Surveillance of invasive infection in children and adults admitted to QECH, Blantyre, 1996-2002

A Rare Case of Cryptococcal Meningitis in a Child with a Congenital Heart Disease

Cryptococcal meningitis, which has a high mortality rate, is rare in immunocompetent children. Although many immunocompromised conditions are identified as predisposing factors, congenital heart disease in children is not well recognized as a predisposing factor for the disease. A 12-year-old female child presented with a progressively increasing headache for one month. There was history of vomiting and fever off and on. On examination, she had a pansystolic murmur and meningeal signs. Lumbar puncture was done; opening pressure was high (27 cm H₂O) and white blood cell (WBC) count in cerebrospinal fluid (CSF) was slightly high. Gram staining, India ink preparation, and culture of CSF were negative. Cryptococcal antigen (CrAg) test was not available. Echocardiography showed a 12 mm ventricular septal defect (VSD). The patient was diagnosed as meningitis with VSD and treated with intravenous ceftriaxone and vancomycin; however, she did not improve after 7 days of antimicrobial treatment. She was then transferred to another hospital where India ink and culture of CSF showed cryptococcus; CrAg test was done, and it was positive. Despite the treatment with lyposomal amphotericin B and flucytosine, she died on 9^th day of admission in pediatric intensive care unit. It is necessary for global advocacy for need of availability of CrAg test in resource-limited regions. Treating doctors should consider VSD, a congenital heart disease, as a predisposing factor for cryptococcal meningitis in children. As CrAg is more sensitive than India ink and culture, it should be the first line of investigation in suspected cases.

Typhoid fever in children in Africa

Estimates for the year 2000 suggested that there were approximately 21.5 million infections and 200,000 deaths from typhoid fever globally each year, making the disease one of the most serious infectious disease threats to public health on a global scale. However, these estimates were based on little data, especially from Africa. Global prominence and high-profile outbreaks have created the perception in Kenya that typhoid is a common cause of febrile illness. The Widal test is used widely in diagnosis. We have reviewed recent literature, taking the perspective of a healthcare provider, to collate information on the prevalence of typhoid in children particularly, and to explore the role of clinical diagnosis and diagnosis based on a crude, but common, interpretation of the Widal test. Data suggest that typhoid in children in rural Africa is uncommon, perhaps 100 times or 250 times less common than invasive disease because of Haemophilus influenzae or Streptococcus pneumoniae, respectively. Frequent use of the Widal test may result in many hundreds of over-treatment episodes for every true case treated and may perpetuate the perception that typhoid is common. Countries such as Kenya need better bacterial disease surveillance systems allied to better information for healthcare providers to promote appropriate decision-making on prevention and treatment strategies.