A clinical review of 105 patients with PFAPA (a periodic fever syndrome).

AIMS: We describe the presentations and clinical outcomes of pediatric patients diagnosed with PFAPA (Periodic Fever, Aphthous lesions, Pharyngitis, and cervical Adenitis). MATERIALS AND METHODS: The medical records of children with recurrent fever and referred between 1998 and 2007 to a tertiary pediatric care hospital were reviewed. Children who met clinical criteria for PFAPA were then asked to participate in a follow-up study. RESULTS: One hundred and five children met study criteria for PFAPA which included at least six episodes of periodic fever. Most (62%) were males, the mean age at onset of PFAPA was 39.6 months (80% were <5 years at onset), the mean duration of individual fever episodes was 4.1 days, and the mean interval between episodes was 29.8 days. Accompanying signs and symptoms included aphthous stomatitis (38%), pharyngitis (85%), cervical adenitis (62%), headache (44%), vomiting with fever spikes (27%) and mild abdominal pain (41%). A prodrome (usually fatigue) preceded the fever in 62% of patients. Parents noted that when their child with PFAPA had fever, other family members remained well. Laboratory tests in patients with PFAPA were nonspecific. Individual episodes of fever usually resolved with a single oral dose ( approximately 1 mg/kg) of prednisilone. The interval between fever episodes shortened in 50% of patients who used prednisilone. PFAPA resolved spontaneously (mean length 33.2 months) in 211105 (20%) patients. PFAF'A episodes continued (mean length 23 months) at the end of this study in 661105 (63%) patients. Cimetidine therapy was associated with the resolution of the fevers in 7/26 (27%) patients; tonsillectomy was associated with the resolution of the fevers in 11/11 (100%) patients. CONCLUSION: PFAPA can usually be defined by its clinical characteristics. Individual febrile episodes usually resolve dramatically with oral prednisilone. The cause of PFAPA is unknown and research is needed to define its etiology. The overall prognosis for children with PFAPA is excellent.

Treatment of adult chickenpox with oral acyclovir.

Thirty-one late adolescents and adults with varicella were studied. Patients identified within 72 hours of varicella exanthem were offered open treatment with acyclovir (4 g/d), and those patients identified after 72 hours of exanthem were followed up but not treated. Twenty-two patients were treated with acyclovir. Nine patients were not treated. No severe complications occurred in any of the 31 patients. Minor complications, including prolonged fever, localized secondary infections, persistent cough, and prolonged fatigue were more frequent in the untreated group. If the acyclovir therapy was begun within the first 24 hours of varicella exanthem, then the rash and clinical illness were dramatically lessened. Treatment with oral acyclovir should be considered for varicella in adults who are identified within the first 24 hours of exanthem.

An audit of chloramphenicol use in a large community hospital.

In a large community hospital during a six-month period, 238 of 19,670 hospitalized patients (1.2%) received chloramphenicol. The drug was administered exclusively by the intravenous route in 98% of these patients. In 78% of the patients, chloramphenicol was used for an appropriate indication, whereas in 22%, its use was inappropriate. Serious toxic effects and unexpected clinical failures were not observed.

Misdiagnosis of erythema migrans.

BACKGROUND: Erythema migrans is a clinical diagnosis that carries possible long-term repercussions. Despite widespread awareness of the clinical presentation of erythema migrans, incorrect diagnosis occurs. PATIENTS AND METHODS: We describe 13 cases in which erythema migrans was misdiagnosed and discuss some pitfalls in diagnosis. These cases were seen at a tertiary referral center in Connecticut, a state where Lyme disease is endemic. The patients selected for inclusion were those who most clearly illustrate potential difficulties involved in making the diagnosis of erythema migrans. RESULTS: The diagnosis of erythema migrans was missed in 5 patients due to atypical presentations. Eight patients with skin eruptions closely mimicking erythema migrans were incorrectly diagnosed with erythema migrans. CONCLUSIONS: There are pitfalls associated with the diagnosis of erythema migrans that may result in overdiagnosis or underdiagnosis.

Yeast connection among 100 patients with chronic fatigue.

PURPOSE: Patients with the "yeast connection" are characterized by fatigue and multiple systemic symptoms. The purpose of our study was to compare patients with chronic fatigue who believed they had the yeast connection to patients with chronic fatigue without the yeast connection. PATIENTS AND METHODS: One hundred consecutive patients with a chief complaint of chronic fatigue were evaluated in a specialty clinic setting at the University of Connecticut Health Center. A complete history was obtained from each patient, and a 168-item review of systems and a complete physical examination were performed. RESULTS: Eight patients believed that their fatigue was due to chronic candidiasis. Of these eight, seven had psychiatric diagnoses that were judged to underlie their fatigue. Of the remaining 92 patients with chronic fatigue, 59 had underlying psychiatric diagnoses. We were unable to find historical, physical, or laboratory differences between chronic fatigue patients with or without the yeast connection. CONCLUSION: From this study and a review of the literature, we are unable to identify findings that are specific for the yeast connection.

Bacillus species isolates from cerebrospinal fluid in patients without shunts.

Of 849 CSF cultures done at Hartford Hospital, nine were positive for nonanthrax Bacillus species. Differentiation of true nonanthrax Bacillus species infection from contamination requires careful consideration of the clinical findings, the clinical course, and the laboratory data. In seven patients the nonanthrax Bacillus species represented contamination. In two patients the nonanthrax Bacillus species represented true infection. In one of these infected patients, nonanthrax Bacillus species complicated a cranial gun shot wound. Bacillus cereus meningitis developed in the second patient, a premature infant, following sepsis from a contaminated IV catheter. Nonanthrax Bacillus species, especially B cereus, can be resistant to penicillins and cephalosporins when nonanthrax Bacillus species infections are being treated, susceptibility testing should always be performed.

Early Lyme disease: a flu-like illness without erythema migrans.

The existence of a form of early Lyme disease characterized by a flu-like illness without erythema migrans is controversial. To confirm the existence and define the clinical characteristics of the flu-like illness without erythema migrans of localized Lyme disease, the authors studied patients from a Lyme disease endemic area of Connecticut who visited their primary care physicians with an undefined flu-like illness. Patients kept a diary of their symptoms. Acute and convalescent sera were obtained. The diagnosis of Lyme disease was based on the appearance of IgM or IgG antibodies to Borrelia burgdorferi as demonstrated by both enzyme-linked immunosorbent assay and immunoblot assay. Twenty-four untreated patients were studied. In five patients acute serologic evidence of Lyme disease developed. The flu-like illness in these five patients was characterized by fever and fatigue and resolved spontaneously in 5 to 21 days. Symptoms recurred in three of these five patients. The existence of a flu-like illness without erythema migrans of early Lyme disease has been clearly established. Prospective, controlled studies are needed to better define its incidence, characteristics, and prognosis so that appropriate diagnostic and therapeutic strategies can be developed.

Bacterial endocarditis caused by vitamin B6-dependent viridans group Streptococcus.

Two cases of bacterial endocarditis in children, caused by viridans group Streptococcus which requires vitamin B6 or thiol compounds for growth are reported. It is important to recognize these organisms as a possible cause of endocarditis because supplemented media are needed for their isolation and sensitivity testing. These organisms may be penicillin-sensitive, -resistant, or -tolerant. An organism is considered tolerant to an antibiotic when the minimum bactericidal concentration of that antibiotic is greater than or equal to 32 times the minimum inhibitory concentration. One of our patients relapsed when treated with a single antibiotic to which the B6-dependent viridans group Streptococcus was tolerant. If a B6-dependent viridans group Streptococcus is isolated from a patient with endocarditis, therapy should be initiated with penicillin and an aminoglycoside until sensitivities are available. Sensitity testing should include both the MIC and MBC and adequate therapy can be confirmed by determing the serum bactericidal activity.

Review of 59 patients hospitalized with animal bites.

We reviewed the charts of 59 pediatric and adult patients hospitalized because of animal bites (46 dog bites, 10 cat bites, 3 monkey bites). The bites of 40 of the 59 patients were infected at the time of admission. Gram-stained specimens correctly predicted the infecting bacteria in only 5 of 20 cases. Eighty-three percent of the bacterial isolates were penicillin-susceptible. Before admission 14 patients had received outpatient antibiotic prophylaxis and the infections in 11 of these 14 patients were caused by bacteria susceptible to the prophylactic antibiotic. Complications were more common if antimicrobial therapy had not been altered according to susceptibility testing results. Of the 59 patients 19 were admitted immediately after being bitten because of severe uninfected bites. Of these 19 patients 18 received prophylactic antibiotics and none developed a serious complication.

Use of polymerase chain reaction for laboratory diagnosis of herpes simplex virus encephalitis.

Polymerase chain reaction was used to detect herpes simplex virus (HSV) specific deoxyribonucleic acid (DNA) sequences in acute and convalescent cerebrospinal fluid (CSF) and brain tissue of a 78-year-old man and in CSF of a neonate who died of complications owing to herpes simplex virus encephalitis (HSVE). Polymerase chain reaction (PCR) was carried out for 35 cycles with a set of primers that bracketed a 92 base pair segment unique to the HSV DNA polymerase gene. Amplified DNA was electrophoresed on 3 percent agarose gel, blotted onto a nylon membrane, and probed with 32p-labeled oligonucleotide internal to the primers. The HSV specific DNA sequences were detected in the specimens from both patients. No HSV specific DNA was detected in CSFs from 20 patients with suspected Lyme disease or neurosyphilis. Polymerase chain reaction is a rapid and noninvasive technique for the diagnosis of HSVE.

Severe meningoencephalitis: complicating Mycoplasma pneumoniae infection in a child.

Mycoplasma pneumoniae (MP) infections are infrequently associated with CNS disease. We studied one case of meningoencephalitis associated with serologic evidence of MP infection. The pathogen grew neither from culture of CSF nor from culture of brain tissue. Electron-microscopic examination of the brain biopsy specimen revealed no organisms. Except for a single case in the literature, MP has never been recovered from the CNS, suggesting that MP-associated CNS disease is not caused by direct invasion of the CNS by MP.

Occult pneumococcal bacteremia and the febrile infant and young child.

Occult pneumonoccemia (OP) is unsuspected Streptococcus pneumoniae bacteremia occurring in a previously well child who presents with fever associated with either no focus or an upper respiratory focus infection. In this report, four cases of OP are presented and the literature is reviewed. The risk of OP appears highest for children, seen in urban emergency rooms and clinics, who are 6 to 24 months of age with rectal temperatures greater than or equal to 38.9 C (102 F) and who have white blood cell counts greater than or equal to 15,000/mm3. Other symptoms associated with OP include irritability, rhinorrhea, and febrile seizures. When recalled because of positive blood cultures, 40 per cent of untreated patients with OP had had spontaneous resolution of their illness, 29 per cent had persistent fever or symptoms and sterile blood cultures, 22 per cent had persistent fever or symptoms and positive blood cultures, while 10 per cent had a febrile course complicated by pneumococcal meningitis.

Addition of rifampin to cephalexin therapy for recalcitrant staphylococcal skin infections--an observation.

We report two pediatric patients with recalcitrant staphylococcal infections whose infections resolved when rifampin was added to standard antistaphylococcal therapy. One patient had a post-varicella staphylococcal ulcerative lesion and did not respond to cephalexin alone but did respond when rifampin was added. A second patient had staphylococcal bullous impetigo and did not respond to dicloxacillin or cephalexin but did respond when rifampin was added to the cephalexin. If a patient fails to respond to traditional antistaphylococcal therapy, the addition of rifampin may be beneficial.

Pseudomonas whirlpool dermatitis. Report of an outbreak in two families.

Pseudomonas aeruginosa skin infections developed in four children and their parents after use of a recreational whirlpool. These patients were carefully followed throughout the course of their illnesses. The incubation period was two to five days. The skin lesions included erythematous macules and papules, pustules, and nodules. The severity of the illness varied from a few scattered pustules in one patient to an extensive truncal rash, malaise, and fever in another patient. P. aeruginosa was recovered from skin lesions and the whirlpool water. Gram stains from two patients revealed polymorphonuclear leukocytes and gram-negative rods. In all patients, the rash improved within seven days and local application of povidone-iodine did not appear beneficial.

Rabies prophylaxis following the feeding of a rabid pony.

A survey was performed to identify people who were exposed to a rabid pony and determine whether or not they received rabies postexposure prophylaxis (PEP). Sixty-one visitors who came in contact with the rabid pony were identified. These visitors heard about the rabid pony via the news media. Forty-five visitors were exposed during the 2 weeks before the pony died. Thirty-two of these 45 visitors received PEP. Thirty-one visitors had or may have had saliva contact to an open wound or mucosa and all 31 received PEP. Fourteen visitors had no saliva contact to a wound or mucosa and one received PEP. Sixteen visitors were exposed before the pony was potentially shedding rabies virus and one received PEP. No visitor was bitten by the pony. Most of the persons 31/33 (94%) who received PEP had an exposure for which PEP was indicated. Nonbite transmission of rabies is discussed.

Sterilization of infant formula: current practices and recommendations.

Home sterilization of infant formula became a standard of well-baby care in the 1940s. Its purpose was to eliminate bacterial pathogens that could contaminate water and bottles. Public water supplies are now rarely contaminated, and studies have confirmed that sterilization is no longer necessary. Connecticut family physicians and Connecticut mothers were polled and it was found that 48 percent of physicians recommend sterilization and that 54 percent of mothers (using public water supplies) sterilize formula. Formula sterilization recommendations by physicians and sterilization practices by mothers need to be updated.