Osteomyelitis in Cat-Scratch Disease: A Never-Ending Dilemma-A Case Report and Literature Review.

BACKGROUND: We performed a review of published case studies of osteomyelitis associated with cat-scratch disease to consolidate existing information on clinical presentation, diagnostic tools, therapy, and outcome, as well as presenting a case of disseminated cat-scratch disease in a 12-year-old female with skull osteomyelitis and spleen involvement. METHODS: A search for articles indexed in PubMed, Embase, and Google Scholar was performed with the search terms "Bartonella," "bone," "osteomyelitis," "osteolytic," and "cat-scratch disease" limited to the immunocompetent pediatric population and articles in English. RESULTS: 51 cases were identified. The average age was 7.8 years with equal sex distribution. Fever (84.3%), often with a prolonged course (64.7%), and osteoarticular pain (88.2%) were the most common clinical findings. Lymphadenopathy was present in 64.7% of patients. Vertebral body was mainly involved (51.9%). MRI (50%) and bone scintigraphy (48.1%) were favored to confirm osteomyelitis, while serology was the preferred microbiological diagnostic. Various antibiotics were prescribed in combined or sequential regimens, with median duration of therapy of 23 days. About 12.5% of patients did not receive any treatment. Most patients had excellent prognosis; in particular, all patients not receiving any therapy showed complete recovery and no recurrence of symptoms. CONCLUSIONS: Bartonella henselae should be considered in differential diagnosis of localized lymphadentitis. Osteoarticular pain or limitation during cat-scratch disease in children should always be investigated for bone spreading. Owing to good prognosis, invasive procedures to obtain the bone material should be avoided. Serology is the gold standard diagnostic tool and MRI is the best radiographic technique to define bone and surrounding tissue involvement. Treatment represents a never-ending dilemma: surgical intervention or use of antibiotics is still controversial, and more studies are needed to define the best antimicrobial regimen.

Mixed exhaled nitric oxide and plasma nitrites and nitrates in newborn infants.

Plasma nitrite (NO2-) and nitrate (NO3-) are the stable end-products of endogenous nitric oxide (NO) metabolism. NO is present in the exhaled air of humans, but it is not clear if exhaled NO may be an indicator of the systemic endogenous NO production. The aims of the study were to determine the levels of exhaled NO and plasma NO2-/NO3- in healthy term and preterm newborns, and to assess if exhaled NO correlates with plasma NO2-/NO3- at birth. After the stabilization of the newborn, we measured by chemiluminescence the concentration of NO in the mixed expired breath of 133 healthy newborns. Measurement of exhaled NO was repeated after 24 and 48 hours. Plasma NO2-/NO3- levels at birth were measured by the Griess reaction. NO concentrations were 8.9 (CI 8.1-9.8) parts per billion (ppb), 7.7 (CI 7.2-8.3) ppb and 9.0 (CI 8.4-9.6) ppb at birth, 24 and 48 hours, respectively. At birth, exhaled NO was inversely correlated with gestational age (p=0.008) and birth weight (p<0.001). Plasma NO2-/NO3- level was 27.30 (CI 24.26-30.34) micromol/L. There was no correlation between exhaled NO and plasma NO2-/NO3- levels at birth (p=0.88). We speculate that the inverse correlation between exhaled NO and gestational age and birth weight may reflect a role of NO in the postnatal adaptation of pulmonary circulation. At birth, exhaled NO does not correlate with plasma NO2-/NO3- and does not seem to be an index of the systemic endogenous NO production.

[Positioning of umbilical vein catheter with ECG-guided technique: randomized study]. / Posizionamento del catetere ombelicale venoso con tecnica ECG-guidata: studio randomizzato.

GOAL: To evaluate the effectiveness of electrocardiography-guided technique to aid in the correct positioning of umbilical vein catheters. DESIGN: A prospective, randomized controlled study. METHODS: Term and preterm newborns who required an umbilical venous catheter were managed by an ECG-guided technique (group A) or by a conventional method (group B). Correct positioning was defined by a chest-X-ray when the catheter tip was located above the diaphragm and outside the right atrium. For the ECG-guided technique we utilized a conductive device Vygocard (Medival, Padova) inserted in a 3-way stopcock connected with the catheter. The catheter was inserted under ECG observation until the appearance of a tall P-wave in lead III, which indicated the tip was within the right atrium. The catheter was then withdrawn until the P wave size returned to normal. RESULTS: We enrolled 44 patients (16 F, 28 M). Median gestational age (GA) and birth weight (BW) were 34 weeks (range 26-41) and 2130 g. (590-3870), respectively. Sex distribution, GA, BW and Apgar scores were not different between patients in group A (n = 22) and group B (n = 22). Catheters could not be advanced till the estimated insertion depth in 11 patients (A = 5, B = 6). In the remaining 33 patients, correct tip placement was more frequent in group A (88%) compared with group B (50%) (p = 0.021 by Fisher's exact test). No side effects specific to the ECG-guided method were noted. CONCLUSIONS: The ECG-guided technique seems to be a safe and effective method for the proper placement of umbilical vein catheters in newborns.