High-dose Intravenous Antibiotics Research Articles

Impact of a structured patient education programme on early diagnosis of prosthetic pulmonary valve endocarditis.

Infective endocarditis is a major threat after prosthetic pulmonary valve replacement. Early diagnosis may improve outcomes. A structured patient education programme for prevention and early diagnosis of infective endocarditis was developed at our institution since 2016. Time delay between onset of symptoms of prosthetic pulmonary valve endocarditis and its diagnosis (defined as initiation of appropriate high-dose intravenous antibiotic treatment) was compared for patients presenting before (cohort 1) and after (cohort 2) initiation of the patient education programme. Between 2008-2019, 26 patients (median age 24.9, range: 16.8-62.0 years, 73% male) were diagnosed with prosthetic pulmonary valve endocarditis, 13 patients (cohort 1) before (1.7 cases/year) and 13 patients (cohort 2) after June 2016 (3.7 cases/year). There were no differences in baseline characteristics or clinical presentation between the study cohorts. Overall, the median delay between onset of symptoms and diagnosis of infective endocarditis was 6 days (range: 0-133 days) with a significantly longer delay among patients in cohort 1, compared to cohort 2 (25 days, range: 5-133 days versus 3 days, range: 0-13 days, p < 0.0001). A delay of >7 days was documented in 11/13 patients (85%) in cohort 1 as compared to 1/13 (8%) in cohort 2 (p < 0.001). Need for urgent valve replacement or permanent deterioration of prosthetic valve function was higher in cohort 1, compared to cohort 2 (11/13, 85% versus 5/13, 39%; p = 0.041). Prosthetic pulmonary valve endocarditis is increasingly recognised. A structured patient education programme may improve early diagnosis and clinical outcomes.

Facial Neuritis as a Manifestation of Gradenigo's Syndrome

AbstractGradenigo's syndrome (GS) is a rare, acquired syndrome caused by middle ear infections or mastoiditis. It is identified by the triad of otorrhea due to otitis media (OM), retro-orbital pain in the region innervated by the first and second divisions of the trigeminal nerve, and diplopia as a result of cranial nerve (CN) VI palsy. As a result of extension of the inflammation, the facial nerve (VII) may also be affected. GS has a poor prognosis unless promptly diagnosed and treated. Herein, we report the clinical and radiological findings observed in two children diagnosed with chronic suppurative OM, mastoiditis, and facial neuritis. Both were medically managed as cases of GS with high-dose intravenous antibiotic and full recovery was achieved a few weeks after discharge. There was no need for any surgical intervention. This case report illustrates the importance of early recognition, diagnosis, and treatment of this treatable syndrome using antibiotics to prevent subsequent fatal complications and further need for surgical intervention.

929 Not Another Abscess - A Case of Streptococcal Myositis Misdiagnosed as a Right Axillary Abscess

Abstract Introduction Streptococcal myositis is a rare form of infectious myositis caused by Lansfield A beta-haemolytic streptococci. It is characterised by rapidly spreading inflammation that can result in severe systemic toxicity and necrosis of the affected tissue if not diagnosed and aggressively treated. Presentation We report a case of a 42-year-old male who presented with a one-week history of worsening right axillary swelling that progressed to painful swelling of his arm. Inflammatory markers were significantly elevated with a white cell count of 17 ×109/L and C-reactive protein of 212 mg/L. On examination, a fluctuant axillary swelling was appreciated, and a decision was made for incision and drainage under general anaesthetic. Intraoperative aspiration of his arm revealed copious purulent fluid prompting intraoperative orthopaedic consult and exploration of the anterior compartment in which there was extensive involvement of the biceps muscle. The microbiological analysis revealed gram-positive cocci in chains, and microbiology advice sought for tailoring of antibiotic regimen. He has recovered well. Discussion Though uncommon, the emergency general surgeon should have a high degree of suspicion when evaluating soft tissue infections to avert potentially disastrous outcomes. Conclusion Early diagnosis, aggressive management with high-dose intravenous antibiotics, and surgical debridement are principles to treat this rare, life-threatening infection.

Renal Toxicity Associated With Resection and Spacer Insertion for Chronic Hip PJI

BackgroundTwo-stage exchange arthroplasty with high-dose antibiotic-loaded bone cement spacer and intravenous (IV) antibiotics is the most common method of managing infected total hip arthroplasties. However, the contemporary incidence, risk factors, and outcomes of acute kidney injuries (AKIs) in this cohort are unknown. MethodsWe identified 227 patients treated with 256 antibiotic-loaded bone cement spacers after resection of an infected primary total hip arthroplasty between 2000 and 2017. Mean age was 65 years, mean body mass index was 30 mg/kg2, 55% were men, and 16% had pre-existing chronic kidney disease (CKD). Spacers were in situ for a mean of 15 weeks, concomitantly associated with IV or oral antibiotics for a mean of 6 weeks. AKI was defined as a creatinine ≥1.5X baseline or ≥0.3 mg/dL. Mean follow-up was 8 years. ResultsAKI occurred in 13 patients without pre-existing CKD (7%) vs 10 patients with CKD (28%; OR 5; P = .0001). None required acute dialysis. Postoperative fluid depletion (β = 0.31; P = .0001), ICU requirement (β = 0.40; P = .0001), and acute atrial fibrillation (β = 0.43; P = .0001) were independent predictors for AKI in patients without pre-existing CKD. Duration of in situ spacer, mean antibiotic dose in cement, use of amphotericin B, and type of IV antibiotics were not significant risk factors. At last follow-up, 8 AKIs progressed to CKD, with one receiving dialysis 7 years later. ConclusionAKIs occurred in 7% of patients with normal renal function, with 5-fold greater risk in those with CKD, and 4% did develop CKD. Importantly, causes of acute renal blood flow impairment were independent predictors for AKI. Level of EvidenceLevel III, comparative study.

Microbial biofilm correlates with an increased antibiotic tolerance and poor therapeutic outcome in infective endocarditis

BackgroundInfective endocarditis (IE) is associated with high rates of mortality. Prolonged treatments with high-dose intravenous antibiotics often fail to eradicate the infection, frequently leading to high-risk surgical intervention. By providing a mechanism of antibiotic tolerance, which escapes conventional antibiotic susceptibility profiling, microbial biofilm represents a key diagnostic and therapeutic challenge for clinicians. This study aims at assessing a rapid biofilm identification assay and a targeted antimicrobial susceptibility profile of biofilm-growing bacteria in patients with IE, which were unresponsive to antibiotic therapy.ResultsStaphylococcus aureus was the most common isolate (50%), followed by Enterococcus faecalis (25%) and Streptococcus gallolyticus (25%). All microbial isolates were found to be capable of producing large, structured biofilms in vitro. As expected, antibiotic treatment either administered on the basis of antibiogram or chosen empirically among those considered first-line antibiotics for IE, including ceftriaxone, daptomycin, tigecycline and vancomycin, was not effective at eradicating biofilm-growing bacteria. Conversely, antimicrobial susceptibility profile of biofilm-growing bacteria indicated that teicoplanin, oxacillin and fusidic acid were most effective against S. aureus biofilm, while ampicillin was the most active against S. gallolyticus and E. faecalis biofilm, respectively.ConclusionsThis study indicates that biofilm-producing bacteria, from surgically treated IE, display a high tolerance to antibiotics, which is undetected by conventional antibiograms. The rapid identification and antimicrobial tolerance profiling of biofilm-growing bacteria in IE can provide key information for both antimicrobial therapy and prevention strategies.

Invasive Eyelid Infections by β-Hemolytic Streptococci of Serogroup A

Invasive soft tissue infections by Streptococcus pyogenes are rapidly progressive and potentially life-threatening infectious diseases. These can also affect the eyelid. Aggressive virulence factors and the synthesis of exotoxins can lead to complications, such as periorbital necrotizing fasciitis (PONF) and streptococcal toxic shock syndrome (STSS). The clinical picture is characterized by four patients with invasive eyelid infections. Photographic documentation, radiological imaging, laboratory and smear diagnostics and intravenous antibiotic therapy were performed on all patients according to the recommendations of the German Robert Koch Institute and the local infectiology board. In all patients, Streptococcus pyogenes was culturally detected in a direct swab. The antibiogram showed sensitivity to the common intravenous antibiotics. The time interval between symptom onset and presentation at the clinic was between two days and one week. All patients had high systemic inflammatory parameters on admission: Pat. 1: CRP 259 mg/l, leukocytes 20.1 giga/l; Pat. 2: CRP 375 mg/l, leukocytes 15.6 giga/l; Pat. 3: CRP 378 mg/l, leukocytes 38.7 giga/l; Pat. 4: CRP 483 mg/l, leukocytes 1.7 giga/l; normal values: CRP < 5 mg/l, leucocytes 4.4 - 11.3 giga/l. In Pat. 2 and 3, a periorbital necrotizing fasciitis was diagnosed due to rapidly progressing necrosis in the area of cutis and subcutis and systemic toxicity. Pat. 3 and 4 met the diagnostic criteria of STSS. Pat.2, 3 and 4 had to be relocated to an intermediate or intensive care unit with sepsis, despite immediate intravenous antibiotic therapy. Patient 3 underwent surgical debridement during the stay in the intensive care unit. Thanks to interdisciplinary management (ophthalmology, infectiology, ear, nose and throat medicine, internal medicine and intensive care medicine), all patients were finally discharged from our inpatient treatment in a significantly improved general condition. Invasive streptococcal infections represent a challenge in the daily routine of an ophthalmologist. Interdisciplinary management and immediate onset of high-dose intravenous antibiotic therapy are crucial for successful treatment.

Bicalutamide-induced Eosinophilic Pneumonitis - A Serendipitous Diagnosis

Bicalutamide is a first-generation non-steroidal anti-androgen. Interstitial lung disease is a rare side effect of bicalutamide. Centres in the United States of America and Japan have previously reported bicalutamide-induced interstitial lung disease. This has not been reported in the United Kingdom.&#x0D; An 86-year-old Caucasian man with a history of advanced prostate cancer, on oral bicalutamide, presented to the emergency department with sudden onset dyspnoea and chest tightness.&#x0D; Bicalutamide-induced eosinophilic pneumonitis co-existing with community acquired pneumonia, and left ventricular systolic dysfunction were suspected, based on physical examination findings and investigation results that include blood tests, chest radiographs, echocardiogram, in addition to computed tomography pulmonary angiogram performed to rule out pulmonary embolism.&#x0D; There was a marked clinical, biochemical and radiological improvements after discontinuation of bicalutamide, initiation of a high-dose steroid, intravenous antibiotics, and diuretic. Prostate cancer retains a high incidence in the Western population. Recognising toxicities due to anti-androgen therapies is relevant to clinical practice.&#x0D;

Life-Threatening paediatric odontogenic cellulitis secondary to a partially erupted primary molar

Abstract: A 15-month-old male was admitted to hospital with a facial swelling of unknown origin which was of rapid onset over three hours, resulting in airway occlusion and septic shock. Ultimately, the swelling was found to be of odontogenic origin and was managed with high dose intra-venous antibiotics. Cellulitis of the face can be life-threatening and it is important to be aware of the clinical signs and ensure that the patient receives appropriate care to prevent deterioration. CPD/Clinical Relevance: It is essential for dentists in primary and secondary care to recognize and understand how to manage or refer a patient with facial cellulitis, and also for medical teams to seek prompt dental input in cases of facial swelling with a possible dental cause.

Managing infective endocarditis in the elderly: new issues for an old disease.

The incidence of infective endocarditis (IE) rises in industrialized countries. Older people are more affected by this severe disease, notably because of the increasing number of invasive procedures and intracardiac devices implanted in these patients. Peculiar clinical and echocardiographic features, microorganisms involved, and prognosis of IE in elderly have been underlined in several studies. Additionally, elderly population appears quite heterogeneous, from healthy people without past medical history to patients with multiple diseases or who are even bedridden. However, the management of IE in this population has been poorly explored, and international guidelines do not recommend adapting the therapeutic strategy to the patient’s functional status and comorbidities. Yet, if IE should be treated according to current recommendations in the healthiest patients, concerns may rise for older patients who suffer from several chronic diseases, especially renal failure, and are on polypharmacy. Treating frailest patients with high-dose intravenous antibiotics during a prolonged hospital stay as recommended for younger patients could also expose them to functional decline and toxic effect. Likewise, the place of surgery according to the aging characteristics of each patient is unclear. The aim of this article is to review the recent data on epidemiology of IE and its peculiarities in the elderly. Then, its management and various therapeutic approaches that can be considered according to and beyond guidelines depending on patient comorbidities and frailty are discussed.

Preoperative antibiotics for septic arthritis in children: delay in diagnosis.

To review the records of 50 children who underwent open joint washout for septic arthritis with (n=25) or without (n=25) preoperative antibiotics. Records of 50 children who underwent open joint washout for presumed septic arthritis with (n=25) or without (n=25) preoperative antibiotics were reviewed. 17 boys and 8 girls aged 3 weeks to 16 years (median, 1.5 years) who were prescribed preoperative antibiotics before joint washout were compared with 12 boys and 13 girls aged one month to 14 years (median, 2 years) who were not. Following arthrotomy and washout, all patients were commenced on high-dose intravenous antibiotics. Patients were followed up for 6 to 18 months until asymptomatic. Patients who were referred from places other than our emergency department were twice as likely to have been prescribed preoperative antibiotics (p=0.0032). Patients prescribed preoperative antibiotics had a longer median (range) time from symptom onset to joint washout (8 [2-23] vs. 4 [1-29] days, p=0.05) and a higher mean erythrocyte sedimentation rate (93.1 vs. 54.3 mm/h, p=0.023) at presentation. Nonetheless, the 2 groups were comparable for weight bearing status, fever, and positive culture, as well as the mean (range) duration of antibiotic treatment (4.9 [4-7] vs. 4.7 [1-8] weeks, p=0.586). Preoperative antibiotics should be avoided in the management of septic arthritis in children. Their prescription delays diagnosis and definitive surgery, and leads to additional washouts and complications. A high index of suspicion and expedite referral to a specialist paediatric orthopaedic unit is needed if septic arthritis is suspected.

Retrobulbar optic neuritis and cystoid macular edema as a first manifestation of lyme disease

Lyme disease is a multi-system disorder caused by the spirochete Borrelia burgdoferi. Eye manifestations are a rare involvement. We report two cases of patients who developed a retrobulbar optic neuritis and a cystoid macular edema as a sole clinical presenting in Lyme disease. A 42-year-old female presented with left eye decreased visual acuity and painful ocular movement. Dilated funduscopy and neurological examination were normal. A diagnosis of left eye retrobulbar optic neuritis was made. The brain and spinal cord MRI showed typical lesions characteristic of MS. Serological tests for Lyme disease revealed positive results for IgM ELISA and Western blot. The possible serologically proven Lyme disease was diagnosed. Visual acuity returned to normal following a course of high-dose steroids and intravenous antibiotic, after by oral antibiotic. A 28-year-old male presented with left eye blurred vision and intermittent blurring vision in his right eye. Dilated funduscopy revealed bilateral cystoid macular edema (left more than right). He was positive for Lyme serology, IgM ELISA and Western blot, and intravenous antibiotic therapy was commenced, followed by oral antibiotic. Visual acuity was restored and fuduscopy was normal. In summary, although Lyme disease is an uncommon cause of these neuro-ophthalmic complications, our two patients highlight the importance of considering this disorder as a differential diagnosis and to initiate an early adequate therapy.

Severe maternal sepsis in the UK, 2011-2012: a national case-control study.

In light of increasing rates and severity of sepsis worldwide, this study aimed to estimate the incidence of, and describe the causative organisms, sources of infection, and risk factors for, severe maternal sepsis in the UK. A prospective case-control study included 365 confirmed cases of severe maternal sepsis and 757 controls from all UK obstetrician-led maternity units from June 1, 2011, to May 31, 2012. Incidence of severe sepsis was 4.7 (95% CI 4.2-5.2) per 10,000 maternities; 71 (19.5%) women developed septic shock; and five (1.4%) women died. Genital tract infection (31.0%) and the organism Escherichia coli (21.1%) were most common. Women had significantly increased adjusted odds ratios (aORs) of severe sepsis if they were black or other ethnic minority (aOR = 1.82; 95% CI 1.82-2.51), were primiparous (aOR = 1.60; 95% CI 1.17-2.20), had a pre-existing medical problem (aOR = 1.40; 95% CI 1.01-1.94), had febrile illness or were taking antibiotics in the 2 wk prior to presentation (aOR = 12.07; 95% CI 8.11-17.97), or had an operative vaginal delivery (aOR = 2.49; 95% CI 1.32-4.70), pre-labour cesarean (aOR = 3.83; 95% CI 2.24-6.56), or cesarean after labour onset (aOR = 8.06; 95% CI 4.65-13.97). Median time between delivery and sepsis was 3 d (interquartile range = 1-7 d). Multiple pregnancy (aOR = 5.75; 95% CI 1.54-21.45) and infection with group A streptococcus (aOR = 4.84; 2.17-10.78) were associated with progression to septic shock; for 16 (50%) women with a group A streptococcal infection there was <2 h-and for 24 (75%) women, <9 h-between the first sign of systemic inflammatory response syndrome and a diagnosis of severe sepsis. A limitation of this study was the proportion of women with sepsis without an identified organism or infection source (16.4%). For each maternal sepsis death, approximately 50 women have life-threatening morbidity from sepsis. Follow-up to ensure infection is eradicated is important. The rapid progression to severe sepsis highlights the importance of following the international Surviving Sepsis Campaign guideline of early administration of high-dose intravenous antibiotics within 1 h of admission to hospital for anyone with suspected sepsis. Signs of severe sepsis in peripartum women, particularly with confirmed or suspected group A streptococcal infection, should be regarded as an obstetric emergency. Please see later in the article for the Editors' Summary.

To drain or not to drain – Management of pediatric deep neck abscesses: A case–control study

Optimal management of deep neck abscesses has been the subject of debate for more than a century: surgical drainage has been the mainstay of treatment, but recently many centres have reported successful non-operative management in selected cases. ObjectivesOur objective was to review the management of deep neck abscesses in our institution and to identify characteristics that would predict successful non-operative management. MethodsA retrospective chart review from January 2001 to August 2010 was performed. Children up to age fifteen years with a CT-confirmed diagnosis of retropharyngeal or parapharyngeal abscess were included. A case–control study of small deep space neck abscesses (≤25mm maximal diameter) was performed, comparing antibiotic treatment alone with antibiotics plus abscess drainage. Results54 children met the inclusion criteria, of whom half had abscesses ≤25mm diameter. Younger children within the group with smaller abscesses were more likely to need surgical drainage (p<0.05). Of 13 children requiring operative management, ten underwent a period of antibiotic treatment and observation prior to surgery, eight (80%) had fever beyond 48h compared with three (23%) in the non-surgical group (p<0.01).27 children had an abscess >25mm diameter on CT scan, four (15%) of whom responded quickly to antibiotics and were managed non-operatively, while the rest underwent surgery. There were no significant differences between the surgical and non-surgical group characteristics with larger abscesses. ConclusionHigh dose intravenous antibiotics are an effective treatment for deep space neck abscesses and may obviate the need for surgical drainage, particularly in smaller abscesses. Children who do not respond quickly to antibiotics are more likely to require surgery to achieve resolution. Children with larger abscesses may respond to antibiotic therapy alone but should be closely observed. A trial of high dose intravenous antibiotics in stable children with close observation is warranted as first line treatment, especially for small deep space neck abscesses.

Actinomyces in Chronic Granulomatous Disease: An Emerging and Unanticipated Pathogen

Chronic granulomatous disease (CGD) is a rare inherited disease of the phagocyte NADPH oxidase system that causes defective production of toxic oxygen metabolites, impaired bacterial and fungal killing, and recurrent life-threatening infections, mostly by catalase-producing organisms. We report for the first time, to our knowledge, chronic infections with Actinomyces species in 10 patients with CGD. Actinomycosis is a chronic granulomatous condition that commonly manifests as cervicofacial, pulmonary, or abdominal disease, caused by slowly progressive infection with oral and gastrointestinal commensal Actinomyces species. Treatment of actinomycosis is usually simple in immunocompetent individuals, requiring long-term, high-dose intravenous penicillin, but is more complicated in those with CGD because of delayed diagnosis and an increased risk of chronic invasive or debilitating disease. Actinomyces was identified by culture, staining, 16S ribosomal DNA polymerase chain reaction, and/or a complement fixation test in 10 patients with CGD. All 10 patients presented with a history of fever and elevated inflammatory signs without evident focus. Diagnosis was delayed and clinical course severe and protracted despite high-dose intravenous antibiotic therapy and/or surgery. These results suggest an unrecognized and unanticipated susceptibility to weakly pathogenic Actinomyces species in patients with CGD because these are catalase-negative organisms previously thought to be nonpathogenic in CGD. Actinomycosis should be vigorously sought and promptly treated in patients with CGD presenting with uncommon and prolonged clinical signs of infection. Actinomycosis is a catalase-negative infection important to consider in CGD.

Gradenigo's syndrome with lateral venous sinus thrombosis: successful conservative treatment

Gradenigo's syndrome (GS) is a rare disease characterised by the triad otitis media, pain in the region innervated by the first and the second division of trigeminal nerve and abducens nerve palsy. Septic sinus thrombosis is one of the most frequent and relevant complication of GS; it is often due to persistent damage and late diagnosis. Computed tomography (CT) scan and magnetic resonance imaging (MRI) allow the correct diagnosis in most cases. Surgical therapy may be necessary for a better and more rapid resolution of the disease. We report the case of a 4-year-old child that was admitted for facial nerve palsy and abducens nerve palsy subsequent to a 2-week persistent pain in the right ear. MRI showed infective acute process of the right mastoid and partial ipsilateral sinus thrombophlebitis. The child was treated with high-dose intravenous antibiotics and with oral anticoagulants. A complete resolution of symptoms and radiological alterations were observed within 7 weeks. In conclusion, lateral sinus thrombosis and Gradenigo's syndrome are rare but potential fatal complications of otitis media and mastoiditis. High-dose intravenous antibiotics and a low dose of anticoagulant can achieve a complete recovery without surgery.

Necrotizing fasciitis and hypothyroidism

Sir, A 51-year-old man was admitted to hospital with extensive cellulites, dermal excoriation, and a deep-seated abscess in the skin over the perineum, extending dorsally over the lower back. Urgent surgical exploration and debridement was undertaken, which revealed extensive necrotizing fasciitis. Further management consisted of high-dose intravenous antibiotics and debridement (on six different occasions, including the lower abdominal wall, penile tissue, perineal tissue extending to the back, perianal and large areas of lumbar skin, overall approximately 18% of body surface area). The wound …

Cerebral abscess of odontogenic origin

Cerebral abscess is a rare but serious and life-threatening infection. Dental infections have occasionally been reported as the source of bacteria for such an abcess. A 54-year-old man was admitted with a right hemiparesis and epileptic fits. After clinical, laboratory and imaging examination, the diagnosis of a cerebral abscess of the left parietal lobe was made. The intraoral clinical examination as well as a panoramic radiograph confirmed the presence of generalized periodontal disease, multiple dental caries, and periapical pathology. The treatment included: (i) Immediate administration of high-dose intravenous antibiotics and (ii) surgical procedures consisting of craniotomy and resection of the abscess cavity first, and secondly removal of the periodontal, decayed and periapically involved teeth of the patient, in an effort to eradicate all the possible septic foci, presuming the cerebral abscess to be of odontogenic infection. The patient made an uneventful recovery, and 29 months postoperatively he had completely recovered from the hemiparesis.

Severe odontogenic infections

Severe odontogenic infections are serious potentially lethal conditions. Following the death of a patient in the authors' institution this study was initiated to determine the risk factors, management and outcome of a consecutive series of patients. All patients admitted to the Royal Adelaide Hospital under the care of the Oral and Maxillofacial Surgery Unit with odontogenic infections in calendar year 2003 were investigated. Detailed information relative to their pre-presentation history, surgical and anaesthetic management and outcome was obtained and analysed. Forty-eight patients, 32M, 16F, average age 34.5, range 19 to 88 years were treated. All presented with pain and swelling, with 21 (44 per cent) having trismus. Forty-four (92 per cent) were as a result of dental neglect and four (8 per cent) were regular dental patients having endodontic treatment which failed. Of those known to have been treated prior to presentation, most had been on antibiotics. Most patients had aggressive surgical treatment with extraction, surgical drainage, high dose intravenous antibiotics and rehydration. The hospital stay was 3.3 (range 1-16) days. Patients requiring prolonged intubation and high dependency or intensive care (40 per cent) had longer hospitalization. No patient died and all fully recovered. Severe odontogenic infections are a serious risk to the patient's health and life. Management is primarily surgical with skilled anaesthetic airway management. Antibiotics are required in high intravenous doses as an adjunct and not as a primary treatment.

Treatment of Pulmonary Crohnʼs Disease with Infliximab

Purpose: Three teenage patients, previously diagnosed with gastrointestinal Crohn's disease developed severe pulmonary symptoms requiring hospitalization. The Purpose of this investigation is to describe the clinical outcome of their pulmonary disease following treatment with Infliximab. Methods: All three patients had their gastrointestinal symptoms well controlled on combinations of medical therapy that included 6-mercaptopurine, mesalamine, and/or steroids. All 3 patients had chest x-rays that showed diffuse pulmonary infiltrates. One patient had a left-sided pleural effusion. Results: CT scans confirmed the radiographic findings. Open lung biopsies in 2 patients showed non-necrotic, non-caseating granulomas consistent with pulmonary Crohn's disease. The other patient had evidence of organizing pneumonia. The 2 patients with pulmonary granulomas were treated initially with infliximab (5 mg/kg) that resulted in rapid improvement of respiratory symptoms within 3 days. The patient with organizing pneumonia was treated with high-dose steroids and intravenous broad spectrum antibiotics and after 2 weeks showed no significant improvement. He was subsequently treated with infliximab (5 mg/kg) that resulted in an equally rapid improvement of his respiratory symptoms. All patients were discharged from the hospital within 3 days of these infusions and all received repeat infliximab infusions at 2 and 6 weeks following the initial infusion and every 8 weeks thereafter. At the present time the follow-up, which ranges from 1 to 18 months, has shown all 3 patients to be free of all respiratory symptoms. Conclusions: Pulmonary involvement, rarely reported in the pediatric population, has been identified in patients with Crohn's disease. Infliximab therapy, which is well-tolerated, may be the drug of choice for these patients.

Pediatric Lateral Sinus Thrombosis: Retrospective Case Series and Literature Review

A comparison between the literature and our management of pediatric patients presenting with otogenic lateral sinus thrombosis. A retrospective case series of five pediatric patients. Four patients were treated at BC Children's Hospital, whereas the fifth patient was treated in New Westminster, BC. All were treated between 1994 and 2001. A retrospective chart review was conducted with a literature review for otogenic lateral sinus thrombosis. Treatment success was based on resolution of acute infection and neurologic symptoms. Five patients, four males and one female, aged 2 to 14 years were reviewed. Three patients were treated successfully without mastoidectomy. One patient received a mastoidectomy that yielded no pus or granulation tissue within the mastoid cavity. One patient required a mastoidectomy after failure to respond to bilateral myringotomy and tympanostomy tube insertion. Although no pus was seen in the mastoid cavity, perisinus pus was found after unroofing the sigmoid sinus plate; free flow of blood was obtained on needle aspiration of the sinus, and the sinus was not surgically opened. The current literature states that the management of otogenic lateral sinus thrombosis includes high-dose intravenous antibiotics with a mastoidectomy and possible opening of the sinus. In our retrospective case series, three of five patients recovered completely without mastoidectomy, and a fourth had a mastoidectomy deemed to have been unnecessary. We conclude that intravenous antibiotics and insertion of a tympanostomy tube are sufficient treatment for selected cases of otogenic lateral sinus thrombosis. Mastoidectomy with possible opening of the sinus should be reserved for patients refractory to the above conservative treatment.