitis: septic or reactive?

We reviewed 165 pediatric cases of Haemophilus influenzae type b meningitis and found 11 (6.7%) with associated arthritis. Synovial fluid culture and Gram stain suggested that only three of these 11 cases were caused by a septic process. In all three children with septic arthritis, joint symptoms were present on admission or within 24 hours. In contrast, of the eight who had reactive arthritis, arthritis did not appear in six until after 1 week of antibiotic therapy. Patients with septic arthritis were older than patients with reactive arthritis (mean 31 months vs 17 months), had a longer duration of symptoms before the start of antibiotic therapy (mean 6.0 days vs 2.5 days), and were more likely to have a positive blood culture (67% vs 18%). It is probable that the majority of episodes of synovitis occurring after H. influenzae meningitis occur as a result of a reactive rather than a septic process. Treatment of reactive arthritis should be with anti-inflammatory agents rather than with multiple joint aspirations and prolonged antibiotic therapy.

Bacterial meningitis in Arizona American Indian children

Bacterial meningitis is a major cause of morbidity and mortality in Arizona infants and children. A retrospective review of 102 cases of meningitis occurring in the American Indian population documents the prevalence of the Haemophilus influenzae organism with a peak incidence in the first year of life. The rate of H influenzae resistance to ampicillin was 16%. Overall morbidity and mortality rates are comparable with reviews of diverse populations, but there is an exceptional mortality and prolonged hospitalization in patients less than 1 year of age. The development of an efficacious vaccine against H influenzae may substantially reduce and prevent this cause of meningitis.

Management of septic arthritis in children

Forty-five children underwent initial nonoperative treatment of hematogenous septic arthritis in joints other than the hip. Only joints with symptoms for less than 6 days and without associated osteomyelitis were included. Thirty-four of the 49 joints were successfully managed by aspiration and antibiotics, whereas the remaining joints were successfully managed by surgical drainage following a lack of response to nonoperative treatment. All children had a satisfactory result after an average follow-up of greater than 3 years. Early diagnosis and treatment are more important than the method of drainage. If a lack of response is seen to initial nonoperative treatment, surgical drainage will still lead to a satisfactory outcome.

Shock in children with gram-negative bacillary sepsis and Haemophilus influenzae type b sepsis

To study the incidence of shock in children in association with gram-negative bacillary (GNB) sepsis and Haemophilus influenzae type b sepsis, we reviewed all episodes of septicemia with those organisms in a 10-month period. GNB were isolated from 10.95% and H. influenzae b from 13.8% of the patients whose blood cultures yielded bacteria. Shock occurred in 12.5% of patients with sepsis caused by GNB and in 10.3% of those with H. influenzae b sepsis. Shock occurred more frequently in patients with H. influenzae b sepsis with meningitis (20.6%) and more commonly in those who had GNB sepsis without meningeal involvement (11.4%). GNB sepsis was associated with severe shock and caused death of three of the four patients. Only one of the five patients with shock caused by H. influenzae b had severe shock and died. The good outcome of patients with sepsis and shock caused by H. influenzae may be related to the health status before illness and prompt appropriate antibiotic therapy.

Buccal cellulitis reevaluated

We studied 72 children (17 prospectively) with acute buccal cellulitis. The median age was 11 months. Fifty-five percent of patients were bacteremic, and three children without meningeal signs or symptoms had concomitant meningitis. Cellulitis aspirate cultures (eight of 35 positive) and urine bacterial antigen tests (13 of 27 positive) were useful in making an etiologic diagnosis. Infections due to other bacteria were clinically indistinguishable from those due to Haemophilus influenzae type b. The right cheek was affected more often than the left, and only 23 (32%) of 72 patients had otitis media ipsilateral to the involved cheek. The pathogenesis of buccal cellulitis likely involves direct mucous membrane invasion rather than spread from the ipsilateral middle ear.

Silent otitis media: clinical applications

Silent (masked) otitis media refers to usually chronic pathological conditions behind an intact tympanic membrane which may be clinically "undetected" or "undetectable." Correlations are described for pathological changes in temporal bones and clinical considerations for silent otitis media associated with Hemophilus influenzae meningitis in infants, silent otitis media--the continuum, silent otitis media--sequelae, and chronic silent otitis media.