Subcutaneous abscess caused by Streptococcus pneumoniae serotype 28F in an infant: a case report.

BACKGROUND: Invasive pneumococcal disease (IPD) is defined by the detection of Streptococcus pneumoniae on culture from samples obtained from a normally sterile site. Pneumococcal conjugate vaccines (PCV) have been developed for the prevention of IPD that is caused by highly virulent serotypes. Despite the effective reduction of IPD caused by vaccine serotypes after the introduction of PCV, there has been a rapid increase in the incidence of IPD caused by non-vaccine serotypes, and serotype replacement has become a global issue. CASE PRESENTATION: We report a previously healthy 4-month-old girl presenting with a large subcutaneous abscess caused by S. pneumoniae, identified as non-vaccine serotype 28F. The patient had received routine vaccination, including PCV vaccination. After the incision and drainage of the subcutaneous abscess, the patient was treated with antibiotics. She was discharged on Day 7 of hospitalization without any residual sequelae. CONCLUSIONS: Subcutaneous abscess is a common pediatric skin and soft tissue infection, whereas pneumococcal subcutaneous abscesses are quite rare. As the pneumococcal serotype 28F caused a subcutaneous abscess, this serotype possibly has a high virulence. The incidence of IPD caused by non-vaccine serotypes, such as 28F, is expected to increase in the future. The consolidation of international data on pneumococcal serotypes is important for the development of novel PCV.

A Japanese Boy With Spotted Fever and Overlapping Symptoms of Kawasaki Disease: A Case Report.

Japanese spotted fever (JSF) is a tick-transmitted infection caused by Rickettsia japonica (R. japonica), which is indigenous to Japan. Patients with JSF typically present with fever and spotted erythema on the palms and/or soles, and most of them have site(s) of tick bites. The prognosis is good, but some cases have a fatal course. Kawasaki disease (KD) is a systemic vasculitis with an unknown cause that is characterized by symptoms such as fever, conjunctival injection, oral findings, amorphous rash, rigid edema, and nonsuppurative cervical lymphadenopathy. Although the symptoms of JSF are partially similar to those of KD, case reports of JSF overlapping KD have never been internationally published. Herein, we report a boy with JSF and KD symptoms. A five-year-old boy presented with fever and rash after he had been on a mountain inhabited by R. japonica. On the fifth day, erythema was spotted mainly on his bilateral palms, bilateral cervical lymphadenopathy, rigid edema of his lower feet, and mild conjunctival injection appeared. Intravenous immunoglobulin (IVIG) therapy was performed because these symptoms satisfied five out of the six diagnostic criteria for KD. However, on the sixth day, the fever persisted, and then we readministered IVIG in addition to tosufloxacin and azithromycin since we found a tick-bite eschar, which suggested a complication of JSF. His symptoms resolved soon after this treatment. Coronary artery lesions were never observed. This case indicates that the R. japonica infection overlaps clinically with KD. Tosufloxacin and azithromycin should be considered to avoid the use of minocycline in younger patients with JSF.

Congenital Echovirus 11 Infection in a Neonate.

Neonates infected with enterovirus in utero would be fulminant at birth or develop symptoms within a few days. Echovirus 11 causes life-threatening hepatic necrosis with coagulopathy and adrenal hemorrhagic necrosis. The prognosis depends on the enterovirus serotype and the absence of serotype-specific maternal antibodies at the time of delivery. We describe a fatal neonatal case of congenital echovirus 11 infection.

Laryngeal web with 22q11.2 deletion syndrome.

Laryngeal web is a rare congenital or acquired disease that results in airway stenosis. Depending on the severity of atresia, patients with laryngeal web show a wide variety of symptoms ranging from asymptomatic to life-threatening respiratory dysfunction that may require emergency tracheostomy immediately after birth. We report a neonatal case of laryngeal web with 22q11.2 deletion syndrome. Post-delivery, the infant showed dysphonia and had a ventricular septal defect with characteristic craniofacial features. The infant underwent an endoscopic incision of the web and cardiac surgery. Among patients with laryngeal web, 30% have 22q11.2 deletion syndrome. 22q11.2 deletion syndrome is the most common chromosomal microdeletion syndrome and the second most common chromosomal abnormality associated with congenital heart disease. Therefore, if an infant has laryngeal web with comorbidities such as congenital heart disease, 22q11.2 deletion syndrome should be considered in differential diagnosis.

Transient encephalopathy with reversible white matter lesions: a case report.

We report on a boy with bilateral optic nerve hypoplasia and mild psychomotor retardation. At 1 year and 9 months of age, he was admitted to hospital with a cluster of febrile convulsions and unconsciousness. Magnetic resonance imaging (MRI) revealed widespread areas of high signal intensity on diffusion-weighted imaging of the deep cerebral white matter and corpus callosum. This imaging disappeared at five days of illness. No atrophy or abnormalities were noted on the 6-month follow-up MRI. Despite full recovery after the acute episode, the patient showed retarded developmental progress. We discuss the differential diagnosis for this case.

[Cost-effectiveness analysis of routine mumps immunization in Japan].

OBJECTIVE: Mumps immunization is not included in routine immunization in Japan. We measured the cost-effectiveness of routine immunization. METHODS: We surveyed outpatients prospectively from June 15, 2004, for 19 months in an area with a population of 100,000. Almost all of the 11 pediatric clinics and hospitals in this area cooperated. In 2006, we retrospectively surveyed all inpatients hospitalized for more than 24 hours and dying of mumps. RESULTS: We collected data from 189 doctors who rated outpatients and 112 families. The disease burden for outpatients including family nursing was estimated to be 47.1 billion yen nationwide. We estimated the total number of inpatients as 4,596. The disease burden of inpatients including the cost of family nursing was estimated to be 1.35 billion yen. Adding cases of sequelae and death, the total disease burden was estimated to be 52.5 billion yen. The incremental benefit cost ratio for routine immunization is higher than 1 even in the lower bounds of the 95% confidence interval. DISCUSSION AND CONCLUSIONS: The incremental benefit cost ratio shows that the additional benefit due to routine immunization exceeds additional cost, emphasizing the benefits of routine mumps immunization.

Reconsideration of the diagnosis and treatment of childhood migraine: A practical review of clinical experiences.

OBJECTIVE: To provide insight into the wide spectrum of migraine during childhood to establish practical and comprehensive treatment strategies. BACKGROUND: Although recent studies have confirmed the effect of anti-migraine agents in childhood headaches fulfilling the criteria of migraine without aura, there have been no studies regarding the efficacy of these drugs in childhood migraine without aura not filling the diagnostic criteria. METHODS: In total, 154 patients with a clinical diagnosis of migraine, with onset of repetitive headaches at the age of ⩽15years, were retrospectively included from clinics in seven tertiary medical centers. RESULTS: Patients' diagnoses included migraine with aura (n=49), migraine without aura (n=65), clinical migraine without aura not fulfilling International Classification of Headache Disorders-3 beta criteria (suspected migraine without aura; n=38), and hemiplegic migraine (n=2). Abortive medicine was effective in 74 of 97 patients, and preventive medicine was effective in 61 of 84 patients. Drugs with high efficacy were acetaminophen and ibuprofen for abortive therapy and cyproheptadine, amitriptyline, and propranolol for preventive therapy. Psychosocial problems were less common, and abnormalities on electroencephalography were more common in the suspected migraine without aura group. Otherwise, clinical features and drug responsibility were comparable among the migraine with aura, migraine without aura, and suspected migraine without aura groups. Retrospectively, experts clinically diagnosed childhood migraine without aura when the headache met at least one of the three criteria B, C, and D in International Classification of Headache Disorders-3 beta in addition to A and E. Abortive and preventive medication including paroxetine (n=2) benefited 10 and 15 of the 33 patients with daily headache, respectively. Psychotherapy/counseling (n=4), treatment for orthostatic dysregulation (n=4), and elimination of stressors (n=3) markedly alleviated headache in this group. CONCLUSION: Our results indicated that those with suspected migraine without aura not filling International Classification of Headache Disorders diagnostic criteria should be included in the treatment for migraine. Treatment should also be targeted to comorbid developmental disorders, orthostatic dysregulation, and psychosocial problems in patients with refractory daily headaches.

[Cost-effectiveness analysis of routine immunization for varicella in Japan].

OBJECTIVE: Immunization for varicella is not currently included in routine immunizations in Japan. This study was conducted to assess test its cost-effectiveness when it becomes a routine. METHODS: We surveyed and collected information for the year beginning 15th June 2004 in one area. Almost all 11 pediatric clinics or hospitals in the area cooperated in this survey. There was a questionnaire form for families and for doctors. Absent days from routine tasks, i.e., job, housekeeping or study, for family nursing and others were asked on family form. Medical costs and other costs were asked on doctor form. Neither form included the patient's name or name of the medical institution. Doctors explained this survey to patients' family on their first visiting day and asked to cooperate. If they refused the doctor form was also discarded. Since family form was written after recovery and mailed, cooperation in this survey was voluntary. Opportunity cost for family nursing is estimated as opportunity cost based on the 2002 Basic Surveillance of Wage Structure. The burden of sequel cases was estimated assuming six million yen per Quality-adjusted Life Years (QALY). Total number of patients was estimated to be 0.84 million, which includes unvaccinated people in a birth cohort. We adopted incremental benefit cost ratios form societal viewpoint as a measure. RESULTS: We collected 402 data from the doctor form and 265 from the family form. Total disease burden in all of Japan is estimated to be 52.2 billion yen, but opportunity cost accounted for 80%. The incremental benefit cost rations averaged more than 4 when vaccination cost is assumed to be five to twelve thousand yen. The lower limit of the confidence intervals is about 1.5. DISCUSSION AND CONCLUSION: The disease burden of varicella was greater than measles in 2000, when there were measles 0.2 million patients. The incremental benefit cost ratio showed that there will almost surely be an additional benefit due to routine immunization is greater than the additional cost. Therefore, we found strong evidence for routine immunization for varicella.

Rhabdomyolysis and acute renal failure in a child with Salmonella enteritidis gastroenteritis.

We report on an 11-year-old boy who developed rhabdomyolysis and acute renal failure following Salmonella enteritidis gastroenteritis. Rhabdomyolysis should be considered as a potentially fatal complication in patients with Salmonella gastroenteritis.

Procedures for prevention of perinatal group B streptococcal diseases: a multicenter questionnaire survey of hospitals in the Kyoto Neonatal Disease Study Group, Japan.

To explore clinical protocols for the prevention of early-onset group B Streptococcus (EOGBS) disease of the newborn in Japan, we conducted a multicenter questionnaire survey. Of 32 regional centers participating in the Kyoto Neonatal Study Group, 28 provided usable data concerning prevention practices undertaken between 2000 and 2004. Twenty-three (82%) of the 28 hospitals implemented bacteriological screening to identify maternal GBS carriage, and all 23 hospitals administered intrapartum antibiotics to all screening-positive pregnant women. There were no institutes that used risk-based strategies. In the 23 hospitals, bacteriological screening was conducted mostly by lower vaginal swab alone (n = 18). Eighteen hospitals performed screening once during pregnancy, either before 34 weeks' gestation (n = 6) or between 35 and 37 weeks' gestation (n = 12). Oral antepartum antibiotics, when carriage was identified, were administered at 12 (52%) hospitals. Twenty institutes used penicillins for intrapartum prophylaxis. However, the loading dose for chemoprophylaxis ranged from 0.5 to 2 g, and the interval between repeat administrations ranged from 4 to 12 h. Although the results indicated that more than 80% of the hospitals surveyed had introduced some screening-based prevention practices, the timing of the bacteriological screening during the pregnancy, the number of screenings, and the screening sites, as well as the antibiotics used, and their dosage, varied widely. Because of these highly variable methods, the efficacy of the implementation of preventive practices could not be determined. This study is the first to have described preventive practices for EOGBS disease in Japan in the era of Centers for Disease Control and Prevention guidelines. In light of the above results, a larger study under a unifying protocol would be warranted.

Intussusception of the small bowel associated with nephrotic syndrome.

We report the case of a 2-year-old boy who developed a small bowel intussusception during treatment failure of his first episode of nephrotic syndrome. Despite the absence of typical symptoms other than abdominal pain, the intussusception was diagnosed by ultrasonography and computed tomography and successfully reduced by air enema. No pathological lead point was discovered, and no symptoms of Henoch-Schönlein purpura developed later. Intussusception should be considered in the differential diagnosis of abdominal pain in patients with nephrotic syndrome, especially in patients exhibiting prolonged edema. Ultrasonography or computed tomography should be performed, even in the absence of other typical symptoms suggestive of intussusception. We should also bear in mind that the intussusception associated with nephrotic syndrome might occur at regions other than the typical ileocolic region, such as within the small intestine.