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Respiratory syncytial virus load and disease severity in the community

Journal of Medical VirologyVolume 83, Issue 5 p. 904-905 Research Article Respiratory syncytial virus load and disease severity in the community†‡ Chadi M. El Saleeby, Corresponding Author Chadi M. El Saleeby [email protected] Department of Pediatrics, Division of Pediatric Infectious Diseases, Massachusetts General Hospital for Children, Boston, Massachusetts Harvard Medical School, Boston, MassachusettsDepartment of Pediatrics, Massachusetts General Hospital for Children, 175 Cambridge Street, CPZS 548 Boston, MA.===Search for more papers by this authorJohn P. DeVincenzo, John P. DeVincenzo Department of Pediatrics, University of Tennessee School of Medicine, Memphis, Tennessee LeBonheur Children's Medical Center, Memphis, Tennessee The Children's Foundation Research Center, Memphis, Tennessee Department of Molecular Sciences, University of Tennessee Graduate School of Health Sciences, Memphis, TennesseeSearch for more papers by this author Chadi M. El Saleeby, Corresponding Author Chadi M. El Saleeby [email protected] Department of Pediatrics, Division of Pediatric Infectious Diseases, Massachusetts General Hospital for Children, Boston, Massachusetts Harvard Medical School, Boston, MassachusettsDepartment of Pediatrics, Massachusetts General Hospital for Children, 175 Cambridge Street, CPZS 548 Boston, MA.===Search for more papers by this authorJohn P. DeVincenzo, John P. DeVincenzo Department of Pediatrics, University of Tennessee School of Medicine, Memphis, Tennessee LeBonheur Children's Medical Center, Memphis, Tennessee The Children's Foundation Research Center, Memphis, Tennessee Department of Molecular Sciences, University of Tennessee Graduate School of Health Sciences, Memphis, TennesseeSearch for more papers by this author First published: 16 March 2011 https://doi.org/10.1002/jmv.22039Citations: 7 † This paper should be attributed to the Department of Pediatric Infectious Diseases at the Massachusetts General Hospital for Children, and Harvard Medical School, Boston, MA. ‡ Disclosures of conflict of interest/Sources of financial support: There are no conflicts of interest or sources of financial support to report for this work. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume83, Issue5May 2011Pages 904-905 RelatedInformation

SEVERE THROMBOCYTOPENIA WITH IRON DEFICIENCY ANEMIA

Although severe thrombocytopenia has been reported among children with iron deficiency anemia, the presence of both anemia and thrombocytopenia can suggest serious or malignant bone marrow dysfunction, requiring further work-up. This paper reviews the management and outcomes of patients with the diagnosis of iron deficiency anemia presenting with severe thrombocytopenia. The authors present 4 pediatric patients with iron deficiency anemia and severe thrombocytopenia at initial presentation. Charts were reviewed after approval by the institutional review boards at both St. Jude Children's Research Hospital and LeBonheur Children's Medical Center in Memphis, Tennessee. All 4 patients’ hemoglobin concentrations and platelet counts normalized within 1 to 3 weeks of initiating iron supplementation, suggesting that in such patients iron supplementation can obviate the need for invasive diagnostic procedures.In addition, these patients all had a platelet “overshoot” phenomenon during iron therapy prior to normalization of platelet counts, the mechanism of which is still unknown. The literature exploring the mechanism behind the current clinical findings is reviewed.

Clinical and molecular characterization of S1118F‐CFTR

Cystic fibrosis is a lethal autosomal recessive disorder usually associated with lung disease, pancreatic insufficiency and high sweat chloride levels. A patient admitted to Le Bonheur Children's Medical Center (LBCMC, Memphis, TN) showed symptoms of meconium ileus which required exploratory laparotomy, bowel resection and ileostomy. Genotyping showed DeltaF508/I1027T on one chromosome and S1118F on the other. Sweat testing on three different occasions gave negative and intermediate results (22.7, 24.6 mmol/L; 55.1, 58.6 mmol/L and 55.1, 58 mmol/L) and pancreatic elastase testing showed normal levels. To characterize S1118F-CFTR mutation at a molecular level to help understand the associated CF-phenotype. Molecular characterization of S1118F-CFTR mutant was studied in HEK-293 cells at 37 degrees C. Various biochemical methods such as Western blotting, real-time PCR, Pulse chase labeling and iodide efflux assay were employed. S1118F-CFTR makes less than 10-15% of mature CFTR (band C) compared to WT-CFTR. The mRNA levels of S1118F-CFTR and WT-CFTR are comparable. S1118F-CFTR is functional but shows about 10-15% of WT-CFTR activity. S1118F-CFTR shows impaired maturation and CF-correctors can increase the amount of mature and functional CFTR by three- to fourfold. S1118F-CFTR shows impaired maturation and an individual with S1118F-CFTR paired with DeltaF508-CFTR exhibits atypical CF symptoms with intermediate sweat chloride level and meconium ileus despite documented pancreatic sufficiency.

Changing Patterns of Acute Hematogenous Osteomyelitis and Septic Arthritis

An increase in the incidence and severity of acute osteoarticular infections in children was perceived after the emergence of community-associated methicillin-resistant Staphylococcus aureus (MRSA) in our community. This study was performed to describe changes in the epidemiology and clinical features of acute osteoarticular infections. The records of patients discharged from Le Bonheur Children's Medical Center with a diagnosis of acute osteoarticular infection between 2000 and 2004 were reviewed. Data regarding signs and symptoms, diagnostic testing, therapeutics, surgery, and hospital course were collected. There were 158 cases of acute osteoarticular infection. The incidence increased from 2.6 to 6.0 per 1000 admissions between 2000 and 2004. The proportion of infections caused by methicillin-susceptible S. aureus (MSSA) remained constant (10%-13%) and that caused by MRSA rose from 4% to 40%. There was no difference between MRSA and MSSA patients in the duration of fever or pain before diagnosis. Seventy-one percent of patients with MRSA had subperiosteal abscesses compared with 38% with MSSA (P = 0.02). Ninety-one percent of MRSA patients required a surgical procedure compared with 62% of MSSA patients (P < 0.001). Median hospital stay was 7 days for MSSA patients and 10 days for MRSA patients (P = 0.0001). Three patients developed chronic osteomyelitis, 2 with MRSA. There was no association between a delay in institution of appropriate antibiotic therapy and presence of subperiosteal abscess (P = 0.8). There has been an increase in the incidence and severity of acute osteoarticular infections in Memphis. Patients with community-associated MRSA infections are at higher risk of subperiosteal abscess requiring surgical intervention.

Short-term outcomes of severe lupus nephritis in a cohort of predominantly African–American children

Renal involvement is one of the major determinants of the outcome in patients with systemic lupus erythematosus. Although African-American ethnicity has been suggested to be a poor prognostic factor in severe lupus nephritis in adult patients, information on outcomes of African-American children with this disease is still very limited. We retrospectively studied the patients diagnosed with severe lupus nephritis by renal biopsy at Le Bonheur Children's Medical Center from January 1990 to December 2003. All patients were below the age of 18 years at the time of biopsy. Clinical features assessed included age, gender, race, estimated glomerular filtration rate (GFR), presence of hypertension, gross hematuria, degree of proteinuria, complement 3 and 4 levels, serum albumin, renal histology and dose of oral prednisone. Forty-four patients were studied: 82% were African-American and 89% were female. Mean age at biopsy was 14.2+/-3 years (median 15.0 years; range 4.7 years to 17.0 years). Renal biopsies were assessed according to the WHO classification. Twenty-seven percent, 43%, and 30% were in class III, IV and V, respectively. At presentation, 55% had hypertension and 23% had a history of macroscopic hematuria. The patients had varying degrees of proteinuria, including 18% with nephrotic syndrome. Eighteen percent had moderate renal insufficiency with estimated GFRs less than 50 ml/1.73 m2 body surface area per minute. All the patients were treated with corticosteroids. Sixty-eight percent also received cyclophosphamide and 20% received either mycophenolate mofetil (MMF) or azathioprine (AZA). Two patients developed end stage renal disease and required chronic dialysis within 12 months of biopsy. At the 12-month follow-up visit, 23% of patients had complete remission and 48% had partial remission. The mean estimated GFR had increased from 96.0 ml/1.73 m2 per minute to 124 ml/1.73 m2 per minute (P=0.03). Mean serum creatinine levels decreased from 1.62 mg/dl to 0.91 mg/dl (P=0.03). Complement 3 levels increased from 54.3 mg/dl to 90.3 mg/dl (P<0.01). Mean serum albumin levels also increased from 2.8 mg/dl to 3.6 mg/dl (P<0.01) and urine protein-to-creatinine ratio decreased from 5.8 to 1.0 (P<0.01). The average prednisone dose decreased from 0.96 mg/kg per day to 0.41 mg/kg per day (P=0.64). In our center, with predominantly African-American children, patients with lupus nephritis presented similarly to those in other studies with predominantly Caucasian patients, and short-term renal outcomes were not different.

C1q nephropathy: features at presentation and outcome

The study population comprised all 20 patients followed since 1990 through December 2004 at the Le Bonheur Children's Medical Center with diagnosis of C1q nephropathy (55% boys; 60% African Americans). All were aged under 18 years at biopsy (mean 11.2 years, 65% aged 11 or over); the youngest presented at age 10 months and progressed to end-stage renal disease at 14 months. None had clinical or laboratory features of systemic lupus erythematosis or membranoproliferative glomerulonephritis. Clinical features assessed at diagnosis were age, gender, blood pressure, history of macroscopic hematuria, urinary protein to creatinine ratio, serum creatinine, estimated glomerular filtration rate, renal histology, and pattern for immunofluorescent reactants. At the time of biopsy 40% had nephrotic syndrome and 30% nephrotic range proteinuria without nephrotic syndrome. Three patients with nephrotic syndrome also had chronic renal insufficiency at diagnosis. The most common histological feature was focal segmental glomerulosclerosis in 40%, but 30% had minimal change lesion. Four patients, all with nephrotic syndrome at diagnosis, progressed to end-stage renal disease. Of the 12 patients not presenting with nephrotic syndrome, none had chronic renal insufficiency at last follow-up. Kidney survival was 94% and 78% at 1 and 5 years, respectively, in all patients and 88% and 49% in those presenting with nephrotic syndrome.

Appropriateness of Anticonvulsant Concentration Monitoring In Hospitalized Pediatric Patients

We assessed the appropriateness of anticonvulsant concentration monitoring in hospitalized pediatric patients admitted to a teaching hospital. Literature-based criteria for anticonvulsant concentration monitoring were approved by the Pharmacokinetic and Neurology Services of Le Bonheur Children's Medical Center. A random sample of anticonvulsant concentrations ordered over a 6 month period was assessed. Patient demographics, anticonvulsant data, the type of professional who recommended the concentration, and sampling time were collected concurrent with hospitalization. Concentrations were assessed for appropriateness of indication and sampling time. Concentrations (n=141) were obtained in 74 patients (mean age = 6.5+5.5 years) admitted to the floor (86%) or ICU (14%). Length of stay was 8.3+16.9 days. Monotherapy was used in 78.3% of patients. Carbamazepine (28.4%), phenytoin (27.5%), phenobarbital (27.6%), valproate (14.8%) or free phenytoin (1.7%) concentrations were recommended by a pediatrician (70.5%), neurologist (21.5%), neurosurgeon (2.1%), or Pharmacokinetic Services (5.9%). Fifty-three percent of all concentrations met appropriateness criteria for indication; however, 8.5% of tests were collected incorrectly. About half of the concentrations recommended by pediatricians (47.5%), neurologists (43.3%), and neurosurgeons (66.7%) did not meet appropriateness criteria for indication. The main reasons for inappropriate anticonvulsant concentration monitoring include frequent repetitive sampling (<24 hours), obtaining an anticonvulsant concentration without an appropriate indication, failure to correctly apply the concept of pharmacological steady-state, incorrect identification of drug-drug interactions, and sampling irrespective of dosing schedule. One-half of all anticonvulsant concentrations fulfilled the indication criteria. There was no difference in appropriateness of indication based on the service recommending the concentration or for each specific anticonvulsant. The appropriateness rates reported are comparable to those reported in other studies. Inappropriate anticonvulsant concentration monitoring fails to improve patient care and contributes to a significant waste of financial resources.

Mark Timothy (Tim) Parris, Ms: A Conversation with the Editor

Tim Parris, president of Baylor University Medical Center (BUMC), was born on August 23, 1956, in Jackson, Mississippi, where he grew up (Figure ​(Figure11). He graduated from the University of Southern Mississippi in Hattiesburg in 1978 and received a master of science degree in hospital and health administration from the University of Alabama at Birmingham in 1981. After completing a hospital administrative residency at BUMC, he remained on the staff and soon became executive director of the Baylor Institute for Rehabilitation. In 1985, he was awarded a White House fellowship and spent 1 year in the executive office of the president, working in the Office of Management and Budget under the Honorable James C. Miller III. After that year, he became chief operating officer of Le Bonheur Children's Medical Center in Memphis, Tennessee. In 1990, he was offered a senior administrative position at the University of North Carolina Medical Center in Chapel Hill and at the same time was offered a vice presidency position at BUMC. Fortunately for us, he chose the latter position, where he rapidly rose to senior vice president, executive vice president, and, in January 2000, to his present position. Tim Parris is a man of action. In his calm and decisive way, he has his finger on essentially all BUMC activities. We are fortunate to have a man of his talents managing the day-to-day operations of this complex medical center. He is also a good guy.

OERSKOVIA XANTHINEOLYTICA PERITONITIS: CASE REPORT AND REVIEW

OERSKOVIA XANTHINEOLYTICA PERITONITIS: CASE REPORT AND REVIEW

Early definitive intervention by thoracoscopy in pediatric empyema

Purpose: Nineteen children had early thoracoscopic intervention for empyema between 1992 and 1997 at the LeBonheur Children's Medical Center. The authors have evaluated the results of this treatment. Methods: Thoracoscopic intervention was performed at the fibrinopurulent state of empyema. An irrigating laparoendoscope was inserted, loculi were disrupted, debris was evacuated, and a chest tube was passed through the port site. Results: The patients were aged between 11 months and 16 years (mean, 6.5 years). The etiology of the empyema was parapneumonic in 17, and there was one case each of perforated appendicitis and mediastinal histoplasmosis. They underwent thoracoscopy at a mean of 4.6 days after hospital admission (range, 1 to 12 days). Chest tubes were removed at 1 to 5 days (mean, 2.9 days) after operation, and resolution of fever occurred at 1 to 9 days (mean, 3.8 days) postoperatively. Patients were discharged home between 4 and 10 days (mean, 6.1 days) postoperatively, and the mean hospital stay was 10.3 days (range, 5 to 21). There were no complications. The surgical technique was simple and well tolerated, requiring few disposable items, and the mean operating time was 77 minutes. Conclusions: Thoracoscopy eliminated the morbidity of thoracotomy and the discomfort and expense of prolonged chest tube drainage. Thoracoscopy may be used as early first-line therapy in a majority of pediatric patients with fibrinopurulent empyema.

The maintenance need for water in parenteral fluid therapy.

In the category of genitourinary and fluid and electrolyte disorders, no paper bridges the discoveries of the 1930s through the 1950s and the practice of today as does the classic paper of Holliday and Segar.1 Today house officers and staff physicians use this same simple method for estimating insensible and urinary water losses of a child or adult of any size or age. Current textbooks and the latest editions of commonly used house officer manuals use this method of determining maintenance water needs based on calorie expenditure.2-5 This method involves a simple formula that relates the average calorie expenditure of a … Address correspondence to Russell W. Chesney, MD, University of Tennessee, Memphis; Le Bonheur Children's Medical Center, 50 N Dunlap, Room 306, Memphis, TN 38103.

Lactation Consulting: Is it for you?

Lactation Consulting: Is it for you?

Repeated invasive pneumococcal infections in young children without apparent underlying immunodeficiency

During a 30-month interval at LeBonheur Children's Medical Center, 394 patients had a blood or cerebrospinal fluid culture positive for Streptococcus pneumoniae . Sixteen of these episodes (4%) were repeated infections; 6 of these 16 patients had sickle cell disease. Six of the remaining 10 patients had immunologic evaluations of varying completeness; no immunodeficiency was identified by these tests or on follow-up. Nine of the ten previously healthy patients with repeated pneumococcal disease were less than 2 years of age. In our experience, repeated invasive pneumococcal infections in otherwise healthy young children were relatively common (10/394, or 2.5% of patients with invasive pneumococcal infections) and did not indicate the presence of an unsuspected immunodeficiency. (J Pediatr 1997;130:284-8)

Cranial burst fracture in infants: acute recognition and management.

In the past, the diagnosis of "growing skull fracture" or "diastatic fracture" has included a subset of injuries better referred to as "cranial burst fracture." Cranial burst fracture, typically associated with severe injury in infants less than 1 year of age, is a closed, widely diastatic skull fracture accompanied by acute cerebral extrusion outside the calvarium. We treated 11 such infants at the LeBonheur Children's Medical Center and 2 at the Children's National Medical Center from January 1986 through December 1994. Infants ranged in age from 1 to 17 months, with an average age of 5.7 months. All presented with marked scalp swelling and a Glasgow Coma Scale score of 10 or less. Twelve had a history consistent with severe injury (motor vehicle accident, 7, abuse 5). The cause of injury in one patient remains unproven. Surgery (reduction of herniated cerebral tissue, repair of large dural laceration, and cranioplasty) was usually performed within 10 days of injury, a time period long enough to assure hemodynamic stability and resolution of acute cerebral swelling, yet sufficiently brief to avoid the chronic changes (scarring, parasitization of scalp vessels by damaged cortex) associated with a "growing skull fracture." Prompt repair of cranial burst fracture may prevent ongoing brain injury such as has been neuropathologically demonstrated in patients with "growing skull fracture." Magnetic resonance imaging establishes the diagnosis of cranial burst fracture in equivocal cases, rendering unnecessary a "waiting period" to see if scalp swelling resolves. Our experience, together with information in the neuropathological and neurosurgical literature, suggests that cranial burst fracture is associated with severe trauma, requires expeditious treatment, and has been underdiagnosed in the past, leading to "growing skull fracture," a condition requiring more extensive surgery.

Penicillin- and cephalosporin-resistant strains of Streptococcus pneumoniae causing sepsis and meningitis in children with sickle cell disease

Objective: We investigated the possibility that antimicrobial-resistant pneumococci were causing invasive disease in children with sickle-cell disease (SCD). Study design: Records of all children with SCD observed at the Mid-South Sickle Cell Center (MSSCC) at LeBonheur Children's Medical Center were reviewed from January 1990 to June 1994. Children with SCD and pneumococcal sepsis were identified. The Streptococcus pneumoniae isolates from these children were examined for serotype and antimicrobial susceptibilities. Two additional children not observed in the MSSCC had pneumococcal sepsis caused by penicillin-resistant isolates and were also included. Results: Antimicrobial susceptibility testing of the six penicillin-resistant isolates revealed that four were resistant to trimethoprim-sulfamethoxazole, two to erythromycin, and one to clindamycin. The two isolates that were resistant to ceftriaxone also were multiply resistant. From the MSSCC, 26 children had pneumococcal sepsis during the 4 1/2-year period studied. Five of these children (19%) died. Four (15%), including one who died, were infected with penicillin-resistant strains. Conclusion: Pneumococcal sepsis, meningitis, and infections of other foci in children with SCD may be caused by S. pneumoniae that is resistant to one or more antimicrobial agents, including penicillin. The addition of vancomycin to the antibiotics currently used for initial management should be considered in areas where the antibiotic resistance of S. pneumoniae is prevalent. (J P EDIATR 1995;127: 526-32)

Invasive group B streptococcal disease in children beyond early infancy.

There is little information available on invasive group B Streptococcus (GBS) infection in pediatric patients older than 3 months of age. Review of infection control records at LeBonheur Children's Medical Center from January 1, 1986, to June 30, 1993, identified 143 patients with a positive GBS culture from normally sterile body fluid. Medical records of 18 (13%) patients > 3 months old with their first GBS infection were reviewed. Age range was 15 weeks to 18 years (median age, 13 months). Ten were black and 11 were girls. Five infants had a history of premature birth and 2 infants were infected with human immunodeficiency virus. The serotype distribution of 12 available GBS isolates was 4 type III, 2 each type V and Ia and 1 each type Ia/c, Ib/c, II and II/c. Bacteremia without a focus (9 patients) was the most common clinical manifestation. All 4 type III isolates were associated with bacteremia. One infant with human immunodeficiency virus infection had sepsis and bullous desquamation; a toxin-producing type V strain was isolated from her blood. Two adolescents with ventriculoperitoneal shunts had meningitis, including one whose cerebrospinal fluid also grew a type V strain. Other clinical manifestations were septic arthritis, endocarditis (Ia, II/c), central venous catheter (Ia/c) and ventriculostomy infections.

Cavernous Sinus Thrombosis: Successful Treatment Using Functional Endonasal Sinus Surgery

Infections of the paranasal sinuses can be complicated by septic thrombosis of the cavernous venous sinuses. After standard antibiotic treatment, fewer than 50% of the patients recover completely, and the mortality rate is approximately 30%. We chose to treat this potentially catastrophic complication with functional endonasal sinus surgery in addition to standard antibiotic therapy. Case study. A 15-year-old boy presented to the emergency room of LeBonheur Children's Medical Center, Memphis, Tenn, with right proptosis, chemosis, ptosis, ophthalmoplegia, cranial nerve palsies, and paresthesia. The physical examination and computed tomographic scans of the sinuses and orbits revealed edema of the right orbit and pansinusitis, with secondary right cavernous sinus thrombosis and right superior ophthalmic vein thrombosis. The patient was started on a regimen of cefuroxime and nafcillin sodium and was scheduled for emergency functional endonasal sinus surgery to drain the primary sites of infection. After surgery, the patient was placed on a 3-week regimen of cefotaxime sodium, metronidazole hydrochloride, vancomycin hydrochloride, and heparin sodium. During surgery, the frontal recess and ethmoid, sphenoid, and maxillary sinuses were found to be filled with polypoid tissue and purulent material. Functional endonasal sinus surgery restored the sinuses to their normal physiologic state. The sinuses demonstrated the progress observed clinically. The improvement in outcome effected by standard antibiotic therapy can be significantly augmented by using functional endonasal sinus surgery in the treatment of cavernous sinus thrombosis.

PLEURAL EFFUSION ASSOCIATED WITH HISTOPLASMOSIS

Divisions of Critical Care (MWQ) and Infectious Disease (RJL), Department of Pediatrics, University of Tennessee, Memphis, LeBonheur Children's Medical Center (MWQ, RJL) Memphis, TN