Staphylococcus aureus septicaemia in a patient with cystic fibrosis.

UNLABELLED: Although bacterial colonisation of bronchi may occur from early childhood onwards, infections extending beyond the lungs are uncommon in patients with cystic fibrosis. A 12-year-old boy with cystic fibrosis, receiving oral corticosteroids for 3 weeks because of allergic bronchopulmonary aspergillosis, experienced pneumonia and septicaemia caused by Staphylococcus aureus. He was treated with flucloxacillin, ticarcillin-clavulanate, aztreonam, cefazolin and rifampin according to resistance testing of S. aureus cultured from the blood. On day 25 the patient finally had recovered. CONCLUSION: Systemic steroid therapy for allergic bronchopulmonary aspergillosis may favour life-threatening systemic bacterial infection which is rare in the immunocompetent patient with cystic fibrosis.

Aminoglycosides and renal magnesium homeostasis in humans.

BACKGROUND: The use of aminoglycosides has been linked with hypomagnesaemia in scattered reports. The objective of the study was to measure prospectively the effect of treatment with the aminoglycoside amikacin on renal magnesium homeostasis. METHODS: Twenty-four cystic fibrosis patients (aged 9-19 years) admitted because of exacerbation of pulmonary symptoms caused by Pseudomonas aeruginosa were treated with the aminoglycoside amikacin and the cephalosporin ceftazidime for 14 days. Renal values and plasma and urinary electrolytes were measured before and at the end of the systemic anti-pseudomonal therapy. RESULTS: In the patients with cystic fibrosis, treatment with amikacin and ceftazidime did not modify plasma creatinine or urea and plasma or urinary sodium, potassium and calcium. Treatment with amikacin and ceftazidime significantly decreased both plasma total magnesium (from 0.77 (0. 74-0.81) to 0.73 (0.71-75) mmol/l; median and interquartile range) and ionized magnesium (from 0.53 (0.50-0.55) to 0.50 (0.47-0.52) mmol/l) concentration and increased fractional urinary magnesium excretion (from 0.0568 (0.0494-0.0716) to 0.0721 (0.0630-0.111)) and total urinary magnesium excretion (from 30.7 (26.5-38.0) to 38.5 (31. 5-49.0) micromol/l glomerular filtration rate). CONCLUSIONS: The present study demonstrates that systemic therapy with amikacin plus ceftazidime causes mild hypomagnesaemia secondary to renal magnesium wasting even in the absence of a significant rise in circulating creatinine and urea.

Autoantibodies directed against bactericidal/permeability-increasing protein in patients with cystic fibrosis: association with microbial respiratory tract colonization.

BACKGROUND: Cystic fibrosis (CF) is associated with the appearance of serum autoantibodies directed against bactericidal/permeability-increasing protein (BPI). OBJECTIVES: To determine the age-specific seroprevalence rates of anti-BPI-IgG and IgA in a population of patients with CF and to correlate anti-BPI antibody concentrations with microbial respiratory tract colonization and pulmonary function variables at the time of serum sampling and 6 years thereafter. METHODS: Determination of BPI antibodies of the IgG and IgA isotypes using a commercial enzyme-linked immunosorbent assay in sera of a CF serum bank of 1992; correlation of anti-BPI antibody concentrations with age, clinical score, pulmonary function variables in 1992 and 1998, total serum immunoglobulin isotype concentrations and respiratory tract colonization with Pseudomonas aeruginosa and Aspergillus spp. RESULTS: Seventy-one patients (age in 1992, 14.1 +/- 7.5 years) were studied. Reactivities for anti-BPI-IgG and IgA were found in 28 (39%) and 26 (37%) patients, respectively. The seroprevalence of anti-BPI-IgA, but not IgG, increased significantly with age. P. aeruginosa colonization was associated with elevated concentrations of anti-BPI-IgG (P = 0.003) and IgA (P = 0.037). There were significant negative correlations between pulmonary function variables (vital capacity, forced expiratory volume in 1 s) in 1992 and 1998, respectively, and concentrations of anti-BPI-IgG or IgA in a multiple regression analysis. Anti-BPI-IgG, but not IgA, remained significantly associated with P. aeruginosa colonization (P = 0.006) and with reduced vital capacity (P = 0.01) in 1998 after correction for total serum isotype concentration. CONCLUSIONS: Anti-BPI-IgG are strongly associated with concurrent P. aeruginosa colonization and with long term restrictive pulmonary function abnormalities.

Diagnosis by polymerase chain reaction of pneumonia caused by Legionella pneumophila in an immunocompetent child.

A 10-year-old, previously healthy child with pneumonia caused by Legionella pneumophila diagnosed by polymerase chain reaction (PCR) of serum is presented. Diagnostic methods were PCR of serum using two different primer sets, and the detection of specific antibody in paired sera using an indirect immunofluorescence assay. Legionella DNA was amplified from serum obtained before and on day 6, but not after completion of a 14-day course of oral clarithromycin. The etiologic role of L. pneumophila was confirmed by seroconversion. The report illustrates that L. pneumophila PCR of serum may contribute to the identification of this microorganism as a cause of severe pneumonia in immunocompetent children.

[Inhalational antibiotic therapy in patients with cystic fibrosis and Pseudomonas infection]. / Zur inhalativen Antibiotika-Therapie bei Patienten mit zystischer Fibrose und Pseudomonas-Befall.

Treating chronic Pseudomonas infection of the bronchial tree is a very important part of the treatment strategy in patients with cystic fibrosis. There are only a few antibiotics which are effective against pseudomonas. Many of them soon lead to bacterial resistance (e.g. fluoro-quinolones). Inhaling antibiotics produces high sputum concentrations and low systemic toxicity. Tolerance is good and resistance rare. Several clinical studies, some of them doubleblind placebo controlled, have shown a positive effect of inhaled antibiotics on symptoms, on frequency of necessary i.v. therapies and also on pulmonary function. Most commonly aminoglycosides (tobramycin) and colistin, which is not yet registered in Switzerland, are used. The main indication is chronic therapy of Pseudomonas infection.

Comparison of different inhalation schedules to control childhood asthma.

In a double-blind, placebo-controlled study control of asthma was assessed by diary symptom cards, peak-flow measurements and lung function within 3 treatment groups over a 6 months period. 36 children (25 boys, 11 girls 5.5 to 13.2 years of age) with exogen allergic, perennial asthma inhaled either beclomethasone dipropionate (BDP) with salbutamol (S) or disodium cromoglycate (DNCG) with S or a placebo preparation with S from metered dose inhalers (MDI) through a large-spaced auxiliary device (Volumatic). At entry, after 2 and 4 months lung function tests were performed evaluating changes in the degree of pulmonary hyperinflation, bronchial obstruction, and bronchial hyperreactivity (BHR). Daily PF measurements showing wide variations (up to 10-12%) were insensitive to indicate any significant changes. In contrast evaluation of symptom diaries presented dramatic improvement during the first 3 months of the study. In addition, the DNCG group showed significant improvement of BHR (p = 0.02). Moreover, the majority of patients on regular therapy with salbutamol and placebo showed an increase of airway resistance. It is concluded that even in mild childhood asthma, for optimal control a combination of a beta 2-stimulant as bronchodilator and DNCG or BDP as protector should be applied.

Psychosomatic symptoms in asthmatic children and adolescents.

In order to identify different patterns of association between physical and psychical symptoms in childhood asthma 102 children have been investigated. Somatic investigations included clinical examination, whole-body plethysmography, total IgE and RAST of specific allergens such as pollens, mites and animals. Psychosocial assessment comprised a semi-structured interview and questionnaires (Achenbach, CBCL and Olson, FACES II). There were typical psychosocial patterns in function of aetiopathogenetic groups. The infection-induced asthma was accompanied by high anxiety and here the most school problems were found. Children with seasonal asthma were psychologically healthy whereas those with perennial asthma showed important psycho-vegetative difficulties secondary to chronic somatic disease. Atypical asthma was found to be most often associated with real psychiatric symptoms. We concluded that psychosocial findings are heterogeneous and should be interpreted in relation to somatic manifestations.

A new method for assessing flow-volume measurements by means of a simple isoflow electronic pocket device (IfloPen).

The IfloPen is a new device for measuring isoflows featuring specific information about the effort-independent part of the flow-volume curve. Whereas the recording of the latter normally requires expensive equipment, the IfloPen is a handy, portable and simple device. In addition, the isoflow technique requires minimal cooperation. Significant correlations have been found between the isoflow-points measured with the IfloPen and PF, MEF50, MEF25 and FEV1 (p < 0.001). The IfloPen showed better correlations with spirometric lung function data than with the Peak-flow-Meter. Even experimentally induced bronchial obstruction during a bronchial challenge with carbachol can be measured functionally by the IfloPen, showing similar changes as obtained by the FEV1 and the MEF50 (p < 0.001). From a practical point of view, the IfloPen features a new device to measure more accurately bronchial obstruction (no overestimation, physiological breathing maneuver, good practicability). It can therefore be used in medical practice and is a suitable device for home monitoring.

The lung clearance index (LCI) as an estimate of ventilation inequalities in patients with cystic fibrosis.

Assessment of respiratory function is indispensable for provision and control of respiratory care in infants and children with lung disease. Based on plethysmographic measurements and the multibreath nitrogen washout (MBNW) distinction of patients with cystic fibrosis (CF) into different functional groups revealed that the mixed type (TGV > 130 % pred. and Raw > 130 % pred.) has to be considered as worst: highest degree of trapped gases (TG) and ventilation inequalities and consequently most impeded gas exchange. Best predictor in patients with abnormal gas exchange are the degree of bronchial obstruction (Raw) and the amount (TG). Vital capacity (VC) as overall estimate of lung function is best predicted by TG, FEV1 and MEF50. The major merit of the MBNW technique is the possibility to have the amount of TG estimated. Based on the present the calculation of the LCI adds no further information of sufficient clinical importance, remaining the question open, whether the assessment of the so called "moment ratios" from the entire washout curve would feature a better estimate of disturbed lung physiology.

The "wheezy infant" diagnosis, epidemiology and management.

Already in the earliest childhood, the onset of an allergic/immunologic inflammatory process may be caused on the basis of an inherited predisposition by an exaggerated mediator-release in the mucosa. Repeated action of trigger factors maintain this inflammation and provoke exacerbations of asthmatic symptoms. The protective task of the bronchial mucosa can not be fulfilled anymore. However, the most important goal of the approach to identify and treat wheezy infants is to avoid structural damage of bronchi and the lung by the underlying process for later life. General measures of treatment such as prophylaxis against house-dust-mite exposure, improved breathing technique and improvement of lung clearance are indispensable measures of an individually adapted, effective symptomatic (bronchodilators) and protective (cromoglycate, topical steroids) drug therapy in infants and young children with the so called "wheezy baby syndrome". A successful therapy should ensure a physiological development of the child.

[Therapeutic aspects in the treatment of juvenile bronchial asthma]. / Therapeutische Aspekte zur Behandlung des kindlichen Asthma bronchiale.

The most important goal of the treatment for bronchial asthma in infants and children is to avoid structural damage to bronchi and lung by the underlying allergic and immunologic inflammatory process. This inflammation is caused by an inherited predisposition to exaggerated mediator-release in the mucosa. Repeated actions of trigger factors maintain this inflammation and provoke exacerbations of asthmatic symptoms. The protective task of the bronchial mucosa can not be fulfilled anymore. General measures of asthma treatment such as prophylaxis against house-dust mite exposure, improved breathing technique and improvement of lung clearance are indispensable measures of an individually adapted, effective symptomatic (bronchodilators) and protective (cromolyn, topical steroids) drug therapy in infants and children with bronchial asthma. A successful therapy should ensure a physiological development of the child.

A new baby-spacer device for aerosolized bronchodilator administration in infants with bronchopulmonary disease.

The response of salbutamol (Ventolin, Glaxo), topically administered from a metered dose inhaler (MDI) through a new baby-spacer-device (Babyhaler, Glaxo) was studied in 14 infants (8 wheezy infants, 3 infants with cystic fibrosis and 3 infants after respiratory distress syndrome), age 2.9-18.8 months. Changes in thoracic gas volume (TGV) as an estimate of pulmonary hyperinflation and changes in airway conductance (Gaw) as an estimate of bronchial obstruction were assessed by whole-body plethysmography. After baseline measurements, 1 puff of 100 micrograms salbutamol was given repeatedly at 5 min intervals until 600 micrograms have been inhaled and TGV and Gaw were measured after each inhalation at 5, 10, 15, 20, 25 and 30 min. Significant improvement in lung function was achieved in 57.1% of infants after 400 micrograms and in 92.9% of infants after 600 micrograms salbutamol. The study shows usefulness of bronchodilator treatment in infants with bronchopulmonary disease by a system with a MDI and baby-spacer-device. However a special dose-time relationship must be respected.