Prognostic factors of severe infectious purpura in children.

The French Club of Pediatric Intensive Care has prospectively studied 90 cases of infectious purpura which were hospitalized in 1981; the purpose of this study was to determine prognostic factors. The statistical study (X2 test) of all these cases is in agreement with data in the literature and shows that the mortality is significantly higher when there is: shock (p less than 0.001), coma (p less than 0.05), ecchymotic or necrotic purpura (p less than 0.01), temperature less than 36 degrees C (p less than 0.05), no clinical meningism (p less than 0.001), white cell count less than 10,000/mm3 (p less than 0.05), thrombocytopenia less than 100,000 (p less than 0.01), fibrinogen less than 1.5 g/l (p less than 0.001), kalemia greater than 5 mEq/l (p less than 0.01), spinal fluid cell count less than 20/mm3 (p less than 0.01). Because shock is one of the main prognostic factors (23 deaths in 55 shocked patients, versus 2 in 35 non-shocked) we have performed another statistical study (with the Benzecri method) to determine a prognostic index for patients in shock. For its determination, five initial parameters are used: age, kalemia, white cell count, clinical meningism, platelet count. The predictive value for survival is 91%. The predictive value for death is 87%. The score was applied on the patients hospitalized in shock in 1982: the predictive value for survival is 75%, the predictive value for death is 61%.

[Linear hyperpigmentation in the newborn]. / Pigmentation linéaire du nouveau-né.

UNLABELLED: Linear hyperpigmentation following the cutaneous bending lines of the fetal position is rarely reported. CASE REPORT: A Senegalese, black, male newborn had presented a pigmentary abnormality since birth. He was born at term and examination revealed extensive linear and retiform pigmentation of the extremities. The hyperpigmentation disappeared completely by two to three months of age. There was a family history in Senegal. COMMENTS: Our case resembles others found in the literature. A defect of migration of the melanocytes and an ethnic factor may be hypothesized.

[Brief antiseptic application of iodine in neonatal intensive care units: effects on thyroid function]. / Application brève d'antiseptique iodé en soins intensifs néonatals: conséquences sur la fonction thyroïdienne.

BACKGROUND: Transient thyroid dysfunction with its adverse effects of diminished levels of thyroid hormone on mental development has been reported in neonates whose skin has been cleaned with iodine-containing substances. We report the results of thyroid screening in iodine-exposed neonates and controls. POPULATION AND METHODS: Thirty seven neonates admitted to an intensive care unit from 1990 to 1992 and whose medical condition required umbilical catheterization were included in the study. There were 21 neonates (six term and 15 preterm) for whom the area around the umbilicus was cleansed with iodine antiseptic and 16 controls (four term and 12 preterm) for whom the antiseptic used did not contain iodine. Levels of serum free T3 and T4, and TSH were determined by 7 days after catheterization as did urinary iodine and creatinine concentrations. RESULTS: Iodine-exposed neonates had significant high levels of TSH (P < 0.01) and low free T3 (P < 0.05); levels of free T4 were lower than in controls but not significantly. Urinary iodine excretion was significantly increased. The increase in TSH disappeared between 15 and 30 days after iodine application. CONCLUSION: Application of iodine antiseptics may cause transient thyroid dysfunction in neonates leading to propose the use of non iodinated substances with similar antibacterial efficacy.

[Neonatal syphilis despite erythromycin treatment of the mother]. / Syphilis néo-natale malgré le traitement de la mére par l'érythromycine.

A one-month old infant whose mother had been treated with erythromycin during pregnancy exhibited signs of severe congenital syphilis with collapse requiring admission to an intensive care unit. Erythromycin has low placental transfer and other treatments would have probably been more adequate. Some authors advocate the use of the latest tetracyclines and doxycycline could also be administered. The WHO's recommendations that all children born of mothers who were not treated with penicillin should receive this antibiotic after birth is still valid.

[Pneumococcal infections and pediatric intensive care (author's transl)]. / Aspects de la pathologie pneumococcique en réanimation pédiatrique.

During the period 1965 to 1978, 62 cases of severe pneumococcal infection were admitted in Saint-Vincent de Paul pediatric intensive care unit. Recovery without sequelae was observed in only 17 of 49 meningitis. 5 fulminant pneumococcal infections after splenectomy or other disorders were observed. This late condition may be preventable by vaccination.

[Use of imipenem-cilastatin in neonatal septicemias caused by gram-negative bacilli multiresistant to beta-lactam antibiotics]. / Utilisation de l'imipénème-cilastatine dans les septicémies du nouveau-né à bacilles Gram négatif multirésistants aux bêtalactamines.

Seven neonates with septicemia due to Gram negative bacteria resistant to beta-lactam received imipenem-cilastatin therapy. Bacteria isolated were Enterobacter cloacae [3], Enterobacter aerogenes [1], Klebsiella pneumoniae [1], Serratia marcescens [1], Pseudomonas fluorescens [1]. The MICs of imipenem were lower 1 microgram/ml. In 3 children septicemia occurred during previous antimicrobial chemotherapy. 3 IV 60 mg/kg doses of imipenem with amikacin (15 mg kg/d) were administered every day. For five children blood cultures were negative after 48 hours of treatment. E. aerogenes septicemia required pefloxacin because blood cultures remained positive (d5) despite an increased dosage (90 mg/kg/d). All children were cured and imipenem-cilastatin was not responsible for any complication. Those results demonstrate the efficacy of imipenem in the treatment of septicemia in newborns due to multiresistant Gram negative bacteria.

Lung functional follow-up in children after severe viral infection.

Pulmonary function tests (PFT) were performed in 12 children after viral infection (VI) due to an adenovirus in 9 cases and occurring before the age of 4 in 10. Functional residual capacity (FRC), thoracic gas volume (TGV), total lung resistance (R1), dynamic lung compliance (C1dyn), expiratory flows and blood gases were measured during three periods after VI: from 3 to 12 months (n = 10), from 1 yr 6 months to 3 yr 8 months (n = 8), and from 4 yr 7 months to 8 yr (n = 6). In the short term period one child had normal PFT, while in the remaining cases there was increased R1, decreased C1dyn and hypoxemia. R1, C1dyn and blood gases did not significantly change between short and mid term periods. In the long term period the children had overinflation with trapped gases, airways obstruction and hypoxemia. These functional sequelae may be related to structural lesions due to VI and abnormal postnatal lung growth.

[Atrioventricular block complicating the use of diphemanil (Prantal) in 2 premature newborn infants]. / Bloc auriculo-ventriculaire compliquant l'utilisation du diphémanil (Prantal) chez deux nouveau-nés prématurés.

BACKGROUND: Diphemanil can be useful in some neonates presenting with bradycardia due to vagal hyperreflectivity. Paradoxically, this drug may induce atrio-ventricular (AV) block in premature babies. CASE REPORTS: Case no 1. A premature neonate suffering from acute respiratory distress from birth required respiratory support, antibiotics and caffeine. Despite this treatment, he underwent many episodes of apnea, and bradycardia that appeared on day 4 and did not respond to IV doxapram (1 mg/kg/h). He was given diphemanil on day 9 (10 mg/kg/d) and permanent bradycardia with complete AV block and a normal QT interval appeared 2 days later. Cessation of diphemanil and administration of IV isoprenaline led to a normal sinusal rhythm, but there were bladder, intestinal and ocular signs of atropinic intoxication. A complete definitive recovery occurred 5 days after cessation of diphemanil. Case no 2. A premature neonate developed episodes of apnea 2 days after birth. These episodes persisted and were complicated by bradycardia on day 4 despite administration of caffeine. Vagal stimulation on day 7 was positive and the infant was then given diphemanil (10 mg/kg/d). Permanent bradycardia occurred 2 days later, with partial AV block and a normal QT interval. The child recovered a normal sinusal rhythm 2 days after cessation of diphemanil. CONCLUSIONS: Anticholinergic therapy may cause permanent bradycardia due to AV block in premature infants. This therapy should not be given to premature infants without a prior ECG. Doses lower than those used in infants are recommended.

[Ischaemic stenosis of the ureter during Henoch-Shoenlein purpura (author's transl)]. / Sténose ischémique de l'uretère au cours d'un purpura rhumatoïde.

Involvement of the ureters (rigid and segmented) and bladder was seen in a 6-year-old child whose clinical lesions were typical of Henoch-Schoenlein purpura. Infrapelvic left uretic stenosis developed secondarily whilst the other lesions disappeared. Histological study and in particular cutaneous and renal immunofluorescence made it possible to eliminate the possible diagnosis of polyarteritis nodosa, and to confirm that of Henoch-Schoenlein purpura. An ischaemic vasculitis was the cause of the ureteric and bladder lesions, and of the progression to stenosis. The existence of this possibility should lead to routine examination to detect such lesions. Sequential radiological studies are necessary whenever such lesions are recognised.

[Neonatal septicemias: biological diagnosis and antibiotherapy. Apropos of a series of 46 cases]. / Septicémies néonatales: diagnostic biologique et antibiothérapie. A propos d'une série de 46 cas.

The records of 46 neonates with proven septicaemia were retrospectively studied. Patients could be divided in 2 groups: in group 1 (21 infants) a positive blood culture was obtained before one day of life; in group 2 (25 infants) a positive blood culture was obtained between days 1 and 28. The sensitivity of 9 chemical and bacteriological tests and the efficacy of the initial antibiotic treatment were examined in both groups. Of the 21 germs isolated in patients from group 1, 86% were Gram positive bacteria and 95% were susceptible to ampicillin. Of the 26 germs isolated in patients from group 2, 80% were Gram negative enteric bacteria and 86% were susceptible to cefotaxime. Bacterial tests (gastric aspiration, antigen detection, feces culture) had a better sensibility than biochemical tests (C reactive protein, orosomucoid, fibrinogen).

[Fetal toxoplasmosis. In utero treatment with pyrimethamine sulfamides]. / Foetopathie toxoplasmique. Traitement in utero par l'association pyriméthamine-sulfamides.

The mothers of 52 cases of toxoplasmic fetopathy diagnosed in utero by fetal blood and/or amniotic fluid sampling were treated with the combination pyrimethamine-sulfadiazine (or sulfisoxazole) and by spiramycine. The infants were compared with 51 other infants with congenital toxoplasmosis whose mothers had received spiramycine alone. Patients of both groups received the same pyrimethamine-sulfadiazine and spiramycine treatment after birth. Parasitologic examination of the placenta was positive in 42 and 76.6% of patients, in group I and group II respectively. The newborns had specific IgM in 17.4 and 69.2% of cases respectively in both groups. These differences were significant. The mean specific IgG titer was significantly reduced at birth and 4 to 6 months of age in the first group. Patients in group I had more often subclinical infection than patients of the comparison group: 57% vs 33.3%. They had less often a high cerebro-spinal protein content during the first week. Prenatal treatment with pyrimethamine-sulfadrugs resulted in a less progressing infection at birth. However in cases with clinically patent toxoplasmosis, the frequency of overt localizations and their sequellae was not significantly altered. This might be related to a relatively late onset of the treatment. The pyrimethamine-sulfadrug combination given to mothers of proved infected fetuses can be rewarding. The indication might be extended to well-documented seroconverted mothers if, in the future, the acquired experience and necessary pharmacological studies bring the proof of its innocuousness.

[6 cases of toxoplasmosis in twins]. / A propos de six observations de toxoplasmose gémellaire.

Studies of congenital toxoplasmosis in twins confirm the definite role of the placenta in the modalities and mechanism of fetal contamination. In single-chorion twin pregnancies, clinical manifestations are generally identical in both infants. Conversely, twins from double-chorion pregnancies usually have different clinical patterns; occasionally, only one of the twins is affected (1 case). The diagnosis can be ascertained antenatally by sampling blood from each of the fetuses (2 cases). The cases reported herein illustrate some of the diagnostic pitfalls that may lead to inappropriate discontinuation of monitoring and treatment: negative placental studies, absence of specific IgM antibodies, transient fall in IgG antibody titers, delayed fetal contamination after a negative fetal blood study, and need for routine tests for increased CSF albumin levels.

[Rhabdomyolysis and acute encephalitis in coxsackievirus infection]. / Rhabdomyolyse et encéphalite aiguës au cours d'une infection à coxsackie.

We report the case of a 6 year-old boy with rhabdomyolysis involving only the inferior limbs. It was complicated by renal failure with anuria and intravenous coagulopathy and associated with encephalitis. Virologic investigations showed a recent infection due to Coxsackie B5 virus. Full recovery was observed after symptomatic treatment with peritoneal dialysis, exchange transfusion and heparin therapy.

Rotavirus induces alpha-interferon release in children with gastroenteritis.

alpha-Interferon (IFN) blood levels were studied in 38 children hospitalized for rotavirus gastroenteritis. During rotavirus infection, a peak of systemic alpha-IFN was observed within 2 days of onset of symptoms. There was a significant positive correlation between alpha-IFN levels and the number of vomiting episodes (p = 0.0003) but not with duration of vomiting, maximal temperature, and duration of fever. alpha-IFN levels were higher in children with peripheral cyanosis compared with children without peripheral cyanosis (p = 0.005) and tended to be higher in children with diarrhea of < 3 days' duration compared with those with diarrhea lasting > 4 days (p = 0.06). alpha-IFN could be partly responsible for the severity of such initial symptoms as vomiting and peripheral cyanosis in rotavirus gastroenteritis and could play a role in recovery from diarrhea.

In utero treatment of toxoplasmic fetopathy with the combination pyrimethamine-sulfadiazine.

The mothers of 52 fetuses with toxoplasma fetopathy diagnosed in utero were treated with a combination pyrimethamine-sulfa drug and spiramycine. Their infants were compared to a group of 51 infants whose mothers had received spiramycine alone. Postnatal treatment was identical in both groups. Parasitological investigation of the placenta was positive in 42 and 76.6%; the newborns had a specific IgM of 17.4 and 69% in groups 1 and 2, respectively. These differences were significant. The mean specific IgG titer was significantly reduced at birth and at 4-6 months of age in group 1. According to the results obtained in the present material the pyrimethamine-sufa drug combination, given to the mothers of fetuses infected with toxoplasma, has a significant effect on the parasitological and serological signs of evolutive fetopathy. It did not significantly alter the clinical pattern, probably because the onset of treatment was too long after maternal infection.