Disseminated invasive infection due to Metarrhizium anisopliae in an immunocompromised child

The first reported human case of possible disseminated infection with the insect pathogen Metarrhizium anisopliae var. anisopliae, a fungus which has been used commercially for biocontrol of insects, is described. The patient, a 9-year-old boy, had a 5-year history of pre-B-cell acute lymphoblastic leukemia and had been on chemotherapy throughout this period. After 10 days of profound neutropenia, lesions consistent with ecthyma gangrenosum appeared on his arms and legs. M. anisopliae was grown from specimens from three separate sites, collected at different times over a period of 1 month: a skin biopsy, a swab from the base of a lesion, and the core of another skin lesion which spontaneously discharged. The initial skin biopsy also showed histological evidence of epidermal necrosis and dermal invasion with fungal hyphae. A computed-tomography (CT) scan of the chest demonstrated a lesion in the superior segment of the lower lobe of the left lung. A CT scan of the brain revealed a lesion in the left temporoparietal region of the brain, consistent with an abscess. Despite antifungal treatment including liposomal amphotericin and 5-flucytosine, the patient eventually died. The initial portal of entry is unknown, but hematogenous dissemination to the skin appears likely because of the multiple ecthymic lesions, and the appearances of the brain lesion on the CT scan are consistent with a hematogenous fungal abscess.

Postal self-exposure treatment of recurrent nightmares. Randomised controlled trial

BACKGROUND

Many nightmare sufferers do not consult a health care professional. Though behavior and cognitive therapy can help, they have not been tested as a self-treatment method at home using a manual.

METHOD

One hundred and seventy adults with primary nightmares were randomised to four weeks' self-exposure or self-relaxation at home using manuals posted to them, or to a waiting-list as a control group for four weeks. Individuals recorded nightmare frequency and intensity in four-week diaries.

RESULTS

At one- and six-month follow-up, the self-rated nightmare frequency fell more significantly in exposure subjects than relaxation or waiting-list subjects. The self-exposure group had the most drop-outs but remained superior in an over-cautious intent-to-treat analysis. The individuals' partners confirmed the superiority of self-exposure to self-relaxation at one- and six-month follow-up.

CONCLUSIONS

Recurrent nightmare sufferers improved more with self-exposure manuals than with self-relaxation manuals or by being on a waiting-list. Self-exposure may be needed for longer than four weeks in order to reduce nightmare intensity as well as frequency. Despite a high drop-out rate, some sufferers of other conditions may benefit from self-treatment manuals.

Development of a health concerns inventory for school-age children

The purpose of this study was to examine the validity and reliability of the "School Age Health Concerns Inventory" developed by the authors. A national sample of students in third to sixth grades was assessed by school nurses using this instrument. Each student's responses were verified in a short interview with the school nurse. The instrument was evaluated on the basis of ease of use, language, and effectiveness in identifying students who need health services.

Postal self-exposure treatment of recurrent nightmares

BACKGROUND

Case reports suggest that recurrent nightmares are alleviated by behavioural treatment. We have administered such treatment to a client by post.

METHOD

The frequency of nightmares was recorded by the client before and during treatment, and at one and six months follow-up. Nightmare problem and target scales, and treatment expectation were recorded at the end of each period. Treatment was by rehearsal relief, self-administered using written instructions.

RESULTS

A reduction in nightmare frequency from 5.5 per week in the baseline period to an average of one per week resulted after treatment.

CONCLUSIONS

The client's chronic nightmares were lastingly relieved after self-administered exposure treatment. A controlled trial is underway.

Intracranial choriocarcinoma causing precocious puberty and cured with combined modality therapy

Precocious puberty can be caused by hormonally active tumours, which may arise intracranially. Treatment of these intracranial lesions traditionally involves biopsy and radiotherapy. Chemotherapy has been used recently, although radiotherapy has been given irrespective of the response to chemotherapy. We report a case of precocious puberty in an 8 year old boy due to a malignant intracranial germ cell tumour. Although one could speculate that he was cured by such combined modality therapy, the patient was left with several long-term problems. Radiotherapy was a major cause of these complications. Radiotherapy is now thought unnecessary for most extracranial germ cell tumours, as chemotherapy alone is curative in most patients. Therefore it seems appropriate to consider the elimination of radiotherapy for patients with intracranial disease.

Immunization status of casualty attenders: risk factors for non-compliance and attitudes to 'on the spot' immunization

Outbreaks of vaccine preventable infections have focused attention on 'missed opportunities' for immunizing children. The immunization status of 520 consecutive children attending Casualty during a 10 day period was studied. Only 70% of children had received their diphtheria, tetanus, pertussis (DTP) and poliomyelitis immunization at the appropriate time, 13% had completed the schedule later than recommended and 17% had immunizations overdue by 4 weeks or more. For measles (mumps/rubella) vaccine (MM or MMR) 75% were up to date, 10% were given late and 15% were overdue. A subset of 171 families was interviewed to evaluate factors affecting compliance. Families possessing a Social Security 'Health Care Card', whose father was unemployed, who spoke poor English or who had lived in Australia for 5 years or less were significantly more likely (P < 0.02) to be inadequately immunized. There were 84 children whose immunization was overdue and who were well enough to be immunized. The parents of 70 (83%) of these 84 said that they would agree to 'on the spot' immunization if it were available; 14 (17%) parents refused, the commonest reason for refusal being that the parents felt that the child was too sick at the time to be immunized.

Strategies for reduction of noise levels in ICUs

This paper reports on a study of noise levels in an intensive care unit. The various noise sources and their sound levels were identified. Sources of noise were classified into those generated by: people, equipment and room furniture. Strategies for the reduction of noise to levels likely to be less disturbing to patients are discussed.

Acute abdominal distension following Cryptosporidium infection

Two children, aged 15 months and 3 years, developed abdominal distension following proven Cryptosporidium enteritis. Both required readmission to hospital and both improved rapidly, one spontaneously and one with the help of an enema. The association of abdominal distension and Cryptosporidium infection has not been described previously.

Prognostic factors in metastatic carcinoma of unknown primary

From January 1980 to June 1984, 70 patients with metastatic carcinoma of unknown primary treated with combination chemotherapy were analyzed for prognostic factors influencing objective response and survival. Suspicious germ-cell tumors and neuroendocrine tumors were excluded since patients with these malignancies tend to live longer than those with metastatic carcinoma of unknown primary. Objective response rate to combination chemotherapy was 28%. Median survival of all patients responding to combination chemotherapy was better than those not responding (16 v 3 months). In patients with good performance status, median survival was longer in responders than nonresponding patients (17 v 7 months). External lymph nodes or subcutaneous disease as the only site of disease and good performance status favorably influenced both objective response and survival, while the number of different metastatic sites favorably influenced only survival. Neutropenia and thrombocytopenia were appreciable but not fatal or a great cause of morbidity in those with good performance status. Thus, patients with metastatic carcinoma of unknown primary with good performance status or only external nodes or subcutaneous disease should be treated with combination chemotherapy regardless of age, histology, or number of different metastatic sites of disease.