Isolated fetal bilateral radial ray reduction associated with valproic acid usage

The authors describe the first case of an isolated bilateral radial ray reduction occurring in a fetus exposed in utero to valproic acid; the diagnosis was made by ultrasound during the second trimester. This case of an isolated radial ray reduction associated with valproic acid use in pregnancy is a reminder for sonographers to carefully examine not only the cardiac and neurologic system, but also the extremities, when a fetus is exposed in utero to valproic acid.

Osteoid osteoma: MR imaging versus CT

PURPOSE

To compare the performance of computed tomography (CT) and magnetic resonance (MR) imaging in diagnosis of osteoid osteoma.

MATERIALS AND METHODS

Nineteen patients with histologically proved osteoid osteoma underwent CT and MR imaging before excision of the lesion. CT and MR images were compared regarding lesion conspicuity and detection of marrow, soft-tissue, and/or synovial changes adjacent to the primary lesion.

RESULTS

CT was more accurate than MR imaging in detection of the osteoid osteoma nidus in 63% of cases. MR imaging was better than CT in showing intramedullary and soft-tissue changes in all cases. This may produce a misleading aggressive appearance on MR images. There was a statistically significant correlation between presence or absence of marrow or soft-tissue changes and treatment with antiinflammatory medications (P < .05).

CONCLUSION

CT remains the best imaging modality for diagnosis of osteoid osteoma. MR images should not be interpreted without reference to plain radiographs and CT scans if serious errors in diagnosis are to be avoided.

A study of cerebral perfusion using single photon emission computed tomography in neonates with brain lesions

In this study we used a single photon emission computed tomography technique (SPECT) with radiolabelled 99mTcHMPAO to assess cerebral perfusion in newborn infants with documented cerebral lesions and to determine to what extent brain SPECT might be useful in the neonatal period. A total of 15 newborn infants with the following cerebral pathologies were enrolled: severe parietal bilateral periventricular leucomalacia (PVL, n = 6); moderate parietal bilateral PVL (n = 2); intraventricular haemorrhage grade II with unilateral parietal parenchymal extension (IHV + PE, n = 3); cerebral infarction (CI, n = 2) in the zone of middle cerebral artery; and post-haemorrhagic hydrocephalus (n = 2). Follow-up was available in all infants. Alterations in cerebral perfusion were seen in only 12 of 15 infants and at the location of severe PVL, PE and CI. We have noted that the regions of diminished perfusion extended beyond the apparent extent of cerebral pathology delineated by ultrasound or magnetic resonance imaging. Markedly diminished perfusion was seen in 1 infant with hydrocephalus, which recovered following placement of ventriculo-peritoneal shunt. Regarding outcome, SPECT data failed to provide additional information than that of neuroradiological investigations. We conclude that the use of SPECT, under these conditions, to assess alteration of cerebral perfusion in the neonatal period will not provide any additional information than that of neuroradiological investigations.

Cerebral perfusion studies during maturation using single photon emission computed tomography in the neonatal period

In this study, we used single photon emission computed tomography (SPECT) radiolabelled 99mTc HMPAO to assess cerebral perfusion during maturation in the neonatal period. Results of SPECT examinations in 18 newborn infants, in whom gestational age ranged form 30 to 41 weeks, and who were found to be neurologically normal in retrospect, were reviewed. The developmental changes in cerebral perfusion during the neonatal period shown by SPECT parallel findings of other methods on maturational changes of the central nervous system (neuropathological studies, positron emission tomography scan, magnetic resonance imaging). Cerebral perfusion progresses from the central part of the brain to the cerebellum, sensorimotor and then visual cortex. A close relation seems to exist between cerebral perfusion, metabolism and behavior under normal conditions in the neonatal period.

Fetal arachnoid cyst: report of two cases

Two new cases of antenatal diagnosis of arachnoid cyst are described. Diagnosis was made at 2.5 and 32 weeks' gestational age. In the first case, a slight increase in the diameter of the anechoic mass was observed in the second trimester. In the second case, ventricular dilatation was present prenatally. Appropriate surgical therapy was initiated at 2 months in the first case and at 8 days in the second and the neurological development of the two children is considered as normal at 18 months of age. Major features of in utero diagnosis, treatment and follow-up are discussed.

Progressive sensorineural hearing loss (SNHL) and peripheral neuropathy: a case report

Sensorineural hearing loss (SNHL) is infrequently associated with peripheral neuropathy. When co-existent with peripheral neuropathy, it tends to present in the early adult years, is slowly progressive and is accompanied by optic atrophy or bowel abnormalities. The following case presents an unusual patient with severe and rapidly progressive SNHL and peripheral neuropathy.

Early treatment of premature infants with recombinant human erythropoietin

OBJECTIVES

The specific objectives of this study were (1) to assess the safety and efficacy of recombinant human erythropoietin (rhEPO) in reducing postnatal hemoglobin decline in premature infants of less than 33 weeks' gestation, and thus reducing the need for transfusion; and (2) to determine the optimal dosage of rhEPO.

MATERIALS AND METHODS

Three groups of premature infants of less than 33 weeks' gestation were treated with rhEPO: group 1 (n = 10) received 300 U/kg per week; group 2 (n = 11), 600 U/kg per week; and group 3 (n = 10), 900 U/kg per week. These three groups were compared to a reference group of 20 infants of the same gestational age and birth weight. Treatment started on the 10th day of life and lasted 6 weeks. All infants were given oral iron and vitamin E supplements.

RESULTS

Treated infants had significantly higher reticulocyte counts, and the effect was dose dependent (P = .009). Postnatal decline of hemoglobin and hematocrit was lessened in the treated groups; the percent of decrease of hemoglobin and hematocrit was significantly reduced in the treated infants at 35 days of age (P = .0025 and P = .0036, respectively). The need for blood transfusion was also reduced in the rhEPO-treated groups: 19% of treated vs 45% of reference infants received transfusions, and the treated infants received less blood. Serum iron and transferrin saturation percentage dropped significantly during the study and a dose-dependent relationship in treated infants was displayed, suggesting high iron consumption (P = .0008 and P = .006, respectively). No dose effect on hemoglobin level and the need for blood transfusion was found, possibly because of the higher degree of illness severity and iron consumption in groups 2 and 3. No side effects related to rhEPO therapy were observed.

CONCLUSIONS

It is concluded that rhEPO therapy is safe in premature babies when given in the three dosages used in this study; in addition, it enhances erythropoiesis and reduces the need for blood transfusions. rhEPO therapy seems more efficient when given in higher dosages; however, illness severity and iron consumption represent major limiting factors. Controlled, randomized studies are warranted to confirm these data and to determine precise modalities and indications of rhEPO therapy in premature infants.

Transcatheter occlusion of patent ductus arteriosus with adjustable buttoned device. Initial clinical experience

BACKGROUND

Several devices are available for transcatheter occlusion of patent ductus arteriosus. Most of these devices either require complicated intracardiac maneuvering, have not been tried in humans, or need a large-sized sheath for implantation of the device.

METHODS AND RESULTS

During a 26-month period ending November 1992, 14 patients underwent transcatheter closure of patent ductus arteriosus with an adjustable buttoned device delivered via a 7F sheath under an institutional review board-approved custom-made device protocol. The children were 15 months to 8 years of age with weight range of 7.2 to 19 kg. The patent ductus arteriosus measured from 2 to 7.5 mm (median, 3 mm) at the narrowest diameter and was conical, short, or tubular. They were occluded with devices measuring 15 to 20 mm. The ratio of pulmonary to systemic flow decreased (P < .01) from 1.9 +/- 0.6 (mean +/- SD; range, 1.3 to 3.2) to 1.05 +/- 0.1 (1 to 1.3). Continuous murmur of patent ductus arteriosus disappeared in all except 1 patient. Small residual shunts were detected by color Doppler studies in 4 of 14 patients (29%). All patients were followed for 1 to 24 months (mean, 6 +/- 7 months). The device was intact in all patients, and no breakage of the wires was noted. No shunts were seen in 12 of 14 patients (86%), and minute residual shunts were seen in 2 children. No major complications were encountered.

CONCLUSIONS

It is concluded that transcatheter closure of patent ductus arteriosus with the adjustable buttoned device is feasible and effective and can be accomplished via small 7F sheaths; a 7F sheath is adequate for all ductal sizes; and the adjustable length of the loop accommodated all types of patent ductus arteriosus. Clinical trials on a larger number of patients are warranted.

Oral acyclovir and recurrent genital herpes during late pregnancy

OBJECTIVE

To assess plasma acyclovir levels in pregnant women given oral acyclovir during late gestation and to determine the role and effect of oral acyclovir on asymptomatic shedding of virus in cases of recurrent genital herpes.

METHODS

Five pregnant women with proven genital herpes isolate (herpes simplex virus [HSV] 2) after 37 weeks' gestation were studied. Oral acyclovir was administered every 8 hours at dosages of 300, 400, and 300 mg in two subjects, and 200 mg five times daily in the other three until delivery. Plasma acyclovir peak and trough levels were determined. Viral cultures were obtained from both the mothers and neonates at delivery.

RESULTS

There was no difference in acyclovir plasma levels among the patients. Furthermore, acyclovir levels were comparable to those of nonpregnant adults. The drug failed to suppress asymptomatic shedding of virus and transmission of HSV 2 to the neonate in one of five of the patients.

CONCLUSION

Our study suggests that asymptomatic shedding of virus is not prevented by use of oral acyclovir during late gestation in proven recurrent genital herpes even though plasma acyclovir levels were within the normal range.

Enterovirus infections in neonates. A retrospective study of 21 cases

OBJECTIVES

The aim of this study was to define the major features of enterovirus infections in the neonatal period based on our own experience.

METHODS

Epidemiology, clinical manifestations and laboratory investigations concerning 21 neonates having experienced a Coxsackie B or an Echovirus infection between 1987 and 1991, were retrospectively reviewed. Aetiological diagnosis was made by classical viral isolation and/or by evidencing Coxsackie B-specific IgM antibodies with an immunocapture enzyme immunoassay.

RESULTS

In 13 neonates the infection occurred between June and September. The onset of clinical signs ranged from day 1 to day 25 after birth with two separate periods: before 7 days of age, suggesting a perinatal transmission of the virus, or beyond this date, more likely connected with a postnatal transmission. Clinical manifestations included hyperthermia, gastroenteritis, meningitis, encephalitis, pneumonia and myocarditis, with a diphasic pattern in 6 cases. Most of the neonates improved gradually and developed normally. The Coxsackie B-specific IgM assay was the most rapid method whereas viral isolation, even though it took more time, was the most sensitive technique to establish the aetiological diagnosis in neonates.

CONCLUSIONS

Enterovirus infections in neonates are difficult to diagnose and to differentiate from bacterial infections. A viral-like illness in the environment of the neonate allows the clinician to anticipate the clinical signs and a possibly fatal disease. Identification of the causal virus should be performed by both viral isolation and search for specific IgM antibodies. Treatment and prophylaxis are so far disappointing.

Herpes laryngitis and tracheitis causing respiratory distress in a neonate

A newborn presented 1 week after birth with the sudden onset of stridor and respiratory distress. At endoscopy, the supraglottic and subglottic tissues were edematous and erythematous, and numerous plaquelike ulcers were seen on the mucosal surface. Cultures of the lesions yielded herpes simplex virus type 2. The infant required a prolonged course of acyclovir and remained intubated for 31 days, but ultimately had both virological and clinical cure. Evaluation and further treatment of this unusual presentation of herpes simplex virus are discussed, as are the implications of herpes infections in neonates.

Subperiosteal orbital abscess in children: diagnosis, microbiology, and management

A chart review was undertaken of 30 patients who were presented to Children's Hospital of Pittsburgh from 1983 to 1990 and underwent surgical management for suspected subperiosteal abscess of the orbit (SPA). All patients had preoperative computerized tomography (CT) scans. Twenty-seven of 30 CT scans were reevaluated, of which 20 (74%) demonstrated findings consistent with or suggestive of SPA. Opacified sinuses were seen in 100% of this study group. Abscess collections were found in 21 patients (70%). Predominant organisms included: Streptococcus pneumoniae (38%), Streptococcus pyogenes (33%), and Haemophilus influenzae (14%); Moraxella catarrhalis was not isolated and anaerobic bacteria were isolated from only one patient. CT scans were found to be accurate predictors of SPA in 16 (80%) of 20 patients. All patients did well following surgical intervention without visual or central nervous system sequelae. We conclude from this study that CT scans should be obtained when SPA is suspected, and antimicrobial therapy should be directed toward the bacteria isolated from these abscesses.

[Medical treatment of chylous effusions in newborn infants. Apropos of 3 cases]

BACKGROUND

Chylous effusions are the most frequent cause of non immunologic hydrops fetalis. They can be recognized antenatally by ultrasonography. Their evacuation is sometimes necessary and medical treatment often effective.

CASE REPORTS

Case n. 1: fetal ascites was detected by ultrasonography at the 30th week of gestation. Paracentesis was performed at 36 weeks, followed 3 days later by spontaneous delivery. The newborn was fed milk formula. A second paracentesis showed a milky fluid, rich in cholesterol, triglycerides and chylomicrons. The child was fed formula rich in medium-chain triglycerides and the chylous ascites disappeared completely within 2 weeks. Case n. 2: a diagnosis of bilateral hydrothorax and hydramnios was made at the 27th week of gestation. An in utero evacuation of the hydrothorax performed at the 30th week was ineffective and a pleuro-amniotic drainage was performed 2 weeks later. The baby was born at the 35th week, and presented a moderate respiratory distress due to the hydrothorax and ascites. Aspiration of the thoracic fluid confirmed its chylous origin. The chylous effusions completely disappeared when the child was fed a high medium chain triglycerides diet. A lymphedema of legs appeared at the age of 1 month. Case n. 3: ascites, hydramnios, hydrothorax and peripheral edema were found at the 21st week of a third pregnancy (the 2 first pregnancies were complicated by lethal hydrops fetalis). Bilateral hydrothorax and peripheral edema were found again after birth at the 37th week. Diuresis and albumin-infusion led to recovery, but chylothorax and chylous ascites reaccumulated after introduction of milk formula, despite repeated evacuations and feeding medium-chain triglycerides formula. The thoracic fluid remains chylous at the age of 9 months.

CONCLUSIONS

In utero, and sometimes post-natal, evacuation of fluid present in the thoracic and peritoneal cavities can be necessary, depending of the functional tolerance. Medical management including feeding a low fat and/or high medium-chain triglycerides diet, and sometimes temporary total parental nutrition, is necessary, together with salt restriction, diuresis and albumin infusion as required. Most cases recover spontaneously or as a result of therapy within a few weeks.

[Prevention of fetal and neonatal transmission of the varicella-zoster virus]

Varicella occurs in 0.7 to 0.13% of pregnant women. The risk of transmission of the varicella-zoster virus to the fetus is small. The virus causes malformations (cutaneous scars and above all central nervous system anomalies). Mother-to-offspring transmission is more common during the perinatal period (20%), when mild or severe (fatal in 20% of cases) congenital varicella may occur. Prevention of transmission of the varicella-zoster virus from the mother to her fetus or neonate rests on detection of fetal varicella (antenatal ultrasonography, fetal IgM assays) and on administration of both specific anti-VZ virus immune globulins and acyclovir to the mother and neonate during the perinatal period.

Lymphocytic sialadenitis of Sjögren's syndrome associated with chronic hepatitis C virus liver disease

Viral infection has often been suggested as a possible cause of Sjögren's syndrome or chronic lymphocytic sialadenitis, and Epstein-Barr virus has been found in the salivary glands of patients with this condition. After we had noted Sjögren's syndrome in several patients infected with hepatitis C virus (HCV), a virus also excreted in saliva, we set up a prospective study to investigate the association of chronic lymphocytic sialadenitis, with or without symptoms, to chronic HCV liver disease. The histological appearances of labial salivary glands in patients with proven HCV hepatitis or cirrhosis were compared with those in dead controls. Histological changes characteristic of Sjögren's syndrome were significantly more common in HCV-infected patients (16 of 28, 57%) compared with controls (1 of 20, 5%). Focal lymphocytic sialadenitis characteristic of Sjögren's syndrome (though only 10 patients had xerostomia and none complained of xerophthalmia) appears to be common in patients with chronic HCV liver disease; if this association is confirmed, identification of the underlying mechanism may improve our understanding of both disorders.

Infections of the ears, nose, and throat in children with primary immunodeficiencies

Children who suffer from primary immunodeficiencies have long been thought to be subject to infections of the ears, nose, and throat due to unusual or resistant organisms. A retrospective chart review was undertaken at Children's Hospital of Pittsburgh from 1979 to 1989 to determine the types and frequency of infections of the ears, nose, and throat, and the bacteriologic findings from cultures of the sinuses, ears, and head and neck abscesses, when obtained. Seventy-five patients were identified with primary immunodeficiencies, and 80% suffered from infections of the ears, nose, and throat. Cultures obtained from 33% of the group showed the majority of the organisms commonly seen in ear and sinus infections. We conclude from this study that children with primary immunodeficiencies who require hospitalization frequently have an infection of the ears, nose, and throat, and that the infection is usually caused by community acquired bacteria. Empiric treatment may therefore be directed to common organisms causing these infections.

Periventricular haemorrhagic infarction associated with subependymal germinal matrix haemorrhage in the premature newborn. Report of two cases

Two cases of unilateral subependymal germinal matrix haemorrhage associated with homolateral periventricular haemorrhagic infarction (PVHI) are reported in two premature newborns. This association is rather rare. Indeed, PVHI occurs generally with large intraventricular haemorrhage. Diagnosis is made by brain imaging (ultrasound, MRI) scans and single photon emission computed tomography. PVHI is probably caused by obstruction of periventricular venous drainage by large intraventricular haemorrhage leading to a haemorrhagic venous infarction. From our cases, we conclude that extraventricular haemorrhage leading to a large subependymal haematoma can result in obstruction of periventricular venous drainage, subsequent PVHI and abnormal neuromotor development.

[Unilateral cerebellar atrophy in 2 newborn infants. Value of MRI]

The authors report 2 cases of unilateral cerebellar atrophia presenting in the neonatal period with facial peripheral palsy and iso-immune thrombocytopenia respectively. The recognition of cerebellar atrophia has been made by MRI. Unilateral cerebellar atrophia be due to ischemia. MRI seems to be a useful tool in the recognition of cerebellar malformations in the neonatal period.

MR diagnosis of subdiaphragmatic anomalous pulmonary venous drainage in a newborn

Our report describes a case of infradiaphragmatic total anomalous pulmonary venous return diagnosed by MR in a newborn with an interruption of the aortic arch with ventricular septum defect and anomalous pulmonary venous drainage. The severity of the congenital cardiopathy did not permit surgical treatment and the infant died soon after. Pathology confirmed the MR findings. Magnetic resonance not only complements echocardiography but also can be used for patients in intensive care and can in our case avoid angiography.

Transcranial Doppler evaluation of cerebral infarction in the neonate

We recorded cerebral artery flow velocities (CAFV) in two neonates with cerebral infarction, using transcranial Doppler sonography (TCD). Cerebral infarction was diagnosed by brain imaging. The arteries investigated were the middle cerebral artery (MCA), the internal carotid artery (ICA) and the anterior cerebral artery (ACA). The whole territory of right MCA was involved. A decrease in CAFV was noted in MCA and ICA of the affected side. Furthermore, early recordings of CAFV allowed us to distinguish perinatal infarction from antenatal infarction: in the former, Doppler signal was completely absent during the first days of life whereas in the latter, Doppler signal was reduced but present. The process of recanalization could be followed. The asymmetry of CAFV recorded in the neonatal period seems to persist definitively at least in MCA. These Doppler data correlate well with the evolutive stages of cerebral infarction shown by brain imaging. Beside US, CT and MRI scans, TCD may be a useful adjunct for identifying and following infants with suspected occlusion of major cerebral vessels.

Concentration of cefuroxime in serum and middle ear effusion after single dose treatment with cefuroxime axetil

Antimicrobial agents play an important role in the treatment of patients with acute otitis media and otitis media with effusion (OME). The study was undertaken to determine the concentrations of cefuroxime in the blood and middle ear effusions (MEE) of children between 6 and 12 years of age with acute otitis media and chronic OME after a single oral dose administration of cefuroxime axetil, the ester prodrug of cefuroxime. Cefuroxime axetil (250 mg) was administered 2 to 6 hours before either myringotomy for acute otitis media or myringotomy and tube insertion for chronic OME. Blood samples and middle ear aspirates were obtained from 31 children and the samples were analyzed by high performance liquid chromatography. Cefuroxime was recovered in measurable concentrations in all serum samples and in 15 (79%) of the 19 MEE specimens analyzed. No correlation was seen between cefuroxime MEE concentrations and effusion type, bacteriology or serum concentrations. This study shows that cefuroxime does penetrate into MEE when OME is present and that therapeutic concentrations can be achieved in some patients.