Allergy to betalactam antibiotics in children: results of a 20-year study based on clinical history, skin and challenge tests

Studies based on skin and challenge tests have shown that 12-60% of children with suspected betalactam hypersensitivity were allergic to betalactams. Responses in skin and challenge tests were studied in 1865 children with suspected betalactam allergy (i) to confirm or rule out the suspected diagnosis; (ii) to evaluate diagnostic value of immediate and non-immediate responses in skin and challenge tests; (iii) to determine frequency of betalactam allergy in those children, and (iv) to determine potential risk factors for betalactam allergy. The work-up was completed in 1431 children, of whom 227 (15.9%) were diagnosed allergic to betalactams. Betalactam hypersensitivity was diagnosed in 50 of the 162 (30.9%) children reporting immediate reactions and in 177 of the 1087 (16.7%) children reporting non-immediate reactions (p<0.001). The likelihood of betalactam hypersensitivity was also significantly higher in children reporting anaphylaxis, serum sickness-like reactions, and (potentially) severe skin reactions such as acute generalized exanthematic pustulosis, Stevens-Johnson syndrome, and drug reaction with systemic symptoms than in other children (p<0.001). Skin tests diagnosed 86% of immediate and 31.6% of non-immediate sensitizations. Cross-reactivity and/or cosensitization among betalactams was diagnosed in 76% and 14.7% of the children with immediate and non-immediate hypersensitivity, respectively. The number of children diagnosed allergic to betalactams decreased with time between the reaction and the work-up, probably because the majority of children with severe and worrying reactions were referred for allergological work-up more promptly than the other children. Sex, age, and atopy were not risk factors for betalactam hypersensitivity. In conclusion, we confirm in numerous children that (i) only a few children with suspected betalactam hypersensitivity are allergic to betalactams; (ii) the likelihood of betalactam allergy increases with earliness and/or severity of the reactions; (iii) although non-immediate-reading skin tests (intradermal and patch tests) may diagnose non-immediate sensitizations in children with non-immediate reactions to betalactams (maculopapular rashes and potentially severe skin reactions especially), the diagnostic value of non-immediate-reading skin tests is far lower than the diagnostic value of immediate-reading skin tests, most non-immediate sensitizations to betalactams being diagnosed by means of challenge tests; (iv) cross-reactivity and/or cosensitizations among betalactams are much more frequent in children reporting immediate and/or anaphylactic reactions than in the other children; (v) age, sex and personal atopy are not significant risk factors for betalactam hypersensitivity; and (vi) the number of children with diagnosed allergy to betalactams (of the immediate-type hypersensitivity especially) decreases with time between the reaction and allergological work-up. Finally, based on our experience, we also propose a practical diagnostic approach in children with suspected betalactam hypersensitivity.

[Pneumonia due to adenovirus type 7: a case report in a healthy infant]

A 15-month-old boy treated with amoxicillin and clavulanic acid therapy for 8 days was admitted for persistent gastroenteritis and fever. He received ceftriaxone for pneumonia modified on day 4 for cefotaxime and josamycin due to extension of alveolar lesions. On day 7, persistent fever and worsened respiratory distress led to addition of rifampicin. The child was then admitted to an intensive care unit. A hemophagocytic syndrome was suspected based on clinical signs and laboratory findings and confirmed by cytological examination of bone marrow. Adenovirus type 7 was identified by polymerase chain reaction and culture of bronchoalveolar fluid. Prognosis was good within 3 weeks. B and T immunologic evaluations were normal 5 months after the infection. This case of severe adenovirus pneumonia was associated with hemophagocytic syndrome in a child without identified primary immunodeficiency. Adenovirus type 3 and 7 are most frequently responsible for severe or fatal respiratory infections.

Oral food challenge in children: an expert review

Oral food challenges are indicated for the diagnosis of food allergy and the double-blind, placebo-controlled oral food challenge is considered the gold standard diagnostic method in children with suspected food allergy. This practice parameter for oral food challenges in children was prepared by a workgroup at the request of the French Society for Allergology and Clinical Immunology (SFAIC) and the French Paediatric Society for Allergology and Pulmonology (SP2A). We aimed to develop practical guidelines for oral food challenges in children for the diagnosis of suspected food allergy or the evaluation of food tolerance. We also considered the safety measures to be implemented during testing and management of the potentially serious allergic reactions that may arise during the test. The strength of the recommendations was established, using the GRADE evidence-based approach. We considered four issues: (1) the selection of children for oral food challenges (indications and contraindications); (2) the procedure used (material, where the test should be carried out, technique and management of reactions); (3) interpretation of the test and (4) consequences of the test.

Low influenza vaccination coverage in asthmatic children in France in 2006-7

In France, annual seasonal influenza vaccination has been recommended since 2000 for patients suffering from chronic respiratory diseases, including asthma. Since 1988, each year from September to December, a free influenza vaccination voucher is sent by the French Public Health Insurance authorities to patients with chronic respiratory disease, including severe asthma. In November 2006, this measure was extended to all asthmatic patients, irrespective of asthma severity. The present paper examines the 2006-7 influenza vaccination coverage rate (VCR) in 433 asthmatic children aged 6 to 17 years (mean age: 9.5 years; male: 61%) who consulted a paediatric pulmonologist between March and September 2007 in eight hospitals throughout France. The influenza VCR was 15.7% for the 2006-7 season (13.9% for the 2005-6 season and 10.9% for the 2004-5 season). General practitioners vaccinated 72.1% of the children. "Lack of information" (42%) was the most frequently reported reason for non-vaccination. Vouchers (received by 39.6% of the children) significantly increased the VCR (31% versus 5.9%; p<0.001). In France, in 2006-7, the influenza VCR in asthmatic children was far below the national public health objective (at least 75% for the year 2008). Concerted action is needed to improve the influenza VCR in asthmatic children.

[Practical advice for exercise-induced asthma in children: experience of the exercise training centre of Necker-Enfants malades hospital]

Now, to care exercise-induced asthma is not only to prescribe drugs. It is a global and interdisciplinary approach: the pulmonary rehabilitation, matching a therapeutic education and a physical training, with the goal of promoting a regular physical activity in the asthmatic child, achieving physiological benefits and improvement of quality of life. Getting from the experience of Necker-Enfants Malades Hospital's Training Centre, a few advises encourage the physical practice of the asthmatic child, and decrease risks of exercise-induced asthma: optimisation of treatments;progressive beginning and end of exercises; use of the diaphragmatic breathing, keeping up with the exercise; use of the ventilatory threshold (or dysponea threshold) as intensity of the aerobic training; practice of different activities promoting play and conviviality in sports and allowing the integration of sports in the daily life of the asthmatic child.

[Acute viral respiratory tract infections and childhood asthma]

Les infections virales respiratoires sont de très importants facteurs déclenchants des crises d'asthme. Chez l'enfant les études épidémiologiques les plus récentes, utilisant la PCR, leur attribuent le déclenchement de 80 à 85 % des crises, aussi bien pour les crises modérées que les crises nécessitant une hospitalisation. Le virus respiratoire syncytial et les virus parainfluenzae prédominent chez le nourrisson, les rhinovirus et le mycoplasme chez l'enfant plus grand. Les mécanismes précis de l'induction des crises d'asthme par les virus restent mal compris, toutefois de récentes études montrent une augmentation de l'activation des cellules inflammatoires dans le lavage alvéolaire. Les sujets atopiques, en dehors des périodes d'allergie, ne semblent pas avoir plus de manifestations respiratoires viro-induites que les non-atopiques. En revanche, chez le sujet asthmatique, l'infection virale aggrave les réactions immédiate et retardée de l'hypersensibilité immédiate après test de provocation allergénique, en augmentant la libération des médiateurs mastocytaires et le recrutement des éosinophiles dans les voies aériennes inférieures. Les études chez l'homme et l'animal suggèrent que la production locale de cytokines (IL4, IL8, RANTES, MIP-1a...) et l'expression accrue chez l'asthmatique de la molécule d'adhésion ICAM1 aient un rôle important pour le recrutement et l'activation des cellules de l'inflammation dans les voies aériennes. Une hypothèse, qui reste à démontrer serait que dans des situations où, comme dans l'asthme, les lymphocytes Th2 prédominent, un excès d'Il4 pourrait inhiber les CD8 cytotoxiques, les cellules NK et les Th1 et ainsi entraîner une diminution des défenses antivirales et une réaction inflammatoire broncho-pulmonaire plus sévère que chez le non-asthmatique.

[An unusual foreign body. Report of a case of subcutaneous emphysema during an asthma attack]

Pneumomediastinum is an uncommon complication after an asthma attack. The essential clinical sign is the presence of subcutaneous emphysema. In the great majority of cases, the treatment of pneumomediastinum corresponds to that of asthma, with resorption over several days. The situation is very different when the development of pneumomediastinum and subcutaneous emphysema is secondary to an aspiration syndrome.

[Streptococcus pneumoniae purulent pleurisy and hemolytic uremic syndrome. A case report]

A 22-month-old infant developed purulent pleurisy caused by Streptococcus pneumoniae and a hemolytic uremic syndrome. The diagnosis was suggested by the classical triad: hemolytic anemia, renal failure and thrombocytemia confirmed by renal biopsy which demonstrated extensive cortical necrosis. Renal involvement was severe, justifying an indication for renal transplantation.

[The AIRE Study: data analysis of 753 European children with asthma]

PROBLEM

To analyse the paediatric data from the AIRE study (Asthma insights and reality in Europe) describing the standard of asthma control in Europe.

MATERIAL AND METHODS

Among the 73,880 households contacted by telephone in 7 countries 753 children under the age of 16 were identified. An interview was conducted with a close relative to determine the frequency and severity of symptoms during the recent month, visits to casualty and hospital admissions during the past year, the medications used, the effects on the lives of the children, the opinions of the parents on the level of control of asthma and the monitoring methods used.

RESULTS

38.2% of children reported diurnal symptoms and 28% disturbance of sleep at least once a week. The consequences were important: limitation of sporting activities (29.5%) and absence from school (42.7% in the past year). Treatment was inadequate: 26% of children used inhaled steroids yet 45.9% had persistent asthma. The level of control was overestimated: 61% of parents of children with severe persistent asthma considered the asthma to be well controlled.

CONCLUSION

European asthmatic children are poorly controlled, under-treated and rarely followed up. The consequences, particularly absence from school, should stimulate an improvement in their therapeutic and educational management.

[Endoscopic exploration of the airways in children]

Airway endoscopic exploration in children has benefited from miniaturization of flexible bronchoscopes, allowing examination in young and even premature infants. Whether endoscopy is performed under conscious sedation and topical anesthesia or under deep sedation, the painlessness of the procedure are very important for the child's comfort. Bronchoscopy may provide direct anatomical information or indirect information from secretions sampling, bronchoalveolar lavage, or bronchial and transbronchial biopsies. Indications are wide, mainly detection of airway obstruction via an intrinsic or extrinsic mechanism, identification of an infectious agent in immunocompromised patients, exploration of chronic interstitial pneumonitis, and interventional endoscopy.

[Clinical, biological and genetic heterogeneity of the inborn errors of pulmonary surfactant metabolism: SP-B deficiency and alveolar proteinosis]

Pulmonary surfactant is a multimolecular complex located at the air-water interface within the alveolus and to which a bulk of functions has been assigned, physical (surface-active properties) as well as immune or depurant. This complex consists of a surface active lipid layer (mainly phospholipids), and of an aqueous subphase. From discrete surfactant sub-fractions, one can isolate very hydrophobic proteins SP-B and SP-C as well as the collectins SP-A and SP-D, which were shown to have structural, metabolic, or defensive properties. Inborn or acquired abnormalities of surfactant, qualitative or quantitative in nature, account for a number human diseases. Beside hyaline membrane disease of the preterm neonate, a cluster of hereditary or acquired lung diseases have been characterized by the storage of periodic acid Schiff-positive material filling the alveoli. From this heterogeneous nosologic bulk, at least two discrete entities presently seem to emerge: 1) SP-B deficiency, in which an essentially proteinaceous material is stored within the alveoli, and which is a bona fide autosomal recessive Mendelian entity linked to the SFTPB gene (MIM 1786640), generally entailing neonatal respiratory distress with rapid fatal outcome, although partial or transient deficiencies have also been observed; 2) alveolar proteinosis, characterized by the storage of a mixed, protein and lipid material, and which constitutes a relatively heterogeneous clinical biological syndrome, with regards to age at onset (from the neonate through to adulthood) as well as the severity of associated signs. Murine models with a targeted mutation of the gene encoding GM-CSF (Csfgm) or the beta subunit of its receptor (Il3rbl) support the hypothesis of an abnormality of surfactant turnover in which the alveolar macrophage would be a key player. Beside SP-B deficiency, in which a near-consensus diagnostic chart can be designed, the ascertainment of other abnormalities of surfactant metabolism is not straightforward. The disentanglement of this disease cluster is however essential, with aim to propose differentiated therapeutic procedure : repeated bronchoalveolar lavages, GM-CSF replacement, bone marrow grafting or lung transplantation.

Clinical biological and genetic heterogeneity of the inborn errors of pulmonary surfactant metabolism

Pulmonary surfactant is a multimolecular complex located at the air-water interface within the alveolus to which a range of physical (surface-active properties) and immune functions has been assigned. This complex consists of a surface-active lipid layer (consisting mainly of phospholipids), and of an aqueous subphase. From discrete surfactant sub-fractions one can isolate strongly hydrophobic surfactant proteins B (SP-B) and C (SP-C) as well as collectins SP-A and SP-D, which were shown to have specific structural, metabolic, or immune properties. Inborn or acquired abnormalities of the surfactant, qualitative or quantitative in nature, account for a number of human diseases. Beside hyaline membrane disease of the preterm neonate, a cluster of hereditary or acquired lung diseases has been characterized by periodic acid-Schiff-positive material filling the alveoli. From this heterogeneous nosologic group, at least two discrete entities presently emerge. The first is the SP-B deficiency, in which an essentially proteinaceous material is stored within the alveoli, and which represents an autosomal recessive Mendelian entity linked to the SFTPB gene (MIM 1786640). The disease usually generally entails neonatal respiratory distress with rapid fatal outcome, although partial or transient deficiencies have also been observed. The second is alveolar proteinosis, characterized by the storage of a mixed protein and lipid material, which constitutes a relatively heterogeneous clinical and biological syndrome, especially with regard to age at onset (from the neonate through to adulthood) as well as the severity of associated signs. Murine models, with a targeted mutation of the gene encoding granulocyte macrophage colony-stimulating factor (GM-CSF) (Csfgm) or the beta subunit of its receptor (II3rb1) support the hypothesis of an abnormality of surfactant turnover in which the alveolar macrophage is a key player. Apart from SP-B deficiency, in which a near-consensus diagnostic chart can be designed, the ascertainment of other abnormalities of surfactant metabolism is not straightforward. The disentanglement of this disease cluster is however essential to propose specific therapeutic procedures: repeated broncho-alveolar lavages, GM-CSF replacement, bone marrow grafting or lung transplantation.

Long-term outcome of idiopathic pulmonary hemosiderosis in children

We retrospectively analyzed the long-term outcome of idiopathic pulmonary hemosiderosis (IPH) in 15 children. IPH started at a mean age of 5 years, and the mean duration of follow-up was 17.2 years (range, 10-36 yr). Four patients developed immune disorders, 3 cases of rheumatoid polyarthritis or rheumatoid polyarthritis-like diseases and 1 case of celiac disease. Respiratory outcome showed that 3 patients had severe symptoms: 2 patients developed severe pulmonary fibrosis resulting in major chronic respiratory insufficiency, and 1 patient had severe asthma. Twelve patients (80%) had mild or no respiratory problems and were able to lead a normal life. According to chest X-ray and pulmonary function test data, 4 patients had normal chest X-ray and no evidence of restrictive syndrome, 6 patients had an interstitial pattern on chest X-ray and evidence of restrictive pattern, 1 patient had an interstitial pattern but normal lung function, and 1 patient had a normal chest X-ray but evidence of mixed obstructive and restrictive pattern. Our results show that long-term survival is possible in patients with IPH. Factors of poor prognosis seem to be the presence of antineutrophil cytoplasm antibodies (ANCA) or other autoantibodies. No other clinical or biological predictive factors for prolonged survival were found.

[Asthma and the child below 5 years of age: diagnosis and treatment]

Asthma is the most frequent chronic disease in pediatrics and the increase in its prevalence is a major public health problem. Diagnosis may be difficult in the young child, symptomatology most often occurring following a viral infection. It is important not to ignore a foreign body in the airways or fibrocystic disease and asthma remains, particularly in infants, a diagnosis of elimination. Misdiagnosis or insufficient treatment of asthma may risk the development of irreversible histological lesions and also could compromise pulmonary growth and the child's lung reserve. Spacer devices and nebulisers enable inhaled therapy to be administered to very young children. The value of early diagnosis is to institute appropriate treatment notably in severe asthma with inhaled corticosteroid therapy, the aim being to reduce remodelling lesions of the airways. The minimal effective dose should be defined to minimalise side-effects. The treatment of asthma is not restricted to pharmacotherapy: attempts should be made to reduce intercurrent viral infections, domestic pollution (including smoking) and allergenic concentrations. However, as for all chronic diseases, the clinician will encounter poor compliance. The work of education and support of health professionals is fundamental to the management of asthma.

Early and prolonged intravenous immunoglobulin replacement therapy in childhood agammaglobulinemia: a retrospective survey of 31 patients

OBJECTIVE

To evaluate the outcome of children who received prolonged intravenous immunoglobulin (IVIg) replacement therapy early in life for X-linked agammaglobulinemia (XLA).

STUDY DESIGN

We performed a retrospective study of the clinical features and outcome of patients with genetic and/or immunologic results consistent with XLA. Patients receiving IVIg replacement therapy within 3 months of the diagnosis and for at least 4 years between 1982 and 1997 were included.

RESULTS

Thirty-one patients began receiving IVIg replacement therapy at a median age of 24 months and were followed up for a median time of 123 months. IVIg was given at doses >0.25 g/kg every 3 weeks, and mean individual residual IgG levels ranged from 500 to 1140 mg/dL (median, 700 mg/dL). During IVIg replacement, the incidence of bacterial infections requiring hospitalization fell from 0.40 to 0.06 per patient per year (P <. 001). However, viral or unidentified infections still developed, including enteroviral meningoencephalitis (n = 3) causing death in one patient, exudative enteropathy (n = 3), and aseptic arthritis (n = 1). At last follow-up, 30 patients were alive at a median age of 144 months (range, 58 to 253 months). Among 23 patients who were evaluated by respiratory function tests and computed tomography, 3 had an obstructive syndrome, 6 had bronchiectasis, and 20 had chronic sinusitis.

CONCLUSION

Early IVIg replacement therapy achieving residual IgG levels >500 mg/dL is effective in preventing severe acute bacterial infections and pulmonary insufficiency. More intensive therapy may be required to fully prevent the onset of bronchiectasis, chronic sinusitis, and nonbacterial infections, particularly enteroviral infections, in all cases.

CT scan patterns of pulmonary alveolar proteinosis in children

BACKGROUND

To study computed tomographic (CT) findings in children with pulmonary alveolar proteinosis (PAP) more extensively.

OBJECTIVE

To describe the CT features at the time of diagnosis and after therapeutic broncho-alveolar lavage (BAL).

MATERIALS AND METHODS

We retrospectively reviewed the CT scans of five children (aged 3 months to 4 years) examined because of incidental bronchitis (n = 1), disease in a sibling (n = 1) and relapsing fever, cough and dyspnoea (n = 3). Each patient had an initial CT scan. Two asymptomatic cases were not treated but were followed up by plain chest films. The other three had BAL and follow-up CT.

RESULTS

Initial CT in all cases showed a diffuse reticulomicronodular pattern associated in three cases with posterior bilateral alveolar infiltrates. CT in the two asymptomatic patients remained unchanged or slightly improved without BAL. After BAL, a variable decrease of lung infiltrates was observed.

CONCLUSIONS

Correlation between the extent of alveolar consolidation and severity of disease was found. Anatomical and pathological considerations allow us to consider that the classical reticulomicronodular pattern is not due to an interstitial infiltration but to alveoli filled with the abnormal material characteristic of PAP.

[Asthma in children below 5 years of age: diagnosis and treatment]

Asthma is the most frequent chronic disease in pediatrics and the increase in its prevalence is a major public health problem. Diagnosis may be difficult in the young child, symptomatology most often occurring following a viral infection. It is important not to ignore a foreign body in the airways or fibrocystic disease and asthma remains, particularly in infants, a diagnosis of elimination. Misdiagnosis or insufficient treatment of asthma may risk the development of irreversible histological lesions and also could compromise pulmonary growth and the child's lung reserve. Spacer devices and nebulisers enable inhaled therapy to be administered to very young children. The value of early diagnosis is to institute appropriate treatment notably in severe asthma with inhaled corticosteroid therapy, the aim being to reduce remodelling lesions of the airways. The minimal effective dose should be defined to minimalize side-effects. The treatment of asthma is not restricted to pharmacotherapy: attempts should be made to reduce intercurrent viral infections, domestic pollution (including smoking) and allergenic concentrations. However, as for all chronic diseases, the clinician will encounter poor compliance. The work of education and support of health professionals is fundamental to the management of asthma.

Successful bronchotracheal reconstruction in esophageal bronchus: two case reports

Esophageal bronchus is the most common congenital bronchopulmonary foregut malformation. Current surgical treatment is resection of anomalous pulmonary tissue, which is often hypoplastic and destroyed by infection. The authors report two cases of bronchotracheal reconstruction. The diagnosis was early, before 15 days of age. The anomalous pulmonary tissue had a pulmonary arterial supply and venous drainage as assessed by angiography and a good functional capacity on selective ventilation. Bronchotracheal anastomosis was successful in both cases: a right main bronchus at 25 days of age and a left main bronchus at 13 days of age. One child underwent reoperation 1 year later for bronchomalacia of the reimplanted bronchus. Both children are well with normal growth 3 and 7 years after surgery. Chest roentgenograms showed normal and symmetrical lung aeration. Tracheal reimplantation may be preferred to pulmonary resection when the anomalous pulmonary tissue is not destroyed. The pulmonary functional capacity is increased and the complications of pneumonectomy avoided.

Insulin responses to intravenous glucose and the hyperglycemic clamp in cystic fibrosis patients with different degrees of glucose tolerance

The relationship between altered insulin secretion and impaired glucose tolerance was studied in 32 cystic fibrosis patients, 16 men and 16 women, aged 8-26 y, using oral and i.v. glucose tolerance tests and a hyperglycemic glucose clamp (10 mmol/L). Seven of these subjects were already being treated with insulin; seven had fasting blood glucose levels below 7.2 mmol/L but satisfied diabetic criteria at the oral glucose tolerance test; glucose tolerance was impaired in 13 subjects and normal in five. The insulin responses to the two i.v. glucose stimuli were inversely correlated with the plasma glucose levels (60 and 120 min) and the area under the curve of the oral glucose tolerance test. However, the acute insulin response to i.v. glucose was severely altered in patients with impaired glucose tolerance, whereas plasma insulin levels during the hyperglycemic clamp did not differ from those of healthy subjects. The responses to the two stimuli were dramatically low in the diabetic patients. These results suggest that cystic fibrosis patients with normal or impaired glucose tolerance retain their capacity to secrete insulin. Alterations in the acute phase of glucose-stimulated insulin secretion seem to be principally responsible for the early impairment in glucose tolerance.

[Anaphylaxis syndrome induced by exercise]

The authors report the case of a 12 year-old boy with exercise-induced anaphylaxis. Angioedema was the main symptom and was accentuated by ingestion of an orange prior to exercise. Exercise-induced anaphylaxis is due to mast cell degranulation that is triggered by exercise alone or, less commonly, by the combination of a sensitizing food and exercise. The symptoms of exercise-induced anaphylaxis may be moderate or severe, with laryngeal dyspnea and shock. Prevention is based on avoidance of the offending food before exercise and a reduction of the intensity (and even the suppression) of exertion.

[Genital tuberculosis in a 14-year-old girl]

The authors report the case of a 14 year-old girl presenting with pulmonary, adrenal and genital tuberculosis. Pelvic pain was the presenting symptom. Association of familial contamination, phlyctenular Mantoux test, apex infiltrate with a calcified nodule on chest x-ray film and numerous pelvic calcifications on plain films of the abdomen led to diagnosis. The authors emphasize the importance of the supervision of Mantoux test and the necessity of treatment of any latent primary tuberculosis.

Mucoid impaction of bronchi. A scanning electron microscopic study

An example of mucoid impaction in the culminal bronchus in a potentially asthmatic child is related. Histological sections of the plug showed the characteristic pattern with clusters of eosinophils and other cells within the impacted mucus, which consisted of mainly sulfated glycoproteins. Scanning electron microscopy revealed new data on the three-dimensional structure of the plug. Ten to fifteen micron thick fascicles of partially rolled-up mucous fibres surrounded wide meshes filled with eosinophils and other components. As far as can be determined, this is the first reported ultrastructural description of this particular lesion.

[Treatment of ventricular septal defects with pulmonary hypertension in infancy (author's transl)]

188 infants presenting with ventricular septal defects associated with pulmonary hypertension underwent early surgical treatment. Overall death rate was 10% (6% since 1979 and even 0% in case of single defects operated on between the ages of 6 and 12 months). Surgical results were excellent in 48 controlled cases operated on during the 1st year of life. When surgery was performed later, risk of residual pulmonary hypertension remained in cases with equal pressure levels. Our results suggest that all the infants who do not respond properly to medical treatment must be operated on and that those with a major pulmonary hypertension have to be operated on during there second semester of life.