Complete heart block in a patient with acute lymphoblastic leukaemia: teicoplanin as a possible cause and review of literature.

WHAT IS KNOWN AND OBJECTIVE: Teicoplanin is a glycopeptide antibiotic used against documented or presumed methicillin-resistant infections. We report a 31-month-old boy with acute lymphocytic leukaemia who developed permanent complete atrioventricular block (CAVB) necessitating pacemaker insertion after receiving teicoplanin for Staphylococcus epidermidis bacteremia. CASE SUMMARY: Clinical assessment of the child revealed febrile neutropenia. After thorough assessment and work-up, the patient was started on teicoplanin intravenously after which he had sudden onset of bradycardia. Electrocardiography showed CAVB that eventually required permanent pacemaker insertion. Twenty-nine months from the incident, the patient is doing well. WHAT IS NEW AND CONCLUSION: We report on a case of teicoplanin-associated CAVB in a child with acute lymphoblastic leukaemia (ALL). This is one of only two similar cases reported in the literature. Teicoplanin remains the most probable cause. The use of teicoplanin should be approached cautiously in the setting of immunosuppression. Whether VZV contributed and teicoplanin triggered remains speculative. Physicians should be aware of this possible complication.

Paediatric infective endocarditis: 19-year experience at a tertiary care hospital in a developing country.

A retrospective study was undertaken to study children who presented with infective endocarditis (IE) to a university teaching hospital in Beirut, Lebanon, between January 1977 and May 1995. Of 41 patients with IE (24F, 17M), 28 (68%) were diagnosed between 1977 and 1985. Patients' ages ranged from 3 to 18 y (mean age 11.3+/-2.8 y), and 13 patients were <10 y of age. Clinical presentations included: fever (in 88%), heart failure (in 39%), neurologic findings (in 20%) and embolic phenomena (in 22%). Nineteen patients (46%) had underlying congenital heart disease (CHD) with tetralogy of Fallot and pulmonary stenosis being the most common. Sixteen patients (39%) had underlying rheumatic heart disease (RHD). A total of 5 children (12%) with normal cardiac anatomy had IE. One had underlying acquired viral myocarditis with mitral insufficiency. Echocardiography showed vegetations in 60%. Blood cultures were positive in 31 patients (76%). IE occurred in three patients following cardiac surgery. In one patient it occurred within 2 mo of surgery and in the other two it occurred within 6 mo. Streptococcus viridans and Staphylococcus aureus were the two most commonly isolated bacteria. Overall mortality rate was 29% (not statistically significant between patients presenting between 1977-1985 and 1986-1995; p = 0.17). There was no statistically significant difference in mortality among the groups (five in the group with CHD, six with RHD and one with structurally normal heart). This study demonstrates that RHD is an important underlying cause of IE in children in our community. This finding is similar to those in other developing countries and different from those in developed countries. Distribution of pathogens and CHD in our study is comparable to some reports in the literature, except for the higher proportion of patients with underlying pulmonary stenosis. Bacterial endocarditis prophylaxis should be emphasized in patients with RHD or pulmonary stenosis.

Rheumatic fever in children: a 15-year experience in a developing country.

Clinical data from 91 patients with rheumatic fever (RF), who were hospitalized at a tertiary hospital in Lebanon between 1980 and 1995, were reviewed retrospectively. Age on hospitalization was 11.1+/-2.9 years (mean +/- SD, range 3-17 years). Nineteen patients were <6 years of age. Manifestations included carditis (93%), arthritis (39%), Sydenham's chorea (2%), erythema marginatum (4%), subcutaneous nodules (1%), fever (62%), arthralgia (55%), and acute congestive heart failure (CHF) on initial presentation (44%). Pericardial effusion occurred in 11%. There was positive family history of RF in 14%. Mitral insufficiency and aortic insufficiency occurred in 67 and 35%, respectively. Both mitral and aortic valves were involved in 30% of cases. Tricuspid insufficiency developed in 3% and pulmonary insufficiency in 1%. Mitral stenosis developed in 19%. Twenty-eight patients underwent surgical intervention: mitral valve repair and commissurotomy in 9/91 (10%), mitral valve replacement in 18/91 (20%), and aortic valve replacement in 9/91 (10%). Overall mortality was 12%: 5 following surgical intervention (3 after mitral valve surgery and 2 after mitral and aortic valve surgery). All patients that died had CHF on initial presentation (p = 0.006). This study includes hospitalized patients with predominant rheumatic heart disease. Initial presentation with CHF is a risk factor for surgical intervention and mortality. A significant high surgical intervention rate is noted that is probably related to the nature of the selected group studied. This study emphasizes the significant morbidity and death in patients with RF and carditis.

Foreign body retrieval in children with respiratory symptoms and no history of aspiration.

To asses the role of bronchoscopy and its yield in children with respiratory symptoms and no typical history of radiological evidence of foreign body aspiration (FBA), we reviewed the records of all patients who underwent bronchoscopy at our institution between 1985 and 1995 and had no history of choking, witnessed FBA or clear radiological evidence of FBA (N = 54, age range 4 months to 16 years). These were subdivided into two subgroups, those with positive bronchoscopy, and those with negative bronchoscopy. Respiratory symptoms and their duration, signs and radiological findings did not differ in both subgroups.

Necrotising infection of the orofacial tissues in neonates (noma neonatorum). Case report.

Noma neonatorum should be differentiated from noma, in that it is typically a disease of seriously ill premature infants whose birth weight was low, and is caused by Pseudomonas aerugenosa septicaemia. We know of only two case reports of noma neonatorum involving newborn infants born at full term, so we report here another case of noma neonatorum in a neonate born at full term. In addition we describe the differences between noma neonatorum and noma (cancrum oris), a clinically related entity.

Intrapericardial teratoma in an adult: a rare presentation.

BACKGROUND: Intrapericardial teratomas are rare and usually present early in infancy or childhood. PROCEDURE: We describe herein a rare case of an adult patient with an intrapericardial teratoma who presented with fever, cardiac arrhythmias, and oppressive substernal chest pain. Preoperative diagnosis was suggested by echocardiography and computerized tomography of the chest. The tumor weighed 530 g and its histologic features were those of a mature cystic teratoma. It was excised totally and 10 years' follow-up revealed no evidence of residual disease. DISCUSSION: Our patient is one of the very few adult patients with intrapericardial teratomas who was treated successfully with surgery. Both echocardiography and tomography of the chest suggested the diagnosis and delineated the relationship of the tumor to the great vessels. CONCLUSION: The diagnosis of Intrapericardial teratomas is suspected by echocardiography and/or tomography of the chest and confirmed by specific histologic features. These tumors should be excised whenever detected.