Serious complications due to acute rhinosinusitis in children up to five years old in Stockholm, Sweden - Still a challenge in the pneumococcal conjugate vaccine era.

OBJECTIVES: The aim of this study was to analyze the rate of admissions, the rate of serious complications (postseptal orbital complications and surgery) and the bacterial etiology of acute rhinosinusitis in hospitalized children under five years old in Stockholm County, eight years after the introduction of the pneumococcal conjugate vaccine (PCV). The secondary aim was to compare this period with the period four years prior to the vaccine's introduction. METHODS: This was a population-based, descriptive observational study with retrospectively collected data from 1 July 2008 to 30 June 2016 in Stockholm County. Hospital admissions of children with a discharge diagnosis of rhinosinusitis and related complications were reviewed and compared to the pre-PCV period of 2003-2007. RESULTS: A total of 215 children were admitted, for a yearly incidence of 18.8 per 100 000 children (22.8 for boys, 14.6 for girls). Computer tomography-verified postseptal orbital complications occurred in 29 cases (13.5%) and surgery was necessary in nine (4.2%). Pathogens other than Streptococcus pneumoniae were found in the cases with postseptal complication or surgery (Streptococcus pyogenes in four, Haemophilus influenzae in three and Staphylococcus aureus in one case). In comparison to the four years pre-PCV, the incidence of admission decreased from 43.81 to 20.31 and 17.45 per 100 000/year for the two four-year periods after vaccine introduction. The incidence of CT-verified postseptal complication increased slightly from 1.51 to 2.34 and 2.74 per 100 000/year. The incidence of surgeries increased marginally but continued to be very low, from 0.22 to 0.54 and 1.03 per 100 000/year. CONCLUSIONS: Complications due to acute rhinosinusitis in children living in Stockholm County continues to be very rare after the introduction of pneumococcal vaccine. Hospitalization has decreased for children under five years old after PCV introduction, but the incidence or postseptal complications and surgery in the same population increased slightly. Predominantly bacteria other than Streptococcus pneumoniae was found. There is a need of larger studies to determine trends, and a need of prospective studies to elucidate the bacterial etiology, of serious complications due to acute rhinosinusitis in children.

Extensive transmission of an isoniazid-resistant strain of Mycobacterium tuberculosis in Sweden.

SETTING: City of Stockholm, Sweden. BACKGROUND: The incidence of tuberculosis (TB) in Sweden increased by 40% between 2003 and 2005. The spread of a unique TB strain resistant to isoniazid (INH) contributed to this increase. OBJECTIVE: To describe outbreaks of TB caused by this single strain, elucidate possible causes for its extensive spread and identify shortcomings of the TB control programme in Sweden. RESULTS: We identified a cluster consisting of 102 culture-confirmed TB cases with identical DNA fingerprints and 26 epidemiologically related cases, not confirmed by culture, all diagnosed between 1996 and 2005. Five partly separate outbreaks of this strain were discovered. Epidemiological links were established for 56% of the culture-confirmed cases and for all cases not confirmed by culture. Three patients died while receiving treatment, four became failures and eight defaulted or were lost to follow-up. Only eight patients received directly observed treatment (DOT) up to a period of 3 months, although 40% had poor adherence. CONCLUSIONS: Shortcomings of the national TB programme were revealed. Improved contact tracing and case holding, including DOT, is crucial to reduce TB transmission in Sweden.

Aluminum Tolerance in Wheat (Triticum aestivum L.) (I. Uptake and Distribution of Aluminum in Root Apices).

We investigated the uptake and distribution of Al in root apices of near-isogenic wheat (Triticum aestivum L.) lines differing in Al tolerance at a single locus (Alt1: aluminum tolerance). Seedlings were grown in nutrient solution that contained 100 [mu]M Al, and the roots were subsequently stained with hematoxylin, a compound that binds Al in vitro to form a colored complex. Root apices of Al-sensitive genotypes stained after short exposures to Al (10 min and 1 h), whereas apices of Al-tolerant seedlings showed less intense staining after equivalent exposures. Differential staining preceded differences observed in either root elongation or total Al concentrations of root apices (terminal 2-3 mm of root). After 4 h of exposure to 100 [mu]M Al in nutrient solution, Al-sensitive genotypes accumulated more total Al in root apices than Al-tolerant genotypes, and the differences became more marked with time. Analysis of freeze-dried root apices by x-ray microanalysis showed that Al entered root apices of Al-sensitive plants and accumulated in the epidermal layer and in the cortical layer immediately below the epidermis. Long-term exposure of sensitive apices to Al (24 h) resulted in a distribution of Al coinciding with the absence of K. Quantitation of Al in the cortical layer showed that sensitive apices accumulated 5- to 10-fold more Al than tolerant apices exposed to Al solutions for equivalent times. These data are consistent with the hypothesis that Alt1 encodes a mechanism that excludes Al from root apices.

Astroviruses as a cause of nosocomial outbreaks of infant diarrhea.

During a 16-month study period at a children's hospital, 32 children developed nosocomial gastroenteritis caused by astroviruses. Twenty-five of these occurred during 2 epidemic outbreaks in medical and surgical infants' wards. From the community, 13 confirmed cases were admitted during the study period. Both community-acquired and nosocomial cases occurred during autumn, winter and early spring. The attack rates during outbreaks ranged between 7 and 62% and were highest among children with underlying gastrointestinal diseases. Diarrhea and vomiting were the most common clinical manifestations. The median duration of symptoms was 4 days and that of virus excretion was 5 days. Hospital infection with astroviruses is common and usually affects children less than 2 years of age. The probable mode of transmission is spread via contaminated hands.

Nosocomial calicivirus gastroenteritis in a pediatric hospital.

At St. Göran's Children's Hospital (a tertiary center), we perform electron microscopy of feces in most cases of nosocomial gastroenteritis. From September 1987 through April 1992 we identified 32 episodes of calicivirus infection, 25 of which were nosocomial and, except for one outbreak, sporadic. Systematic study of the nosocomial outbreak of calicivirus gastroenteritis from November 1991 to January 1992, revealed calicivirus in the stools of 8 of 23 children with diarrhea and 0 of 10 without diarrhea. In 3 of 7 sampled after cessation of diarrhea, calicivirus excretion continued for 3 to 6 days. We found no calicivirus in 42 staff members or 9 members of infected patients' families. Nosocomial transmission of calicivirus can occur among infants.

Incidence and estimates of the disease burden of rotavirus in Sweden.

Laboratory and hospitalization data from two children's hospitals with large primary catchment areas and national laboratory and hospitalization data for children under 4 y of age with acute diarrhoea were compiled to estimate the number of hospitalizations and the cost burden associated with rotavirus diarrhoea in Sweden. According to our estimates 1500-1700 rotavirus-associated hospitalizations occur annually in Sweden in children under 4 y of age (3.7 hospitalizations/1000 children/y). This number represents 2.3% of admissions for all diagnoses in children of this age group. The cost of these hospitalizations is 13.5-15 million Swedish crowns (US$1.8-2 million). Serotyping by PCR for two years revealed that serotype 1 (G1) was the most common (49% and 58%, respectively) identified. Serotypes 2-4 were identified in the following proportions G2 (23% and 5%), G3 (21% and 0%) and G4 (7% and 16%). The national laboratory report data for 1993-96 show that as much as 7-13% of rotavirus infections occur in elderly people.

Mianserin induced agranulocytosis presenting as an abscess.

A case of Mianserin induced agranulocytosis presenting as a localised infection is presented and the literature reviewed. The importance of a thorough drug history in patients presenting with minor surgical ailments is stressed.

Borrelia antibodies in children evaluated for Lyme neuroborreliosis.

BACKGROUND: We wanted to elucidate the value of Borrelia antibodies in serum and cerebrospinal fluid (CSF) for the diagnosis of Lyme neuroborreliosis (LNB). MATERIAL AND METHODS: We analyzed the serological findings, by anti-flagellin assay, in 267 patients with neurological symptoms from the Stockholm area, where Lyme borreliosis is endemic. RESULTS: In the 70 children with LNB, intrathecal Borrelia antibody production was diagnostic and found in 50 (71%). Sixteen (23%) showed an elevated antibody titer in serum only, and 4 (7%) had no serologic findings. Borrelia IgG in serum, with or without concomitant IgM, was a specific (98%), but insensitive (43%) marker of infection. Isolated, false-positive serum IgM titers were common and found in 10 of 67 children (15%) with viral meningitis, as well as in 28 of 111 (25%) with various neurological symptoms and normal CSF. The specificity of an isolated Borrelia IgM titer in serum was 81%, and the positive predictive value for Borrelia infection only 50% in our material. On the other hand, absence of antibodies in blood had a negative predictive value of 94%, which increased to 97% if also CSF findings were included. CONCLUSIONS: Intrathecal antibody production is strongly supportive of an LNB diagnosis. Conversely, isolated, elevated levels of Borrelia IgM in serum occur in up to one-fourth of children with various neurological complaints, and should be interpreted with caution, especially in nonendemic areas.

Herpes zoster in a 2-week-old premature infant with possible congenital varicella encephalitis.

This report concerns a case of neonatal herpes zoster associated with maternal gestational varicella. The child developed skin lesions at 18 days of age virologically confirmed to be varicella-zoster. The baby also had encephalitis and aspiration probably due to bulbar paralysis. Multiple small necrotic areas were found in the thalamus at post-mortem examination.

Development of the faecal anaerobic microflora after caesarean section and treatment with antibiotics in newborn infants.

Qualitative and quantitative anaerobic cultures were performed on faecal samples from 27 normal full-term newborn infants; from 32 preterm infants during intensive or intermediate care, not treated with antibiotics; and from 106 mostly preterm newborns, treated with antibiotics for various reasons. There were no major differences between the children in the first two groups. In these, Caesarean section led to a lower isolation rate of bifidobacteria and a much lower incidence of Bacteroides spp. During antibiotic treatment anaerobic bacteria were isolated from only 10% of the infants. After treatment, there was a slow regrowth of bifidobacteria, but Bacteroides spp. were not usually re-established. There was a colonisation of infants delivered by Caesarean section with new Lactobacillus spp. after treatment. In particular Bacteroides colonisation may be facilitated and more stable if it occurs during passage through the birth canal.

Wheezing following lower respiratory tract infections with respiratory syncytial virus and influenza A in infancy.

We examined the incidence of subsequent wheezing in 292 children, hospitalized for influenza A or respiratory syncytial virus (RSV) lower respiratory tract infection, during two consecutive seasons (November-December, 1993 and March-April, 1995). Questionnaires concerning episodes of wheezing and known risk factors for wheezy bronchitis were mailed to parents 1 year after hospitalization. Sixty per cent of parents reported two or more episodes of wheezing following either influenza A or RSV. Hospitalization as a result of wheezing was necessary in 15% of the patients. The severity of the primary infection, as indicated by the need for treatment in the intensive care unit (ICU), was correlated with later wheezing. No additional significant risk factors predicting later wheezing could be identified.

Non-tuberculous mycobacterial lymphadenitis in healthy children: another "lifestyle disease"?

UNLABELLED: An increasing incidence of non-tuberculous mycobacterial (NTM) lymphadenitis has been reported in previously healthy children in the western world since about 1985. In this study we investigated the sociodemographic and individual characteristics of these patients. Information about patients was collected prospectively from 1977 to 1996. For comparison, an ad hoc group of hospitalized children with bacterial cervical lymphadenitis was chosen. In addition to individual characteristics, information was collected on the country of birth of the patients and their parents, and the socioeconomic characteristics of the domicile area. We identified 81 children with NTM, 14 with tuberculous and 192 with septic lymphadenitis. Significantly more parents of children with NTM than in either of the other two groups were Swedish-born and lived in privileged socioeconomic areas. CONCLUSION: The increase in NTM lymphadenitis in healthy children has taken place at the same time as the reported increase in atopic disease and asthma in childhood. Both groups of patients seem to come from favourable living conditions. It is speculated that NTM lymphadenitis, like asthma and certain other diseases triggered by the immune system, might be a "lifestyle disease".

Inverse correlation between natural antitumor antibodies and tumor susceptibility in individual xid-bearing mice.

Natural antibodies (NAb), natural killer (NK) cells and activated macrophages have all been implicated in the rejection of threshold syngeneic tumor inocula. Previous analysis of tumor susceptibility in normal versus inbred and F1 mice bearing the B cell deficiency associated with the xid mutation of CBA/N mice demonstrated an inverse relationship between the tumorigenicity of the RI-28, a radiation-induced leukemia of the CBA/H strain, and the pooled anti-RI-28 serum NAb levels in mice with the same genetic origins. No relationship with tumor susceptibility was seen with NK cell or in vivo activated macrophage cytolysis. Flow-cytometric determination of antitumor serum NAb bled from individual male and female (CBA/N X CBA/J)F1 mice 1 week prior to the threshold tumor inoculation has revealed extensive heterogeneity within the NAb levels of each sex. A comparative analysis of tumor fate with NAb activity revealed that tumors appeared in only 26.3% of animals with a mean fluorescence channel binding above 60 channels in contrast with 77.3% of animals with lower NAb levels. These data extend to the level of individual hosts the support for an inverse relationship between host NAb activity and tumor susceptibility. In addition, subsequent analysis of serum antitumor NAb levels, splenic NK cytolysis and in vitro lymphokine-activated macrophage activity with all three mediators originating from the same individual F1 mice showed no consistent correlations between these natural resistance activities, arguing for the exclusion of deficiencies in NK cell or macrophage function as the basis for the differential tumor susceptibility in individual F1 mice.