Columbia Children's Hospital Research Articles

Trends in paediatric sport- and recreation-related injuries: An injury surveillance study at the British Columbia Children's Hospital (Vancouver, British Columbia) from 1992 to 2005

Sport- and recreation-related injuries are a major source of morbidity in the paediatric population. Long-term trends for these injuries are largely unknown. A traumatic injury surveillance system (the Canadian Hospitals Injury Reporting and Prevention Program) was used to examine the demographics and trends of paediatric sports injuries in children who presented to or were directly admitted to the British Columbia Children's Hospital (Vancouver, British Columbia) emergency department or intensive care unit from 1992 to 2005. Over the 14-year study period, there was a significant increase in sport- and recreation-related injuries among patients who presented to the British Columbia Children's Hospital. Of 104,414 injuries between 1992 and 2005, 27,466 were related to sports and recreational activities. The number of sport-related injuries increased by 28%, while all-cause injuries did not change significantly. Males comprised 68% of the sport-related injuries, and both sexes displayed an increasing trend over time. Cycling, basketball, soccer and ice hockey were the top four injury-causing activities. The main body parts injured were the face, head and digits. Paediatric sports injuries significantly increased at the British Columbia Children's Hospital over the 14-year study period. This is likely due to increased sport participation, increased risk associated with certain sports, or both. Trends in paediatric sports injury may be predicted by changes in popular media, possibly allowing prevention programs to help to avoid these injuries before they occur.

Validation of diabetes case definitions using administrative claims data

Our aim was to validate three diabetes case definitions for children and adolescents aged <20 years in Canada using administrative and clinical data in the province of British Columbia. We identified potential cases of diabetes from physician claims, hospitalizations and prescription drug records between 1992/1993 and 2007/2008 using the three different case definitions, which included a national standard as well as two regionally developed case definitions. Each case definition used a different combination of administrative data; however, only one definition used prescription drug records. The sensitivity of each definition was calculated against the 'gold standard' of diagnosed cases recorded in British Columbia's Children's Hospital Endocrinology and Diabetes Unit clinical database. During this time period, 2611 patients were seen at the British Columbia's Children's Hospital. The sensitivities (95% CIs) of the national and two regional case definitions were 0.95 (0.941-0.958), 0.97 (0.964-0.977) and 0.82 (0.800-0.830), respectively. Our results highlight the benefit of regional case definitions that exploit the availability of different data sources, but also support that a nationally derived definition is sensitive among children and adolescents.

The effect of changing oxygen saturation protocols on the incidence of laser treatment for retinopathy of prematurity

Objective: To compare the incidence of retinopathy of prematurity (ROP) requiring laser treatment among infants with birth weights of ≤ 1250 g before and after the implementation of a new oxygen saturation protocol in the neonatal intensive care unit of British Columbia Children's Hospital. Design: Retrospective, comparative review of medical records. Participants: Premature infants with birth weights of ≤ 1250 g who were screened for retinopathy of prematurity from November 2003 to October 2005 and February 2006 to January 2008 (269 patients). Methods: The hospital's ROP database was reviewed, and the patients were divided into 2 groups. The preprotocol group (November 2003–October 2005) consisted of patients who were screened before the new oxygen monitoring protocol was instituted and the postprotocol group (February 2006–January 2008) consisted of patients screened after its implementation. Results: A total of 141 patients were in the preprotocol group and 128 patients in the postprotocol group. The mean birth weight and gestational age of the 2 groups were comparable (p = 0.81, 0.71, respectively). There was a 30% reduction in the incidence of laser treatment in the postprotocol group (preprotocol group = 22/141 [15.6%] vs postprotocol group = 13/128 [10.2%]; p = 0.19). Conclusions: We observed a decrease in the rate of severe ROP requiring laser treatment after the implementation of the new oxygen monitoring protocol. While not statistically significant, this is consistent with what has been found at other centres.

The British Columbia's Children's Hospital Tone-Evoked Auditory Brainstem Response Protocol: How Long Do Infants Sleep and How Much Information Can Be Obtained in One Appointment?

There are few published reports providing quantitative information of clinical feasibility for tone-evoked auditory brainstem response (ABR) protocols. In this study, the authors reviewed charts of 188 ABR assessments during a 20-mo period: 116 sedated (median age, 23 mos) and 72 nonsedated (median age, 4 mos). Fifty-one percent of infants had normal thresholds. The average amount of sleep time was 58 mins for sedated assessments, during which an average of 7.6 measures were obtained; nonsedated assessments averaged 49 mins with 6.2 measures obtained. Thus, a substantial amount of both test time and information about hearing can be obtained within one ABR appointment.

Electrocorticography and seizure outcomes in children with lesional epilepsy

The use of electrocorticographically (ECoG)-guided cortical resection in children with lesional epilepsy is controversial. Given the important developmental issues associated with recurrent childhood seizures, sustained seizure control is a key therapeutic goal. We therefore evaluated the effect of the decision to perform lesionectomy or ECoG-guided cortical resection on seizure outcome and surgical morbidity in the pediatric population. We retrospectively analyzed seizure outcomes in 67 patients between the ages of 3 months and 16 years who underwent surgery for lesional epilepsy at British Columbia Children's Hospital. Thirty-four patients underwent ECoG, and 33 patients had lesionectomy without ECoG. One year post-operatively, 80% of patients who had ECoG-guided cortical resection or lesionectomy were seizure free. However, there was a trend toward improved seizure freedom in patients who had ECoG at most recent follow-up (79% patients with ECoG seizure free, vs. 61% with lesionectomy only; mean follow-up time 5.8 year, P=0.078). There was no increase in neurological morbidity in patients who had ECoG-guided cortical resection, and these patients were less likely to experience repeat epilepsy surgery. Overall, using ECoG to guide additional cortical resection may lead to more robust seizure freedom in children with lesional epilepsy without increasing their risk of surgical morbidity.

Adhesive small bowel obstruction in children: should we still operate?

Purpose Adhesive small bowel obstruction (ASBO) is a significant cause of postoperative morbidity, yet studies characterizing outcomes in children are limited. Our aim was to review our experience to describe the role of operative and nonoperative therapy, markers of outcome, and burden of disease in children. Materials and Methods Admissions for ASBO at British Columbia Children's Hospital (Vancouver, British Columbia, Canada) identified by International Classification of Disease, Ninth Revision, codes were reviewed over a 10-year period. Demographic, clinical, laboratory, and operative details were collected for all patients. Results Our study identified 165 admissions of which 32 (19%) were managed with immediate operation, whereas 133 were initially managed nonoperatively. One hundred seven patients went on to laparotomy, whereas 26 (16%) were managed nonoperatively. Absence of leukocytosis and older age appeared to be associated with successful nonoperative therapy. Tachycardia and younger age appeared to be independent risk factors for failure of nonoperative management. Delayed surgery or conservative management did not cause an increase in complications. Appendectomy, stoma formation and closure, Nissen fundoplication, and Ladd's procedures were the most common procedures leading to ASBO. Conclusions Conservative therapy is the preferred approach in selected patients with ASBO. However, 84% eventually require surgery. This differs markedly from results in adults where most resolve nonoperatively. Younger patients were more likely to fail conservative trials and were more likely to develop advanced disease, pointing to ASBO as a distinct disease entity in children.

Wideband Reflectance in Normal Caucasian and Chinese School-Aged Children and in Children with Otitis Media with Effusion

Wideband reflectance (WBR) is a middle ear analysis technique that quantifies frequency-specific sound conduction over a wide range of frequencies. One shortcoming of WBR is that there is limited normative data, particularly for pediatric populations and children with middle ear pathology. The goals of this study were to establish normative WBR data for early school-aged children; to determine whether WBR differs significantly between Caucasian and Chinese children, male and female children, and children and adults (experiment 1); and to compare the normative pediatric WBR data with the WBR data obtained from children with abnormal middle ear conditions (experiment 2). WBR was measured from 78 children with normal middle ear status with an average age of 6.15 yrs and 64 children with abnormal middle ear status with an average age of 6.34 yrs. Control group subjects and subjects without previously diagnosed middle ear pathology were recruited from eight elementary schools in the Greater Vancouver Area. Subjects with known middle ear pathology were recruited through the British Columbia Children's Hospital Otolaryngology department. Middle ear effusion (MEE) was identified in one of the two ways. In the British Columbia Children's Hospital group, MEE was diagnosed by a pediatric otolaryngologist (OTL) using pneumatic otoscopy and video otomicroscopy. These cases (21 ears) were classified as OTL confirmed. Subjects who were assessed through screenings at their elementary schools and suspected to have MEE based on audiological test battery results including elevated air conduction thresholds, flat low- and high-frequency tympanograms, and absent transient-evoked otoacoustic emissions were classified as not OTL confirmed (21 ears). Data were statistically analyzed for effects of gender, ethnicity (Caucasian versus Chinese), age (child versus adult), and middle ear condition. WBR equipment used for this study was from Mimosa Acoustics (RMS-system, version 4.03). Data were averaged in one-third octave bands collected from 248 frequencies ranging from 211 to 6000 Hz. Control group subject data (experiment 1) revealed no effects of gender or ear, and their interactions with frequency were not significant. There was a significant interaction between ethnicity (Caucasian versus Chinese) and frequency. Chinese children had lower energy reflectance (ER) values over the mid-frequency range. ER was significantly different between pediatric data and previously collected adult data. Diseased group ER was significantly different among all four middle ear conditions (normal, mild negative middle ear pressure, severe negative middle ear pressure, and MEE) (experiment 2). The overall test performance of ER was objectively evaluated using receiver operating characteristic (ROC) curve analyses; it was compared across frequencies averaged in one-third octave bands. Statistical comparison of the area under ROC (AUROC) plots revealed that ER above 800 Hz (except for ER at 6300 Hz) had better test performance in distinguishing normal middle ear status from MEE compared with ER at 630 and 800 Hz. Although not statistically different from other frequencies between 800 and 5000 Hz, ER at 1250 Hz had the largest AUROC curve (sensitivity of 96% and specificity of 95%) and was selected for further analysis. Comparison of AUROC curves between WBR at 1250 Hz and static admittance at 226-Hz probe tone frequency revealed significantly better test performance for WBR in distinguishing between healthy ears and MEE. A preliminary set of normative ER data have been generated for a pediatric population between the ages of 5 and 7 yrs, which were significantly different from previously gathered normative adult ER data. In this study, pediatric normative data were warranted for testing children, but ethnic-specific norms were not required to detect middle ear pathology and changes in middle ear status. WBR shows promise as a clinical diagnostic tool for measuring the mechanoacoustic properties of the middle ear and the changes that result in the presence of negative middle ear pressure or MEE.

Safety and efficacy of continuous morphine infusions following pediatric cranial surgery in a surgical ward setting

Morphine is avoided by many neurosurgeons following cranial surgery. There exists a concern regarding the potential complications and a perception that cranial surgery is less painful than other surgical procedures. At British Columbia Children's Hospital continuous morphine infusions (CMI) have been used to control pain in pediatric neurosurgical patients. The purpose of this study was to compare the safety and efficacy of continuous intravenous morphine infusion to standard oral analgesics in a neurosurgical ward setting. A retrospective review of medical records for 71 children was completed. The patients underwent either cranial reconstruction (2002-2007) or craniotomies for intradural pathology (2005-2007) at British Columbia Children's Hospital. Outcome measures included pain control and adverse events. Comparison was made between patients receiving a CMI and patients receiving acetaminophen and codeine. Thirty-seven children received CMI on the ward (30 cranial reconstruction and 7 craniotomy), while 34 (10 cranial reconstruction and 24 craniotomy) received acetaminophen and codeine. There was no statistical difference in pain control. There was significantly more nausea on post-operative day one in the CMI group (p = 0.002). There were no other significant adverse events. These findings suggest that CMI is comparable to acetaminophen and codeine with respect to analgesia and serious side effects. We recommend the use of CMIs as an alternative when pain is poorly controlled in post-operative pediatric neurosurgical patients to prevent the potential adverse consequences of inadequate analgesia.

Tobacco and Lead Exposures and ADHD

The independent and joint effects of prenatal tobacco and childhood lead exposures on ADHD in a national sample of US children were studied by researchers at Cincinnatti Children's Hospital, OH; British Columbia Children's Hospital, Vancouver, Canada; and University of North Carolina, Chapel Hill, NC.

Automatisms in Absence Seizures in Children With Idiopathic Generalized Epilepsy

Automatisms are well recognized to occur in complex partial seizures; however, their occurrence in generalized epilepsies is not always appreciated. There has been considerable debate regarding the nature, triggers, and timing of automatisms in absence seizures. To examine the frequency and nature of automatisms in new-onset absence seizures and assess the influence of the state of arousal, provocation, age, and epilepsy syndrome on the presence and type of automatisms. Analysis of absence seizures through video electroencephalogram (EEG) recordings. British Columbia's Children's Hospital, Vancouver, British Columbia, Canada. Seventy consecutive children with new-onset untreated absence seizures in idiopathic generalized epilepsy recruited between January 1, 1992, and June 30, 1997. Each seizure was analyzed for the presence and characteristics of automatisms. The influence of the following variables on the presence of automatisms was statistically analyzed: state of arousal (awake, drowsy, asleep), provocation (hyperventilation, photic stimulation), age, and epilepsy syndrome. Automatisms occurred in 163 of 405 seizures (40%) in 53 of 70 children (76%). Automatisms were more likely in longer seizures and hyperventilation. Only 23% of spontaneous awake seizures had automatisms. Automatisms were similar for an individual child; however, automatisms were not present in all their seizures. Age, epilepsy syndrome, or state of alertness had no effect on the presence of automatisms. Automatisms are frequently seen during childhood absence seizures. The high frequency of automatisms during EEG recordings is predominantly due to the effect of hyperventilation. Their preponderance during longer seizures may relate to opportunity for automatisms to occur. The characteristic pattern of automatisms suggests a reactive phenomenon to internal and external stimuli.

In Vitro Inferiority of Ceftazidime Compared With Other β-lactams for Viridans Group Streptococcus Bacteremia in Pediatric Oncology Patients

Viridans group Streptococcus (VGS) is a leading cause of bacteremia in pediatric oncology patients, primarily in children with acute myeloid leukemia or after hematopoietic stem cell transplantation. We retrospectively identified all positive blood cultures in oncology patients at the British Columbia Children's Hospital for a period of 54 months. VGS was the second most commonly isolated pathogen, present in 19% of all the positive blood cultures. Susceptibility analysis of 46 VGS isolates from that period was performed using the Etest method for penicillin, cefotaxime, ceftazidime, and piperacillin/tazobactam. The geometric mean minimal inhibitory concentration for ceftazidime was found to be 9 to 12-fold higher than for any other beta-lactam antibiotic. Penicillin resistance was of 13% with an additional 20% of samples with intermediate susceptibility. The study underscores the prevalence of VGS bacteremia in pediatric patients, especially with acute myeloid leukemia or postallogeneic hematopoietic stem cell transplantation, and the in vitro inferiority of ceftazidime compared with other beta-lactams in that context. We conclude that monotherapy with ceftazidime, or its use along with an aminoglycoside, is not an optimal therapy in pediatric oncology patients with febrile neutropenia.

Infant injuries from child restraint safety seat misuse at British Columbia Children’s Hospital

Child restraint safety seats (CRS) are used to prevent injuries or deaths among child passengers involved in a motor vehicle crash. When used outside of a motor vehicle, CRS use could potentially place an infant at risk of injury. The objective of the current study was to describe the proportion of CRS misuse injuries among infants <12 months old and associated factors presenting to the British Columbia (BC) Children's Hospital Emergency Department over 5 years (1997-2002). The Canadian Hospital Injury Reporting and Prevention Program (CHIRPP) was the source for the emergency department injury surveillance data used in the present study. BC Children's Hospital is the participating CHIRPP site in British Columbia. A search of individual level patient records was conducted to capture all injuries from CRS misuse taking place during the study period using a predetermined code for 'child car seat-related injuries'. A retrospective analysis of 87 infants <12 months old, who presented at BC Children's Hospital for CRS-related injuries between January 1997 and December 2002 was performed in order to describe the epidemiologic and background factors related to injury occurrence. Infants aged 0-4 months accounted for approximately 59.7% of cases (52/87). Among all infants, falls were a common mechanism of injury resulting from CRS misuse (98.8%, 86/87). Falls from elevated surfaces (e.g. chairs, tables, counters) were also common among infants presenting to the emergency departments and accounted for 43% of all falls (37/86). Injury prevention efforts should be focused on reducing CRS outside the motor vehicle setting and preventing placement of the CRS at an elevated surface. Educating caregivers on the dangers of falls resulting from CRS misuse in a variety of care settings is also recommended.

Complications of the Catheterizable Channel Following Continent Urinary Diversion: Their Nature and Timing

We reviewed the incidence, nature and timing of complications related to the catheterizable channel following continent urinary diversion. We retrospectively reviewed the records of 67 patients who underwent continent urinary diversion at British Columbia Children's Hospital from 2000 to 2006. Catheterizable channels included 54 Mitrofanoff appendicovesicostomies and 13 ileovesicostomies. Medical records were reviewed for predetermined complications and their timing, that is early -12 months or less, or late - more than 12 months. At a median followup of 28 months (range 3 to 62) a total of 17 complications were identified in 14 patients (21%). Superficial cutaneous stenosis developed in 4 of 67 cases (6%) as an early and as a late complication. These cases were initially treated with operative dilation and surgical revision as necessary. Channel stricture, which developed in 4 of 67 patients (6%) as an early and as a late complication, was treated with operative revision in 2 and endoscopic resection in 2. Three patients (5%) had stomal prolapse, which was generally a late occurrence and required operative revision in all. Channel leakage developed in 6 of 67 patients, presenting as an early complication in 50%. Endoscopic injection of bulking agents was attempted in 4 of these patients and it was successful in 2. Overall 82% of complications were successfully managed by endoscopic or superficial procedures. Complications of the catheterizable channel are a frequent and challenging problem. They appear to occur throughout the life of the channel with most developing within the first 2 years. Further followup is required to assess the performance and durability of continent catheterizable channels in children as patients progress to adulthood.

Long-term bowel function and quality of life in children with Hirschsprung's disease

Background/PurposeLittle is known about the quality of life (QOL) of children with Hirschsprung's disease (HD) as they grow older. The purpose of this study was to measure the QOL and bowel function of these children as they mature. MethodsAll children who were surgically treated for HD at British Columbia Children's Hospital, Vancouver, British Columbia, Canada between 1986 and 2003 were invited to participate. Each family was sent 3 previously validated questionnaires exploring current QOL and bowel function. ResultsFifty-one families participated (49%), with children between the ages of 3 and 21 years. Fecal continence improved significantly with age (P = .04) and was the strongest predictor of QOL scores of all variables in our study. There was no statistically significant difference in QOL scores between children with HD and healthy children, although a clinically relevant impairment in QOL may be present, especially in psychosocial scores. ConclusionsFecal continence is an important predictor of overall QOL in children surgically treated for HD. Although continence tends to improve with age, a number of older children still have ongoing continence problems, and they seem to be a group at risk for impaired QOL. Our study indicates that interventions for children with incontinence may offer gains in QOL as well as bowel function.

Subperiosteal Release of the Floor of the Mouth in Airway Management in Pierre Robin Sequence

Procedures to relieve airway obstruction in Pierre Robin sequence (PRS) include glossopexy, mandibular distraction, and tracheostomy. Previously, it has been suggested that the imbalance of the genioglossus insertion on the mandible could be responsible for the micrognathia, tongue elevation, and glossoptosis seen in PRS. We performed a retrospective study to determine the usefulness of subperiosteal release of the floor of the mouth in PRS with airway problems. Between 1991 and 2005, 14 consecutive patients with PRS were treated with subperiosteal release of the floor of the mouth performed at the British Columbia's Children's Hospital. There were 8 boys and 6 girls. Mean age at surgery was 15 weeks (range, 1-68 weeks). Postoperative follow-up ranged from 8 months to 13 years. Seven patients (4 boys and 3 girls) were successfully treated, and a tracheostomy was prevented. Fifty-five percent of the syndromic patients needed a tracheostomy, whereas 1 patient (33%) with isolated PRS needed a tracheostomy. The most common syndrome associated with PRS was Stickler syndrome. Five (72%) of the 7 patients who required a tracheostomy were boys. If conservative measures fail to relieve supraglottic airway obstruction seen in patients with PRS, a subperiosteal release of the floor of the mouth can be an effective intervention in certain patients. It is a simple intervention with few complications and little morbidity. More investigations are mandatory to precisely define patient characteristics ideal for this intervention.

Pediatric lumbar Chance fractures in British Columbia: Chart review and analysis of the use of shoulder restraints in MVAs

Chance fractures of the skeletally immature spine classically occur in frontal motor vehicle accidents (MVAs) when the occupants are restrained by a lap belt only and undergo traumatic hyperflexion of the torso during the impact. We retrospectively examined all MVA-related Chance fractures at British Columbia's Children's Hospital since 1986, by collecting injury and seat-belt use information from chart data and imaging studies. Twenty-six patients were included in the study, 14 wore a lap belt only, seven wore a three-point restraint properly, and five were reportedly misusing the shoulder portion of a three-point restraint. The subjects ranged in age from 3 to 16 with a mean age of 10.6 years. Eleven of the 26 (42%) patients sustained abdominal viscera injuries, seven of the 26 patients suffered neurologic injury (spinal cord and/or spinal nerve injury) associated with their spinal fracture, with two cases of complete paralysis, and there was a 38% incidence of head injury. Concomitant injuries (i.e. to the head, abdomen and abdominal contents) tended to be mitigated by the presence of a properly worn shoulder restraint. This leads to the conclusion that Chance fractures can be sustained even when the occupant is using a shoulder belt to restrain their torso. The mechanism responsible for this is unknown. This may indicate that Chance fractures can be caused by a lesser degree of torso hyperflexion than previously thought. Alternatively, we also speculate that Chance fractures can occur while the torso is restrained by the shoulder belt if the hips submarine beneath the lap belt and the torso experiences hyperflexion secondary to forward excursion of the pelvis and legs during the collision. Future work is necessary to confirm these mechanisms and to find ways to prevent them. These studies will need to use computational or experimental child surrogates that can sit in a slouched posture and submarine during a collision.

Severe retinopathy of prematurity and visual outcomes in British Columbia: a 10-year analysis

To describe the incidence trend and long-term visual outcomes of infants diagnosed with stages 3 to 4 retinopathy of prematurity (ROP) or laser-treated ROP born in British Columbia (Canada). Data from all (n=1384) neonates with birth weight (BW) <1250 g, admitted to British Columbia Children's Hospital between period 1 (January 1992 to December 1996) and period 2 (January 1997 to December 2001) were analyzed. Ophthalmologic records of infants with stages 3 to 4 ROP or laser-treated ROP were abstracted. chi(2)- and t-test were used to compare neonatal characteristics between periods. Logistic regression was used to identify risk factors associated with visual impairment (defined as visual acuity <or=20/60 or visual field restriction of 20 degrees binocularly). Of 1159 surviving infants, 887 were examined for acute ROP (473 in period 1, 414 in period 2). Stages 3 to 4 ROP or laser-treated ROP were present in 35 infants in period 1 (7%) and 59 in period 2 (14%), P<or=0001. Infants born in period 2 had lower mean BW and gestational age. Among infants who developed severe ROP or laser-treated ROP, binocular visual impairment was present in eight children in period 1 and seven in period 2. Refractive errors, including myopia and astigmatism, were increased in period 2. Children who developed periventricular leucomalacia had the highest risk of visual impairment at 4 to 6 years of age. During the 10-year study period, a significant increase in rates of stages 3 to 4 or laser-treated ROP was not associated with increases in visual impairment rates.

Aerobic and anaerobic capacity in Juvenile Idiopathic Arthritis: evaluation of the cardiorespiratory response

Objectives: To compare the cardiac response during maximal aerobic exercise in JIA with healthy children. Methods: Thirteen children aged 10 to 17 years with JIA and 9 controls (CON) participated. All performed maximal VO2 and Wingate tests on a cycle ergometer. Cardiac output (CO) was measured during exercise with Doppler echocardiography. Arterial – mixed venous oxygen index (A-VO2) and systemic vascular resistance (SVR) were calculated. Results: JIA subjects had decreased aerobic fitness (VO2 31.3, CON 47.9 ml/kg/min p = 0.013]. There was no significant difference in CO, A-VO2 or SVR but we observed trends towards lower CO and higher SVR in JIA. During anaerobic exercise JIA subjects completed less total work. Conclusions: Children with JIA have moderate impairment in aerobic fitness. CO and A-VO2 during aerobic exercise did not differ between JIA subjects and CON. Further research with is required to determine factors contributing to limited fitness in JIA. CONTRIBUTING INSTITUTIONS Divisions of Rheumatology and Cardiology, British Columbia Children's Hospital, Department of Pediatrics, University of British Columbia, Vancouver, Canada. School of Human Kinetics, University of British Columbia, Vancouver, Canada.

An analysis of sport-related injuries: British Columbia children's hospital Emergency Department 1999 – 2003

An analysis of sport-related injuries: British Columbia children's hospital Emergency Department 1999 – 2003

Erythema Nodosum, Mycobacterium avium Lymphadenitis, and a 15-mm Mantoux Test

To the Editors: We report the case of a girl with erythema nodosum (EN)1 that was triggered by a Mycobacterium avium intracellulare (MAC) cervical lymphadenitis. The association of EN with nontuberculous mycobacteria (NTM) is very rare in pediatrics.2 A 2-year-old healthy girl was admitted to our children's hospital with a 3-week illness that began with an upper respiratory infection with fever. She then developed left cervical lymphadenitis followed by erythematous maculopapular lesions in her skin, 2 weeks before admission. Outpatient amoxicillin and cefixime courses were given for presumed bacterial lymphadenitis, with no improvement. On admission, she had a solitary 5 cm indurated, warm, nonfluctuant, painful, left cervical mass and multiple erythematous and violaceous demarcated, shiny, painful raised lesions on her legs, arms, and shoulders. They erupted in patches consistent with EN. She was Canadian born and had no prior BCG vaccination, contacts with or family history of tuberculosis. Ultrasound examination confirmed extensive left-sided cervical lymphadenopathy without abscesses. Tuberculin skin test induration was 15 mm. Chest radiograph was normal and gastric aspirates were negative for M. tuberculosis. Serologic tests were negative for cytomegalovirus, Lyme disease, Epstein-Barr virus, Mycoplasma pneumoniae, and Bartonella henselae. Throat, blood, and stool cultures revealed no pathogens. Screening tests for connective tissue disorders and antistreptolysin O titer were negative. Intravenous clindamycin was administered for 6 days but the patient did not improve. Surgical drainage of the mass revealed pus that contained no organisms on Gram stain. She was discharged without antibiotics, pending culture results. Eight days later, her EN rash had resolved, but drainage was again required. Initial investigations for bacteria and fungi were negative on both specimens. The second specimen contained acid-fast bacilli. MAC was grown after 10 days of incubation from both specimens. Clarithromycin was prescribed but stopped because of oral intolerance. She required a complete excision after which rifampin was given for 6 months. No further recurrence occurred. EN is an acute panniculitis occuring more commonly in adults, associated with infectious and noninfectious etiologies.1 It presents as tender, erythematous nodules predominantly in the lower limbs, with associated symptoms including fever. It usually resolves in weeks and the etiology remains undetermined in up to half of the cases. In one of the largest EN series ever published,1 no case of NTM infection was found among 129 patients seen during 35 years. Among the infectious etiologies, Streptococcus pyogenes and tuberculosis have been the most common triggers. BCG vaccination has been occasionally implicated, and reports of pediatric EN triggered by NTM as in our patient are extremely rare in the literature.2 This case illustrates that a positive Mantoux skin test, independently of the induration size, can be seen in NTM infections.2–4 In this girl, it seems likely that a massive MAC antigen release might have contributed to the EN lesions. In children, NTM should be considered among the infectious etiologies of EN. Cervical lymphadenitis in presence of a positive Mantoux test should include suspicion of NTM infection. Presented in part as an abstract at the 41st Annual Meeting of the Infectious Diseases Society of America (IDSA)—San Diego, CA. October 9–12, 2003. Abstract No. 810.5 Heidi Budden, MD Department of Pediatrics British Columbia's Children's Hospital and The University of British Columbia Vancouver, British Columbia Canada Rolando Ulloa-Gutierrez, MD Simon Dobson, MD, FRCPC David Scheifele, MD Infectious and Immunological Diseases Division