Significance of fever in Jamaican patients with homozygous sickle cell disease

OBJECTIVE: To investigate the cause and outcome of high fever in Jamaican children with homozygous sickle cell disease. DESIGN: Retrospective review of febrile episodes in a three year period (1 September 1993 to 31 August 1996). SETTING: Sickle Cell Clinic, an outpatient clinic in Kingston run by the Medical Research Council Laboratories (Jamaica). PATIENTS: Patients with homozygous sickle cell disease under 17 years of age presenting with an anxillary temperature o 39.0§c (102.4§F). MAIN OUTCOME MEASURES: Diagnosis, death. RESULTS: There were 165 event in 144 patients (66 (45.8 percent) boys) with a median age of 6.1 years. Bacteraemia was found in 10 (6.1 percent) events (three Streptococcus pneumoniae, two Haemophilus influenzae type b, two Salmonella sp, one Escherichia coli, one Enterobactor sp, and one Acinetobacter sp), and urinary tract infections in four (2.4 percent). All cultures of cerebrospinal fluid were sterile. Acute chest syndrome occured in 36 (21.8 percent) events. A painful crisis was associated with 45 (27.3 percent) events and was the only pathology identified in 20 events (12.1 percent). Hospital admission was necessary in 66 cases including all those with bacteraemia and 31 with acute chest syndrome. There were two deaths: a 5 year old boy with septic shock associated with H influenzae septicaemia, and a 3 year old boy with the acute chest syndrome. CONCLUSIONS: Painful crisis and acute chest syndrome were the most common complications associated with high fever, but other important associated features included bacteraemia and urinary tract infection. Enteric Gram negative organisms accounted for 50 percent of positive blood cultures. (AU)

Nitric oxide levels in children with febrile illnesses - Poster abstract

OBJECTIVE: To determine nitric oxide (NO) levels in children with febrile illness and to investigate its prognostic value in early dengue virus infections. DESIGN AND METHOD: A pilot case control study was conducted from September 1998 to March 1999 at the Eric Williams Medical Sciences Complex, Priority Care Facility (PCF), in Trinidad. Serum NO concentrations were measured in children <12 years presenting with febrile illnesses in the absence of clinically significant bacterial infection. RESULTS: Of 59 blood samples collected, there were 22 from individuals diagnoses as virally induced gastroenteritis (VGE), with 31 non-specific viral illnesses (VI), and 6 viral infections associated with upper-respiratory tract infection (URTI-VI). The mean (NO) in all cases was above normal (11.9 uM SD 5.9) 81.17 uM in VGE, 41.30 uM in VI and 57.83 uM in URTI-VI. Krushkal-Wallis test revealed that there was a significant difference (p = 0.007) between all three means and that the mean (NO) for VGE was significantly higher (p = 0.003) than that of VI. CONCLUSIONS: The degree of elevation of NO varies between viral illnesses in children and its potential as a rapid prognostic marker warrants further investigation.(AU)

Concomitant malaria and filariasis infections in Georgetown, Guyana

OBJECTIVE: To determine the prevalence of concomitant malaria and bancroftian filariasis among febrile patients in Georgetown, Guyana, South America. METHODOLOGY: From January to December 1997, all patients visiting the Georgetown Malaria and Filariasis Clinics were enrolled in the study. At the Filariasis Clinic, nocturnal thick blood smears prepared from blood taken between 8:00 pm and 12:00 midnight were dried and stored overnight. At the Malaria Clinic, thick blood smears were taken during the period 8:30 am to 4:00 pm, representing the diurnal study. All slides were stained using the standard Giemsa protocol and microscopically examined for the presence of filariasis and malaria. RESULTS: Of 1,267 persons, 83 percent were of African descent, 10 percent were of East Indian descent, and 7 percent were mixed or of other ethnic origins. Sixty-one per cent (769/1267) of smears were prepared from nocturnal blood samples whereas 509/1267 (40 percent) were diurnal samples from the Malaria Clinic. One hundred and three of 769 nocturnal blood smears were positive for only W bancrofti and 3 smears contained mixed infections, W bancrofti and malaria parasites. Only 21/509 diurnal blood smears had malaria parasites while 17 persons had both malaria and microfilaria parasites. CONCLUSION: The 20 cases of concomitant infection of malaria and bancroftian filariasis in this study may represent the first report of the occurrence of this phenomenon in Guyana.(AU)

Febrile morbidity and hospital stay in high risk caesarian section patients at a non-teaching hospital

This was a retrospective chart review of all patients who had Caesarian section between January 1995 and December 1996. The objective was to determine the incidence of post operative febrile morbidity, and to relate this to hospital stay in a high risk indigent population treated at a private non-teaching hospital. Discharge summaries, antepartum progress notes and laboratory results were reviewed for each patient. 5 of 257 charts reviewed were inadequate. All but 5 patients had labour after ruptured membranes of 12 hours of more. Four had a prolonged second stage. Board certified surgeons performed a nd assisted in the operations. 21 patients had scant prenatal care and 6 had no prenatal care. In all cases the abdomen was scrubbed with "Betadine" soap prior to painting. No shaving was done. Gloves were changed after closure of the uterine incision. The pelvis was copiously irrigated with 3-4 litres of saline. The subcutaneous layer was irrigated from a height of 1" to 12" with 0.5 to 1 litre of fluid. After this step, this layer was not touched by any thing from the operating field. Of 162 patients with primary Caesarian sections, 20 (12.3 percent) had post operative fever, 18 due to endometritis and 2 due to wound infections. Two of 28 failed VBACs had fever whereas none of 59 patients with elective repeat Caesarian sections became febrile. The mean hospital stay was 4.4 days for febrile patients and 2.7 days for afebrile patients. The incidence of fever in the entire study group of 249 was 8.8 percent, and the incidence of wound infections was 0.8 percent. This study demonstrates that the adoption of the simple measures described above can dramatically decrease the incidence and severity of post Caesarian fever and wound infection, thereby allowing safe, early hospital discharge.(AU)

The painful crisis of homozygous sickle cell disease: clinical features

The details of onset, perceived precipitating factors, associated symptoms, and pain distribution in the painful crisis of homozygous sickle cell (SS) disease have been prospectively recorded in 183 painful crises in 118 patients admitted to a day-care centre in Kingston, Jamaica. Painful crises developed most frequently between 3 p.m. and midnight, most commonly affected patients aged 15-29 years, affected the sexes equally, and were not obviously influenced by menstrual cycle. Of the perceived precipitating factors, skin cooling occurred in 34 percent, emotional stress in 10 percent, physical exertion in 7 percent, and pregnancy in 5 percent of women of child-bearing age. Cold as a precipitant was not less common in patients with more subcutaneous fat. Pain affected the lumbar spine in 49 percent, abdomen in 32 percent, femoral shaft in 30 percent, and knees in 21 percent. There was a highly significant excess of bilateral involvement in limb and rib pain. Recurrent painful crises occurred in 40 patients but showed no evidence of involving similar sites on successive occasions. Abdominal painful crises were associated with abdominal distention in 18 ( 31 percent) and with referred rib pain in a further 15 (26 percent) of crises. Fever was common even in apparently uncomplicated painful crises, suggesting that fever is characteristic of the painful crisis itself after and not necessarily indicative of infection. Following investigation and treatment in a day-care centre, over 90 percent of patients returned home (AU)

Gallstone-related morbidity in Jamaican children with homozygous sickle-cell disease: a six-year review

The clinical details of 17 patients aged 18 years and under with homozygous sickle-cell disease (SS) who presented with gallstone-related symptoms to the University Hospital of the West Indies, and the Bustamante Hospital for Children are analysed. All patients had right upper quadrant signs pre-operatively and all were confirmed to have acute or chronic cholecystitis based on gallbladder (GB) histology. Other gallstone-related complications were obstructive jaundice in 2, mucocoele of the GB in 1 and GB empyema in 1. While 16 of 17 had gallstones detected preoperatively ultrasound, only 2 of 6 patients later confirmed to have common bile duct (CBD) stones, were also detected. One patient had retained CBD stones post-operatively which were successfully dislodged by saline irrigation via t-tube. There was no mortality but 3 patients developed the acute chest syndrome, 4, unexplained pyrexia and 1, wound abscess. We believe that gallstone-related morbidity in children with SS disease may so far be underestimated. Even the youngest develop life-threatening complications. The risk of associated choledocholithiasis and obstructive complications may be just as high in paediatric SS disease patients with gallstones as in adults similarly affected (AU)

Pulmonary artery pressure and the acute chest syndrome in homozygous sickle cell disease

OBJECTIVE; to investigate whether attacks of acute chest syndrome affected pulmonary artery pressure in patients homozygous for sickle cell disease. MAIN OUTCOME MEASURES: Pulmonary artery pressure, assessed by non-invasive echocardiographic techniques. PATIENTS; 20 patients with homozygous sickle cell disease with a history of at least six episodes of acute chest syndrome and in 20 age, sex, and height matched controls with homozygous sickle cell disease without a history of acute chest syndrome. RESULTS: There was no difference in any of the echocardiographic or Doppler indices between these two groups. CONCLUSIONS: Repeated attacks of acute chest syndrome by the mean age of 12 ( range eight to 16 ) years have not had a discernible effect upon pulmonary artery pressure (AU)

Fever with rash illness surveillance English-speaking Caribbean & Surinam 1991-1992

The English-speaking Caribbean and Suriname have targeted measles for elimination by the end of 1995, One of the main strategies is to have in place an active and sensitive system of surveillance at regional and national levels so that all suspected cases of measles can be detected, investigated and analysed, and appropriate control measures implemented to stop transmission (AU)

Outcome of kawasaki disease in Barbados

Kawasaki disease (KD) often presents as an acute multisystem febrile illness which is most often self-limiting. During an 11-year period, 39 patients with KD, aged 11 weeks to 15 years (mean 2.5 years), were admitted to the Queen Elizabeth Hospital, Barbados. Eighty-seven per cent of children were less than 4 years of age. There were 26 males (67 percent) and 13 females (33 percent) with a sex ratio of 2:1. A peak occurrence was observed in 1985 and the mean hospital stay of cases was 12.7 days. Treatment regimes included antibiotics in 36 patients (93 percent), aspirin in 32 (82 percent) and steriods in 3 (7 percent). Major complications were observed in 11 patients (26 percent), with these being gastrointestinal bleeding in 1, broncho-pneumonia in 3 and cardiac abnormalities in 7 (18 percent). Among the latter were abnormal proximal coronary arteries in 5 patients (2 with dilatation and 3 with aneurysms) and carditis in 2. Other complications included croup (1), hydrops of the gallbladder (2), paralytic ileus (1), and abnormal focal neurological signs in two patients. There were no deaths. Follow-up ranged between one month and four years. Although KD often presents as a benign self-limiting illness, it is extremely important to make a diagnosis early in the course of the illness, institute appropriate therapy and be on the alert for possible fatal complications. (AU)

Bacterial meningitis in children in Barbados: a decade later - abstract

Forty-eight paediatric patients admitted with bacterial meningitis during a 10-year period, comprising 22 males (46 percent) and 26 females (54 percent), were reviewed. Ages ranged between 7 weeks and 12 years (mean 2.7 years). The mean 10-year incidence was 29/10,000 ward admissions, with a peak incidence of 69/10,000 admissions in 1989. The highest seasonal prevalence occurred during the dry months. Twenty-five patients (52 percent) were less than 2 years of age. Predominant symptoms were fever (85 percent), gastrointestinal (65 percent), and lethargy (40 percent). Frequently associated illnesses included upper respiratory infections in 21 (44 percent), and otitis media in 5(10 percent) of cases. H. influenzae was cultured from the cerebrospinal fluid in 34 cases (71 percent), S. pneumoniae in 4 cases (8 percent), and no organism in 10 cases (21 percent). Thirteen patients (27 percent) had received antibiotic therapy within a week of admission. Initial therapy consisted of parenteral ampicillin and chloramphenicol in 37 cases (77 percent), penicillin and chloramphenicol in 9 cases (19 percent) chlodramphenicol in 1 (2 percent), and trimethoprin/sulfamethoxazole in 1 case (2 percent). These data support a case for routine administration of H. influenzae B vaccine which will lead to the eradication of, or reduction of the overall incidence of bacterial meningitis in childhood (AU)

Conclusions and agreed activities measles surveillance workshops Trinidad & Tobago Antigua and Jamaica

Three separate meetings were held to discuss, and plan the intensification of measles surveillance which will be required for the elimination of the indigenous transmission of measles in the English-speaking Caribbean and Suriname by the end of 1995. Participants from Anguilla, Antigua & Barbuda, Bahamas, Barbados, Belize, British Virgin Islands, Cayman Islands, Dominica, Grenada, Guyana, Jamaica, Montserrat, Suriname, St. Christopher & Nevis, Saint Lucia, St. Vincent & the Grenadines, Trinidad & Tobago and Turks and Caicos Islands were in attendance. Observers were from the Ministries of Health of Brazil and Mexico. Staff from the Caribbean Epidemiology Centre (CAREC) and the Pan American Health Organization (PAHO) served as resource personnel. The major resource document was the Measles Elimination Field Guide which will now require further iteration as a result of the workshops (AU)

Febrile response in malnutrition

The febrile response to a standard dose of triple (DPT) vaccine was assessed in sixteen malnourished children before and after recovery. Increase in temperature was significantly lower in the malnourished children (p<0.005) (AU)

A serological survey for leptospiral agglutinins among patients in a Barbadian general practice - abstract

Sera from 1,419 patients who attended a Barbadian general practice for a variety of complaints between 1st April and 30th April 1988 were examined for leptospiral agglutinins by the microscopic agglutination test. Sera from patients presenting with pyrexia of unknown origin, jaundice or kidney complaints, and from those whose titre was > 1:400, were also examined by the ELISA for IgM and IgG antibodies. Only one patient was diagnosed clinically as possibly having mild leptospirosis, but three others had been recently infected and some mild cases may have been missed. Altogether, 177 of the patients (12.5 percent) were positive at titres> 1:50. These were 104 of the 739 males (14 percent) and 73 of the 680 females (11 percent) (no statistically significant difference). Seropositivity tended to increase with age (p<0.01), and the highest rates were in agricultural workers (35 percent), labourers (24 percent) and non-manual outdoor workers (19 percent). The difference in seropositivity between the various indoor and outdoor occupational groups was highly significant (p<0.005). Autumnalis (31 percent of the sero postives), Panama (15 percent), Australia (14 percent) and Pyrogenes (11 percent) were the serogroups most commonly recorded among the seropositive patients. Autumnalis predominated in each of the main occupational groups except indoor non-manual workers where Panama, Pyrogenes and Australis occurred more frequently. Ninety-five per cent of the positive titres ranged between 1:50 and 1:400. Titres tended to increase with age, but there was no obvious association between higher titres and particular occupations (AU)

Fever in children: ideas and illusions - abstract

Fever is a common symptom in children. Yet concepts vary between physicians and parents. We interviewed 120 mothers at three participating locations (University Hospital of the West Indies, Bustamante Hospital for Children and Shortwood Medical Centre) to ascertain their concepts and practices concerning fever in their children. None of the mothers used thermometers to detect fever; the majority (85 percent) were unable to define fever in terms of temperature. Tepid sponging with alcohol and administration of antipyretics were the measures most frequently undertaken to reduce fever. There is a need to educate parents and health-care personnel about fever and its management in children, particularly to discourage the use of topical alcohol (AU)

Thyroid function in dengue fever, meningitis, encephalitis, poliomyelitis and other febrile conditions

Thyroid function was studied by estimating serum thyroxine (T4), triodothyronine (T3) and thyrotropin (TSH) in 52 patients suffering from dengue fever, bacterial meningitis, viral encephalitis, paralytic poliomyelitis and other febrile illnesses. Mean serum concentrations of total T4 and T3 were significantly lower in all patients except those suffering from poliomyelitis. Serum TSH was significantly low in dengue fever and pyrexia of unknown origin (PUO). Though the TSH levels were also low in patients with bacterial meningitis and encephalitis, the differences were not statistically significant. Decreases in serum T4, T3 and FT1 in severe illnesses as compared to normal subjects may signify a state of secondary hypothyroidism of a functional type. It will be erroneous to say that decreases in T4 and T3 in systemic illnesses is entirely an adaptive or protective process to maintain metabolic rate. The possible value of thyroid hormone replacement therapy in these illnesses needs further investigations. (AU)

A survey of leptospirosis in febrile patients mainly from hospitals and clinics in Trinidad

Acute and convalescent sera were obtained from 202 febrile patients, most of whom were admitted to or attended hospitals or clinics in northern Trinidad during the 12 months from mid-February 1977 to mid February 1978. Laboratory tests confirmed that 10 of the patients were suffering from current leptospirosis while another 54 had serological evidence of previous leptospiral infections. Antibodies to strains of the Icterohaemorrhagic serogroup were the most commonly found, followed by those to the Hebdomadis and Autumnalis serogroups. Isolates were obtained from the blood of two and the urine of three of the current cases. Four of thoses strains were identified as belonging to copenhageni serovar of the Icterohaemorrhagiae serogroup and one to the Bataviae serogroup. Seven of the patients suffering from leptospirosis were male, all rural dwellers, and all except one under 20 years of age. Two of the three female patients were over 60 years old and were urban dwellers. It was not possible to identify the sources of infection with certainty, although dogs may have been responsible for three of the Icterohaemorrhagiae and one of the Canicola infections. Of the 192 patients who were not currently infected, serological evidence of previous infection was obtained in 31 (40 percent) males and 23 (21 percent) females and was most common among farmers and rural workers. (Summary)

Anhidrotic ectodermal dysplasia in an infant presenting with pyrexia of unknown origin

Anhidrotic ectodermal dysplasia is a rare condition resulting from faulty development of the embryonic ectoderm and its derivatives. It is heredofamilial, sex linked and recessive. There may be some manifestation in the carrier female. In some families a dominant gene has been described. The disease is characterized by anhidrosis, hypotrichosis, and hypodontia. Other features commonly associated are prominent supraorbital ridges, depressed bridge of the nose, large deformed ears, fine wrinkling of the preiorbital skin, chronic rhinitis hoarseness, recurrent otitis, soft thin dry skin, and lack of body odor. The present communication describes the syndrome in a West Indian child of Spainsh-East Indian descent