Localized acute generalized exanthematous pustulosis with amoxicillin and clavulanic acid.

Acute generalized exanthematous pustulosis (AGEP) is a rare skin disorder, characterized by acute development of numerous, pin-head sized, nonfollicular pustules on erythematous skin, with high fever and neutrophilia. The condition is frequently caused by hypersensitivity reaction to drugs or viral infections. Diagnosis is established according to clinical and histological criteria. Herein, we report a 17-year-old girl with localized AGEP related to the use of amoxicillin-clavulanate.

Risks and outcome of fungal infection in neutropenic children with hematologic diseases.

In this retrospective study, we report the results of antifungal treatments (AFTs) in febrile neutropenic episodes in patients with acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML) and aplastic anemia (AA) in our center. From January 2004 to December 2005, a total of 52 patients and 221 febrile neutropenic episodes were evaluated. AFT was started in 96 (43%) of the 221 episodes. Amphotericin B and fluconazole were used in 44 (46%) and 52 (54%) febrile neutropenic episodes, respectively. Microbiologically or histopathologically evident fungal infections were detected in 35 of 96 febrile neutropenic episodes. The mortality rate due to fungal infection was higher in patients with AA (7/8 patients) and AML (7/12 patients) than in ALL patients (1/32). Mortality for the whole group was 28%. When the mortality rate was compared between the two treatment groups (amphotericin B vs fluconazole), mortality was significantly higher in patients receiving amphotericin B [n = 14 (93%) and n = 1 (7%), respectively].

Pediatric pleural effusions: etiological evaluation in 492 patients over 29 years.

Pediatric pleural effusions present a changing profile over time, both in terms of etiological subgroups and causative microorganisms in parapneumonic effusions. This retrospective study aimed to review pediatric pleural effusions in a large cohort over a 29-year period, with special emphasis on the etiological subgroups and microbiological causes of parapneumonic effusions. The medical records of 492 pediatric patients were reviewed for a comparison of subgroups of pleural effusions and microbiological causes of parapneumonic effusions between three decades. Parapneumonic effusions (381 patients) made up 77.4% of the group. Tuberculous pleurisy decreased, but malignant effusions doubled in number over time. A causative microorganism was identified in 34.6% overall, with Staphylococcus aureus and Streptococcus pneumoniae being the two most common. Relative frequency of S. aureus decreased, whereas pneumococci and Haemophilus influenzae were more frequent in recent years.

Animal carcass and eyelid anthrax: a case report.

Anthrax is a worldwide zoonosis of herbivores, which is caused by the spore-forming bacteria Bacillus anthracis, and humans become infected when they are exposed to infected animals and their tissues or the organism directly. In this report, we present a 13-year-old boy who developed eyelid anthrax after contact with a sheep carcass during his summer holiday that resulted in eyelid anthrax and cicatricial ectropion.

Preseptal and orbital cellulitis: 15-year experience with sulbactam ampicillin treatment.

The infection of the orbita and ocular tissues can result in severe local and systemic complications. We aimed to determine the predisposing factors for preseptal and orbital cellulitis, the clinical and routine laboratory differences between orbital and preseptal cellulitis, and the change in the spectrum of the pathogens and the antibiotics used in the last 10 years. One hundred thirty-nine patients, hospitalized in Hacettepe University Faculty of Medicine Children's Hospital between 1 January 1990 and 31 December 2003 with diagnosis ofperiorbital or orbital cellulitis, were reviewed retrospectively. Ten of the patients (7%) had orbital and 129 (93%) had preseptal cellulitis. The male/female ratio was 1.7:1. The average age (mean+/-standard deviation) was 5.7+/-4 years. The seasonal distribution was most marked in spring and fall periods. When compared with preseptal cellulitis, the mean blood cell count, erythrocyte sedimentation rate and C-reactive protein levels were significantly higher in patients with orbital cellulitis. Staphylococcus aureus was isolated in 13 (41.9% of total microbiologically confirmed cases), coagulase-negative staphylococcus in 8 (25.8%), and H. influenza type b in 2 patients (6%). Thirty out of 77 clinical sample cultures (39%) were positive. In clinical studies, etiological agents of orbital and preseptal cellulitis could be identified in only 20-30% of cases, so in clinical practice treatment is usually empiric. We observed that sulbactam-ampicillin was a safe and effective choice of treatment in orbital and preseptal cellulitis in our cases.

Cytomegalovirus hepatitis and ganciclovir treatment in immunocompetent children.

Ganciclovir treatment in children with cytomegalovirus (CMV) infection is still controversial and only indicated in selected cases. The aim of thi study was to evaluate clinical and demographic features of CMV hepatitis in immunocompetent children and to determine the effect of ganciclovir treatment in these patients retrospectively. The study was carried out in a group o 29 children with CMV hepatitis. All the patients were investigated for signs of infection, inborn errors of metabolism, genetic diseases, extrahepatic biliary atresia and other causes of hepatitis. Two patients with congenital CMV infection and two patients with biliary atresia were excluded from the study group. The patients included in the study were divided into two groups: non-cholestatic hepatitis (n=16) as Group I and cholestatic hepatitis (n=9) as Group II. Four (25%) patients in the non-cholestatic group and four (44.4 in the cholestatic group were treated with ganciclovir for a median of 21 days. The mean age was 9.6+/- 10.9 months (median age 6 months) in Group I, while cholestatic hepatitis patients in Group II were significantly younger, with a mean age of 2.7+/-0.9 months (p<0.01). The most prominent symptoms at admission were diarrhea and vomiting (25%) in Group I. In Group I, all cases (100%) and in Group II, three of four cases (75%) treated with ganciclovir had recovery from acute CMV hepatitis. In the non-cholestatic group, no relapses were observed while one patient in the cholestatic group relapsed and progressed into chronic liver disease. Patients who received supportive treatment showed a marked decrease in GGT, ALT, AST and bilirubin levels spontaneously and no relapses of hepatitis were observed in at least one year of follow-up. Although ganciclovir therapy is not indicated particularly in immunocompetent cases, since most were self-limited infections, in case of progressive and persistent hepatitis, such as in our cases, ganciclovir was a treatment option; no side effect due to ganciclovir therapy was observed in our cases. Although ganciclovir seems to be effective in progressive CMV hepatitis, multicenter randomized studies in a large study group are necessar to determine the efficacy and indications for ganciclovir treatment.

Long-term effects of dexamethasone on hearing ability in children with pneumococcal meningitis.

Controlled trials concerning adjuvant dexamethasone therapy in bacterial meningitis do not point unequivocally to a beneficial effect on hearing ability. We investigated the remote adverse outcomes of pneumococcal meningitis and, if any, beneficial effects of adjuvant dexamethasone therapy on hearing ability. Fifty-five subjects who experienced pneumococcal meningitis between 1987-97 were divided into two groups as 25 subjects who did not receive dexamethasone (Group 1) and the remaining 30 subjects who did (Group 2). All subjects underwent pure tone thresholds estimation. There were a total of 11 subjects (20%) with sensorineural hearing impairment (SNHI): 6 in the first group (24%) and 5 in the second group (16%). Although there was no statistically significant difference in the SNHI ratio between the groups, all the subjects who used adjuvant dexamethasone therapy suffered only minimal-borderline SNHI, whereas 2 patients in Group 1 had moderate-serious SNHI. Even though adjuvant dexamethasone therapy had no statistically significant impact on hearing ability after long-term follow-up, its use may be a good choice in terms of preventing serious SNHI.

Community-acquired pneumonia and parapneumonic effusions in developing countries.

Ninety-eight patients with diagnosis of community-acquired pneumonia and parapneumonic effusion were retrospectively evaluated in order to determine the demographic properties of the patients, etiologic microorganism and the resistance patterns. Ages of study groups were between 2 to 16 years (mean 6.5 +/- 3.5 years) and 56 of 98 patients (56%) were male. There were four groups: Pneumonia (Group 1, n: 57), pleural effusion-medical treatment (Group 2, n: 18), pleural effusion-tube thoracostomy (Group 3, n: 19), and pleural effusion-operative treatment (Group 4, n: 4). Pre-admission antibiotic use was up to 84% in study groups. Evaluation of seasonal dispersion revealed that 86.7% of patients were admitted to hospital in the October-May period. Blood cultures were positive in 4 of 98 patients (4%). Nine of 27 (33.3%) pleural effusion cultures were positive and 4 of them revealed Streptococcus pneumoniae. Intermediate penicillin resistance was found in 1/4 of S. pneumoniae isolates (25%). Our study illustrates the problems in the diagnosis and management of pediatric respiratory tract infections in developing countries. Chest X-ray together with erythrocyte sedimentation rate (ESR) was also shown to be important in classifying lower respiratory tract infections. Increase in the usage of specific viral serologic studies will probably lower the percentage of antibiotic usage and lower the costs of cultures.

First vancomycin-resistant blood isolate of Enterococcus faecium in a children's hospital and molecular analysis of the mechanism of resistance.

The first clinical isolate of vancomycin-resistant Enterococcus spp. in Hacettepe University Children's Hospital was isolated from a blood culture of a patient hospitalized in the intensive care unit. He had been on vancomycin therapy for the last four months for consecutive pneumoniae and sepsis. The isolate was identified as Enterococcus faecium (E. faecium) and minimal inhibitor concentration (MIC) values were determined as >256 microg/ml and 256 microg/ml for vancomycin and teicoplanin, respectively, with E-test. The isolate was shown to carry the vanA gene with polymerase chain reaction (PCR). Twelve colonizing strains were isolated from the surveillance cultures during the same period and identified as E. faecium, and were also shown to carry the vanA gene. However, arbitrarily-primed-PCR and pulsed-field gel electrophoresis results could not confirm the source of the resistant strain nor did they suggest a clonal spread in the hospital.

Accentuated varicella exanthems due to cast application.

We report a case of 14-year-old male with local augmentation of varicella zoster exanthems on the forearm on which cast application was performed. After 1 week, the first varicella zoster exanthems began to appear on the left forearm under the cast and trunk, while lesions on the other forearm and extremities were very rare. We postulated that the local pressure and heat increased the number of exanthems.

Primary sternal osteomyelitis in a healthy child due to community-acquired methicillin-resistant Staphylococcus aureus and literature review.

Primary sternal osteomyelitis is a rare condition. Most of the recent cases have been reported in intravenous drug abusers. A 4-y-old male case of primary sternal osteomyelitis due to community-acquired methicillin-resistant Staphylococcus aureus with no apparent risk factors is reported. The diagnosis should be suspected in a young patient presenting with acute inflammatory swelling over the sternum. While bacteriological culture results are pending, antibiotic therapy with Staphylococcus aureus coverage should be initiated empirically and the possibility of community-acquired methicillin-resistant S. aureus must be borne in mind. In this report we also review the literature of paediatric primary sternal osteomyelitis.

Erythema nodosum in childhood: evaluation of ten patients.

Erythema nodosum (EN), which is a rare skin manifestation among children, is precipitated by a range of infectious and non-infectious diseases. The purpose of this study was to evaluate the epidemiology, etiology, clinical manifestations and course of EN among children. A total of 10 patients diagnosed with EN between January 2000 and March 2004 at Hacettepe University Ihsan Dogramaci Children's Hospital, Pediatric Infectious Diseases Outpatient Clinic, were studied retrospectively. The study population consisted of five girls and five boys, with a mean age of 8.8 +/- 3.3 years (range, 4-14 years). In five of the 10 children (50%), the etiology of EN was established: three had streptococcal infection and two were diagnosed as primary tuberculosis; the etiology of EN could not be determined in 50% of the cases. The duration of the recovery of lesions varied from 4 to 12 days (mean, 8.2 +/- 2.6 days). Our data confirm the predominance of streptococcal infections among the etiologic factors while also considering tuberculosis as a causative factor among children with EN in Turkey.

Micrococcus sedentarius bacteraemia presenting with haemophagocytic syndrome in previously healthy boy.

Haemophagocytic syndromes are the clinical manifestation of an increased macrophagic activity with haemophagocytosis. Infection-associated HS was originally described by Risdall in 1979, in viral disease. Since the initial description HS has also been documented in patients with bacterial, parasitic or fungal infections. We describe a case of Micrococcus sedentarius bacteraemia in a previously healthy 10-y-old boy with haemophagocytic syndrome. Species of micrococci are generally considered as non-pathogenic commensals that colonize the skin, mucosae and oropharynx. We report the first case of Microccoccus sedentarius bacteraemia in an immunocompetent host and first case of HS associated with Micrococcus species.

Atypical presentation of spondylitis in a case with sickle cell disease.

Salmonella osteomyelitis is rarely seen and vertebral involvement by this organism is very rare, especially in childhood. Salmonella should be considered in the list of etiologic agents of osteomyelitis in sickle cell disease. Herein we report a five-year-old boy with sickle cell disease and Salmonella paratyphi B spondylitis who was diagnosed with atypical clinical findings of infection. We would like to emphasize the importance of differentiation between osteomyelitis and infarction even if there is no obvious sign of infection in the sickle cell patient even at atypical localization.

Prolonged cellulitis due to plant thorn.

We report the case of a five-year-old healthy boy who was admitted with abscess and soft tissue infection between the left wrist and the distal end of the forearm. Postero-anterior X-ray examination of the forearm showed a transverse line on the radius; however, further comparative radiographic examinations of the forearm were not compatible with fracture. Enterobacter cloacae was identified in the pus culture and initial intravenous empiric treatment with sulbactam-ampicillin was continued. Although the microorganism was susceptible to the empiric antimicrobial agent, at the eighth day of the treatment, inflammatory drainage was still present so further evaluations were performed. Ultrasonography of the forearm and wrist revealed only collection; magnetic resonance imaging showed a foreign body on the anterior distal section of the left forearm. The patient underwent operation and a 22 mm wooden foreign body was removed. Detailed history after removing a tree branch particle revealed that the boy had recently fallen from a tree causing an abrasion over the left wrist. The postoperative course was uneventful and clinical response was excellent in two days. In view of this case report, we would like to emphasize the importance of medical history and imaging studies in cases of cellulitis that do not respond to appropriate antimicrobial therapy. Another point to be kept in mind is that Enterobacter cloacae, which is very rarely reported as a causative agent for cellulitis, could be the etiological agent in cases after plant thorn injuries.

Mumps hydrocephalus ameliorated with external drainage.

Mumps is still one of the most common childhood diseases in areas where national immunization has not been implemented. Although central nervous system manifestation is not so uncommon, hydrocephalus secondary to mumps is very rare. In this report, we present a toddler who developed severe hydrocephalus during mumps infection, which resolved via timely cerebral spinal fluid (CSF) drainage. We would like to emphasize early intervention for CSF external drainage.

Pediatric blood culture: time to positivity.

The aim of this study was to determine how long it takes blood culture to become positive using a blood culture system that can be monitored continuously in pediatric patients. Data were collected prospectively on 1,000 positive blood culture results from a tertiary pediatric university hospital from April 2000 to May 2002. The laboratory used the BACTEC 9120 fluorescent blood culture system. Patient's age ranged from less than a day to 20 years of age (mean 3 years). Five hundred and four cultures (50.4%) out of 1,000 yielded coagulase negative staphylococcus (CNS), 81 (8.1%) S. aureus, 53 (5.3%). Pseudomonas and 50 (5.0%) Klebsiella species. Of the 504 coagulase negative staphylococcal blood culture isolates, 314 (62.3% of CNS) were regarded as skin contaminants. Of the 1,000 cultures, 9.6% were reported as positive in the first day, 27.8% in the second day, 54.7% in the third day, 77.0% in the fourth and 89.4% in the fifth day. There was no association between previous antibiotic usage and the period required for isolate recovery. The clinician can expect to get results of positive blood cultures with susceptibility data, at a rate of 77.1% by day four and almost 90% by day five of sampling in the bacteriemic patient. Blood cultures yielding coagulase negative staphylococci in the first three days almost always show bacteremia with those microorganisms.

Back to the basics: hemorrhage after vaccination: a case report.

A 50-day-old girl with swelling and ecchymosis of right hand dorsum after DTP vaccination on ipsilateral deltoid area was referred to the pediatric infectious disease outpatient unit with a presumed diagnosis of gangrenous cellulites. Physical examination and laboratory evaluation revealed intramuscular bleeding as a result of vitamin K deficiency. We would like to emphasize the importance of both vitamin K prophylaxis in the newborn to prevent hemorrhagic disease of the newborn and of the education of persons administering vaccines about this very basic aspect of pediatrics for early recognition.

Acute neck infections in children.

A retrospective review was conducted on 132 patients aged between two and 15 years with cervical lymphadenitis and/or with abscess formation to determine the epidemiologic and clinical presentation of these infections. The most common locations were the upper anterior cervical space (43.2%) and the submandibular space (27.3%). The duration of symptoms ranged from 12 hours to 20 days. Results of the pus cultures were available in 31 patients (23.5%). Of these, 16 cultures (51.6%) were positive. The isolated organisms were Staphylococcus aureus (50%), Staphylococcus epidermidis (31.3%), group A beta-hemolytic streptococcus (12.5%), Streptococcus pneumoniae (6.3%) and Escherichia coli (6.3%). One of the specimens yielded mixed organisms (Staphylococcus epidermidis and Streptococcus pneumoniae). Penicillin resistance was documented in six (37.5%) of the 16 gram-positive bacteria isolated from the pus culture. Both throat and blood cultures were available in all 132 patients. Seven throat cultures (5.3%) were positive for group A beta hemolytic streptococci, whereas five blood cultures (3.8%) were reported to have bacterial growth. Sixty-seven patients (50.8%) were treated with ampicillin-sulbactam, 53 patients (40.1%) with ampicillin-sulbactam and ornidazole and 12 patients (9.1%) with ceftriaxone parenterally. The mean duration of hospital stay related to the infection was 7.30 +/- 3.89 days (range, 2-28 days). The mean period for downsizing of the cervical mass by half was 4.05 +/- 2.05 days, and the recovery period (total antibiotic usage period) was 13.72 +/- 5.33 days. All of the patients had an uneventful recovery without complications. Results of both throat and blood cultures were not predictive for etiologic agents in our study group. Since ultrasonographic evaluation of each patient has limited additional benefits in clinical management, it must be reserved for selected cases to document abscess formation.