Amebic liver abscess: spare the knife but save the child.

BACKGROUND/PURPOSE: Amebic liver abscess (ALA), the most common extraintestinal manifestation of infection with Entameba histolytica, carries significant morbidity and mortality in the pediatric age group. The efficacy of metronidazole in the treatment of ALA is well established, but the role of surgical intervention remains controversial. Many investigators still advocate aggressive surgical therapy for complicated and ruptured ALA. Reports regarding management of ALA in children are sparse and deal with small numbers of patients. The objective of this study was to assess the effectiveness of parenteral metronidazole combined with judicious aspiration of ALA in obviating the need for surgical intervention. METHODS: The medical records of all children admitted with the diagnosis of ALA between 1986 and 1997 to the Aga Khan University Hospital were reviewed retrospectively. The diagnosis of ALA was confirmed in 48 patients by an ultrasound scan together with elevated indirect hemagglutination (IHA) titres (>250). Ages ranged from 3 weeks to 14.5 years. RESULTS: Thirty-seven (75%) children were below the fifth percentile for height and weight, and 45 (93.7%) presented with a hemoglobin level of less than 10.0 g/dL. Comorbid factors included pulmonary tuberculosis (n = 2, chicken pox (n = 1), tetralogy of Fallot (n = 1), and thalassemia major (n = 2). There was a mean delay of 13 days before presentation to the hospital. All patients were treated with parenteral metronidazole and broad-spectrum antibiotics. The latter were discontinued on confirmation of the diagnosis. The duration of treatment with metronidazole ranged from 2 to 5 weeks. Percutaneous aspiration of the ALA was performed under ultrasound guidance using sedation in 28 patients for one or more of the following indications; ALA greater than 7.0 cms (n = 20), left lobe involvement (n = 8), and no response after 48 hours of medical therapy (n = 6). Nine patients required more than one aspiration. One patient with peritoneal rupture of the ALA additionally underwent percutaneous aspiration of the peritoneal cavity under ultrasound guidance. One patient required insertion of a chest tube after rupture of the ALA into the right pleural cavity, and another underwent urgent bronchoscopy after rupture of the abscess into the tracheobronchial tree. The hepatobronchial fistula closed spontaneously with medical therapy. No patient required open surgical drainage, and all recovered without relapse. The mean duration of hospitalization was 12 days. CONCLUSION: Our experience suggests that parenteral metronidazole combined with timely aspiration of the abscess can obviate the need for surgical intervention in large and complicated ALA even in malnourished children who present late for treatment.

Malignant abdominal tumors in children.

The medical records of 53 patients between the ages of 1 and 18 years, with malignant abdominal tumors seen between 1987 and 1993 were reviewed. Wilms' tumor was the most common tumor constituting 28.3% of all cases. The others included Non- Hodgkin's lymphomas (20.8%), neuroblastomas (11.3%), rhabdomyosarcomas, germ cell tumors 9.4% each and a miscellaneous group. Majority of patients (60.3%) were under 5 years of age. The male to female ratio was 1:1. Among 15 patients with Wilms' tumor, majority (46.7%) had stage III tumors at presentation and all but one patient, were referred to our Hospital more than a month following initiation of their symptoms. In contrast, 5 out of 7 patients with Stage I and II tumors were seen within the first month of their symptoms. The commonly utilized techniques to aid diagnosis were ultrasonography and computerized tomography scan and the common treatment modality was a combination of surgery and chemotherapy. For Wilms' tumor, the mean follow-up was 1 year and nine months, the survival rate was 93.3% and there were no recurrences. With early diagnosis and multimodality treatment, the survival rates for childhood malignancies can be greatly improved.

Pediatric urolithiasis: to cut or not to cut.

Urolithiasis is a major source of morbidity in children of the third world. Since its advent in 1982 and despite uncertainties about the long-term effects on the kidney, extracorporeal shock wave lithotripsy (ESWL) has rapidly replaced traditional surgery in the management of this condition. A retrospective study was conducted to compare the outcome of ESWL with that of open surgery in the management of paediatric urolithiasis in a single institution between November 1988 and December 1991. Emphasis was placed on the rate of stone clearance, complications, duration of follow-up, and cost of treatment of each modality. A total of 83 patients under 14 years of age underwent management of 101 stones; the stones were located in the kidneys (63), ureters (13), or bladder (25). Thirty-one patients who enrolled directly through the Lithotripsy Clinic underwent a total of 65 ESWL sessions for 44 calculi (mean, 2.1 sessions per patient). The overall stone clearance rate was 82%, with an 83% clearance rate for renal stones. There were three failures. Nine patients did not return after the first ESWL session, and by the end of 6 months, 93.5% were lost to follow-up. The cost of ESWL ranged from $600 to $1,000 (mean, $780). Fifty-two children were managed through the Pediatric Surgery Clinic and underwent open surgery (57 stones). The overall stone clearance rate was 96%, with a clearance of 88% for renal calculi. There were two wound infections and no deaths. All patients returned for the first follow-up visit, but by the end of 6 months, only 34.5% were available for follow-up. The total cost of treatment ranged from $520 to $900 (mean, $580). The authors believe that with the present level of knowledge, use of the lithotriptor should be restricted to children with small stones and/or those for whom long-term follow-up is possible.

Ethical dilemmas of health care in the developing nations.

Limited resources, widespread poverty, and the absence of health insurance pose daily ethical problems for Third World physicians, who must balance their roles as individual patient advocates against a desire to provide health care to the greatest number of children. Pakistan has a per capita income of Rs. 7,220 (US$ 380) per year, or Rs. 800 (US$ 32) per month. The annual population growth of the country is 3.1%, and approximately 360,000 infants are born each year in Karachi, the largest city in the country. The Aga Khan University Hospital, a private teaching institution, is the only hospital in Karachi with a Level III Neonatal Intensive Care Unit (NICU). The financial and medical data of 200 infants admitted to the NICU in 1988 were reviewed retrospectively, and compared with those of two specific subgroups. (1) Among 15 infants who underwent surgical intervention, the average total cost of hospitalization was Rs. 36,040 (US$ 1,900) per patient, with an average daily cost of Rs. 923 (US$ 49). The longest hospital stay was 6 months, for a child who had total colonic aganglionosis associated with a short gut syndrome. There were two deaths in this group. (2) Of the 21 premature neonates admitted having Idiopathic Respiratory Distress Syndrome (IRDS) during this period, the total hospitalization cost per patient was Rs. 23,260 (US$ 788), with a daily cost of Rs. 1,050 (US$ 55). Eleven patients required ventilatory support. There were 16 survivors. Among both groups, 6% of all revenues generated in the NICU were used to help families pay for the bills under a welfare scheme.

Successful cryotherapy of a benign tracheal neoplasm.

A 10-year-old black male with a 6-month history of progressive dyspnea and stridor was found to have a submucosal mass occupying 75% of the subglottic airway. Biopsy specimens showed a pleomorphic adenoma of minor salivary gland origin--a tumor with a predilection for local recurrence after resection. A tracheostomy was performed for airway control and the lesion was treated with endotracheal cryotherapy. Two months later, the tracheostomy was removed and the patient has remained asymptomatic for 9 years. Pulmonary function studies 2 years following cryotherapy demonstrated a forced vital capacity (FVC) of 81% predicted, and a forced expiratory volume-one second (FEV-1) of 73% predicted. Bronchoscopy with biopsy at 5 years showed no evidence of recurrent airway obstruction or persistent tumor. This represents the first reported case of successful treatment of an airway tumor in a child utilizing profound cryotherapy. The case illustrates the utility of endotracheal cryotherapy in the treatment of certain benign and malignant obstructing lesions of the airway in children.

Caustic ingestion and its sequelae in children.

Management of caustic ingestion in children remains a difficult challenge, with the outcome ranging from an asymptomatic state to intractable esophageal strictures. We reviewed the cases of 56 children ranging in age from 10 months to 5 years treated from 1973 to 1984 at the University of Florida. For children seen primarily at our institution, initial management consisted of prompt endoscopy and early institution of steroids and antibiotics. Esophageal burns were confirmed in 37 patients, 21 (56.75%) of whom subsequently had esophageal strictures of varying severity. In seven patients, limited esophageal strictures were managed successfully by dilation, but 14 children with multiple strictures required eventual esophageal replacement. Substernal right colonic interposition was tolerated well by these patients, with few complications, and their growth and development have been satisfactory over follow-up periods ranging from nine months to 13 years. A review of these cases suggests that the character of the ingested caustic material is the most important determinant of the severity of esophageal injury, with preparations containing lye being the most injurious; that in the presence of full-thickness esophageal injury, there is a high potential for stricture formation, regardless of the type of initial management, including early use of steroids; and that multiple esophageal strictures are refractory to dilation, and esophageal replacement should be an early consideration.

Magnetic resonance imaging of bicornuate uterus with unilateral hematometrosalpinx and ipsilateral renal agenesis.

A complex solid and cystic pelvic mass in a young patient was demonstrated by computed tomography (CT) and ultrasound (US). These modalities failed to accurately characterize the solid components as bicornuate uterus and the cystic areas as hemorrhage. Magnetic resonance imaging (MRI) using multislice multiecho spin echo (SE) sequences made it easier to characterize the mass, clearly depicting the abnormality in transaxial and coronal planes and at the same time demonstrating ipsilateral renal agenesis.

Total lung lavage for pulmonary alveolar proteinosis in an infant without the use of cardiopulmonary bypass.

Pulmonary alveolar proteinosis is a rare disease that usually affects the adult patient, but is now being recognized as a possible cause of neonatal respiratory distress. In the adult patient, whole lung lavage, as described by Ramirez-R in 1965, is considered the most effective therapy for management of this condition. The lavage can be accomplished safely and with relative ease by using a Carlens or Robertshaw tube to isolate and lavage one lung while ventilating the other. The unavailability of a small double-lumen tube makes this procedure impossible in the pediatric age group. Therefore, whole lung lavage has been possible in only a few children in the past with the help of cardiopulmonary bypass to allow simultaneous oxygenation during the pulmonary lavage. Due to the hazards and technical difficulties of cardiopulmonary bypass, total pulmonary lavage can not be considered a practical option in the very small infant. A 15-week-old infant is reported, weighing 2 kg with a diagnosis of pulmonary alveolar proteinosis, who underwent total pulmonary lavage safely on three different occasions without employing cardiopulmonary bypass. A double-lumen Swan-Ganz catheter, introduced transbronchoscopically through the side-arm of a rigid, 3.5-mm Storz bronchoscope was used to isolate and lavage one lung while ventilation to the other lung was maintained through the bronchoscope. A Nellcor oximeter, utilized for transcutaneous monitoring, revealed satisfactory oxygen saturation during the entire pulmonary lavage. The transbronchoscopic lavage was monitored under direct vision with a video monitor, ensuring correct position of the bronchoscope and the catheter at all times.(ABSTRACT TRUNCATED AT 250 WORDS)

Congenital anorectal malformations. Harbingers of sacrococcygeal teratomas.

Since 1973, seven infants treated at the University of Florida, Gainesville, for congenital anorectal anomalies have been found to have concomitant sacrococcygeal teratomas. As anorectal anomalies occur in approximately one in every 5,000 live births and sacrococcygeal teratomas are noted in one in every 40,000 live births, this presentation would suggest a prevalence that precludes a random association. The presence of significant anorectal strictures in these patients resulted in a delay in the diagnosis of the presacral teratomas. As the frequency of malignant change in sacrococcygeal teratomas has been documented to increase proportionately with age, early diagnosis and excision of these lesions is essential. Our experience with these children suggests that the presence of congenital anorectal malformations in infancy should raise the physician's index of suspicion for associated sacrococcygeal teratomas.

Inguinal hernias after ventriculoperitoneal shunt procedures in pediatric patients.

The results of this study of 134 patients confirm the increased incidence of previously unrecognized inguinal hernias after ventriculoperitoneal shunting procedures. Infants with intraventricular hemorrhage appeared to be the most susceptible, although associated prematurity may play an additional role. Close observation of infants and children who undergo ventriculoperitoneal shunting is required, to allow early detection and repair of inguinal hernias. Inguinal herniorrhaphy can be performed safely with few or no postoperative complications and no deleterious effects to the VP shunt.

Transcervical myotomy for wide-gap esophageal atresia.

A primary end-to-end anastomosis of the esophagus can be accomplished in the wide-gap esophageal atresia by obtaining extra esophageal length through circular myotomy of the proximal esophageal pouch. However, a very short proximal esophageal pouch may not be accessible through the standard thoracic incision, precluding this procedure. An infant is reported in whom the inaccessible proximal pouch was exteriorized into the neck through a concomitant cervical incision, allowing three circular myotomies to be performed with ease. The proximal esophagus was then reintroduced into the chest cavity and a primary esophagoesophagostomy performed without difficulty.

Total parathyroidectomy and autotransplantation for tertiary hyperparathyroidism in children with chronic renal failure.

An association between chronic renal failure and skeletal deformities in the adolescent patient was first documented by Lucas in 1883. Since then it has been established that the kidneys play a major role in the regulation of calcium, phosphate, and parathyroid hormone, and that chronic renal failure is characterized by profound alterations in the normal metabolic homeostasis of the human body. With the hyperphosphatemia of uremia, compensatory hyperparathyroidism is also a well known complication. Due to these factors, loss of normal renal function ultimately leads to derangement in mineral and bone metabolism resulting in severe skeletal deformities. Reports in the English literature suggest that the changes of renal osteodystrophy are much more pronounced in the pediatric patient, as compared to those in the adult. In the last two decades, renal transplantation has come to be recognized as a satisfactory modality for controlling renal failure and its complications. This procedure is often not available as an option, however, in small patients, especially those under three years of age. The pediatric nephrologist is often forced to manage these patients for long periods with conservative therapy, in an attempt to control the ravages of renal osteodystrophy. The problem becomes unmanageable when the compensatory hyperparathyroidism proceeds to autonomy. When this occurs, despite maintenance of normal serum calcium levels, the renal osteodystrophy progresses rapidly, producing pain, deformities and growth retardation. At this point, the condition is often refractory to medical management and resection of parathyroid tissue remains the only satisfactory modality for control.(ABSTRACT TRUNCATED AT 250 WORDS)

Physiology of serum gastrin production in neonates and infants.

Conflicting data exist regarding the physiology of serum gastrin production in neonates and infants, and the response of the neonatal gastric antrum to feeding. Normal neonates and infants underwent serial determination of fasting and postprandial serum gastrin levels from birth to 4 months of age. The mean fasting serum gastrin levels in newborns and infants up to 4 months remained considerably higher than the mean maternal levels, the elevations being statistically significant until 2 months of age. In addition, in the first 2 months of life, there was no evidence of postprandial stimulation of serum gastrin levels 30 minutes following normal feeds consisting of breast milk or commercial formula. At 3 and 4 months of age, the response appears to revert to an adult pattern with statistically significant postprandial elevations following normal feeds (p = 0.003 and p = 0.02, respectively). This study confirms the presence of neonatal hypergastrinemia and reveals a persistence of elevated serum gastrin levels through early infancy. A maturation of the antral gastrin release response with postprandial elevations of serum gastrin levels occurs at approximately 3 months of age.

Hepatic artery ligation for hepatic hemangiomatosis of infancy.

Capillary and cavernous hemangiomas of the skin and subcutaneous tissue, usually follow a benign course with enlargement in the first year of life followed by gradual involution. Hemangiomas of the liver, on the other hand, can be responsible for life threatening complications in infancy. The presence of major intrahepatic arteriovenous communications may produce a high output cardiac failure, refractory to intensive medical therapy. Use of radiation therapy and high doses of steroids have proven to be of limited success with a 90% mortality in infants managed with nonoperative therapy. Hepatic artery ligation in such patients may provide dramatic control of the high output failure, with negligible side effects. Two infants are reported in whom bilateral hepatic artery ligation provided prompt control of fulminant congestive failure secondary to hepatic hemangiomatosis, after failure of medical therapy.

Retroperitoneal malignant schwannoma: a case report.

Malignant schwannomas are primary nerve sheath tumors that usually arise from peripheral nerves and only rarely occur within the retroperitoneum. Only 13 instances of this neoplasm occurring in such an anatomic location have been reported in the English literature, and none have been described previously in children. The present report details a case of a retroperitoneal malignant schwannoma in a 14-yr-old child.

Endotracheal cryotherapy in the treatment of refractory airway strictures.

In 1977 we reported the successful use of endotracheal cryotherapy in the treatment of experimental tracheal strictures. This technique has now been employed in the treatment of 29 refractory airway lesions in 27 patients ranging in age from 3 months to 42 years. The technique utilizes a nitrous oxide cryoprobe measuring 3 mm in diameter and 43 cm in length. The tip of the probe is applied directly to the stricture through the endoscope and cooled to -80 degrees C for 45 seconds. On removal of the probe, the frozen tissue is resected with biopsy forceps. Cryotherapy has successfully relieved the airway strictures in 20 of the 24 lesions in which treatment was completed. The technique of endotracheal cryotherapy has proved helpful in the management of selected patients with refractory airway strictures.

Near-total pancreatectomy in persistent infantile hypoglycemia.

To prevent the devastating effects of hypoglycemia on the CNS of the infant, persistent infantile hypoglycemia should be recognized early and treated promptly. To avoid mental retardation, surgical intervention should not be considered as a last resort. When an insulinoma is identified at surgery, subtotal pancreatectomy is adequate in achieving normoglycemia. However, the most common cause of insulin excess in infancy appears to be islet cell hyperplasia or nesidioblastosis, both diffuse processes. In these patients, subtotal pancreatectomy is often ineffective in achieving normoglycemia. Near-total pancreatectomy, retaining the spleen and duodenum, is a safe procedure, well tolerated by infants and children, and should be considered early for the correction of hypoglycemia of infancy that is not readily controlled by medical intervention.

Thoracoscopy for intrathoracic tumors.

The technique of thoracoscopy has been performed on 49 occasions in 45 patients for the diagnosis or staging of intrathoracic tumors. The patients ranged from 8 months to 68 years old. Eight procedures were performed for pleural disease, 16 for mediastinal masses, 22 for parenchymal lesions, and 3 for intrathoracic staging. Seventeen patients had had previous invasive procedures performed without a pathological diagnosis being established. In 28 thoracoscopy procedures, a positive diagnosis for malignancy was obtained; in 6 instances, areas of unsuspected tumor involvement were identified. A correct diagnosis was obtained by thoracoscopy in 45 procedures for a 92% overall accuracy rate. There was no clinically significant morbidity in this series and no procedure-related mortality. Thoracoscopy, performed under stellate ganglion block and regional anesthesia, has proved to be a very attractive method of diagnosing intrathoracic neoplasia with very low morbidity.