Asymptomatic dermatophyte carriers in the households of children with tinea capitis.

OBJECTIVES: To determine the prevalence of the carrier state in household contacts in children with tinea capitis, the duration of the carrier state, factors associated with carriage, and the proportion of carriers who develop clinical disease. DESIGN: Cross-sectional, cohort, prevalence study. SETTING: General pediatric clinic serving an indigent, inner-city, African American population. PATIENTS: Household contacts in children with tinea capitis. Index cases and carriers (no clinical evidence of infection) were identified by culture. Carriers were monitored until the results of their culture became negative, they developed clinical disease, or a 6-month period had elapsed. RESULTS: Fifty-six index cases and 114 contacts (50 adults and 64 children) were evaluated. Ninety-eight percent of the dermatophytes identified in index cases and 100% in carriers were Trichophyton tonsurans. At the initial visit, 18 (16%) of 114 (95% confidence interval [95% CI], 10-24) of contacts were carriers and 14 (32%) of 44 of the families studied had at least 1 carrier. At the 2-, 4-, and 6-month visits, the carrier state persisted in 7 (41%) of 17 (95% CI, 19-67), 3 (20%) of 15 (95% CI, 4-48), and 2 (13%) of 15 (95% CI, 2-40), respectively. Three of the carriers were lost to follow-up. Of the carriers, 1 (7%) of 15 (95% CI, 0.2-32) developed tinea capitis. Univariate and multivariate analysis showed no association of carrier state to age, sex, comb sharing, or cosleeping. However, cosleeping and comb sharing were common among the contacts, occurring 75% and 78% of the time, respectively, making statistical correlation difficult with our sample size. CONCLUSIONS: Initial prevalence of asymptomatic carriage of dermatophytes among household contacts of a child with tinea capitis was 16%, with 41% of carriers persisting up to 2 months. Thirty-two percent of families had at least 1 member who was a carrier. Seven percent of the carriers developed an active infection. Treatment of carriers with sporicidal shampoo should be considered since they may act as a reservoir for infection or develop active disease. The high prevalence of cosleeping and comb sharing may be important factors in the spread of the disease.

Do missed opportunities stay missed? A 6-month follow-up of missed vaccine opportunities in inner city Milwaukee children.

OBJECTIVES: To determine 1) the frequency of missed vaccine opportunities (VOs) in inner city children

The systematic evaluation of the skin in children.

A large proportion of children seen by primary care pediatricians involve problems related to the skin. In this chapter, the importance of history and, particularly, physical examination in the diagnosis of various skin disorders is discussed. The ability to describe a rash using proper terminology will help narrow the differential and enable one to communicate what is seen to other physicians. The various primary and secondary lesions that may be present will be described along with various dermatoses as examples. Four common skin disorders that often fool the primary care physician are also discussed.

Subgaleal hematoma with delayed proptosis and corneal ulceration.

We report the delayed occurrence in a child of proptosis caused by a subgaleal hematoma. A corneal ulcer resulted from the proptosis, which developed 9 days after mild head trauma. Evaluation revealed a heterozygous factor VII deficiency. The coagulopathy and, more likely, the use of the nonsteroidal antiinflammatory drug ibuprofen may have contributed to the extension of the hematoma into the orbital space. Careful follow-up of patients with subgaleal hematomas is necessary because the development of proptosis may be delayed.

Serious bacterial illnesses in recently hospitalized young infants.

We undertook a retrospective chart review of 27 patients less than 60 days of age, hospitalized for possible serious bacterial illness (SBI), but who were culture negative, and then readmitted within seven days for the same reason. Upon repeat evaluation for sepsis, five of these infants had significant illnesses; two (7.4%) had SBIs (one had pneumococcal bacteremia and the other a urinary tract infection), and three (11.1%) had aseptic meningitis. Our results suggest that young infants, despite recent hospitalization for possible SBI, may be at risk for a serious infectious process and need reevaluation if symptoms recur.

Management errors leading to unnecessary hospitalization for kerion.

OBJECTIVE: Tinea capitis is a common problem in the inner city, outpatient population. It is known that some children were being admitted for treatment of the kerion type of tinea capitis. The purpose of this study was to determine why these children were being admitted and whether hospitalization was justified. DESIGN: A retrospective study of all children hospitalized at Children's Hospital of Wisconsin between January 1990 and December 1992 with the diagnosis of tinea capitis was performed. RESULTS: Twenty-nine children who were hospitalized with tinea capitis were identified. In 10 cases, tinea capitis was the primary reason for admission, in 19 patients it was a secondary diagnosis. All of the patients with a primary diagnosis of tinea capitis were presumed to have a secondary bacterial infection of the kerion; however, this was not verified by the workup of any patient. Numerous deviations from optimal treatment were noted in both groups of patients. Although tinea capitis had been correctly diagnosed before admission in seven primary tinea capitis patients, only two of these patients received oral griseofulvin. The patients in whom tinea capitis was a secondary diagnosis also had a number of therapeutic deficiencies including failure to prescribe griseofulvin (16%), failure to administer griseofulvin with a fatty food or meal (58%), and failure to prescribe a sporicidal shampoo (63%). CONCLUSIONS: Although all patients were assumed to have a secondary bacterial infection, this could not be documented. With the possible exception of one patient all the symptoms described by the patients could be explained by the highly inflammatory nature of a kerion. A better understanding of the degree of inflammation that may accompany a kerion, as well as its proper treatment, may prevent unnecessary hospitalization of children.

Early detection and treatment of sexually transmitted disease in pregnant adolescents of low socioeconomic status.

This study evaluated the prevalence of sexually transmitted disease (STD) in adolescents presenting to a primary pediatric care clinic (PPCC) for the diagnosis of pregnancy and our ability to eradicate identified infections. We followed 168 pregnant adolescents of low socioeconomic status from their original pregnancy diagnosis until their first prenatal clinic visit. We collected screening cervical cultures for Neisseria gonorrhoeae and Chlamydia trachomatis by completing a pelvic examination on 91 patients at our PPCC. At the PPCC visit, 29% were positive for gonorrhea, chlamydia, or both. Screening tests for these infections were collected on all patients at the initial prenatal clinic visit. The risk for presenting to the prenatal clinic with a STD was significantly greater in patients not screened and treated for STD at the PPCC. Average delay from diagnosis to first prenatal clinic visit was 35.7 days. Thus, in this adolescent population, primary care providers are missing an important therapeutic opportunity by failing to identify and treat STD at initial diagnosis of pregnancy.

PIP: Maternal sexually transmitted disease (STD) is an important and preventable cause of infant morbidity and mortality. The early identification and treatment of STDs could, however, reduce the number of premature deliveries, low-birthweight infants, and neonatal deaths. Sexually active adolescents of low socioeconomic status (SES) are at increased risk for perinatal morbidity and mortality due to their substantially higher STD rates compared to adult women. Despite these facts, many primary care providers simply diagnose pregnancies with urine tests, then refer adolescents to a prenatal program for a thorough evaluation, including a screen for STDs. This practice means that young women infected with STDs at the diagnosis of pregnancy will most likely remain infected until they return to begin prenatal care and are subsequently diagnosed and treated for the problem. This study followed a group of pregnant adolescents from the initial diagnosis of pregnancy at a primary pediatric care clinic (PPCC) until the initial prenatal clinic visit. The study was undertaken to document the frequency of STD in adolescents presenting at such a PPCC for pregnancy diagnosis and to evaluate the ability to treat the infections once they are identified. 235 pregnancies were identified at the PPCC serving urban adolescents of low SES in Milwaukee, Wisconsin, over the period August 1, 1988, to January 31, 1992. 44 of these patients were seen at other prenatal programs, nine had miscarriages and nine had induced abortions before starting prenatal care, and five met the exclusion criteria, so the study findings pertain to only 168 subjects. 91 subjects were screened at the initial visit to the PPCC for gonorrhea and chlamydia with a pelvic exam and 77 were not. The screened group was of mean age 16.4 years compared to the unscreened group at 15.9 years, while the former also reported more STD-related symptoms than the unscreened group at the time of the initial PPCC visit. 29% of the 91 were positive for gonorrhea, chlamydia, or both. The average delay from pregnancy diagnosis to first prenatal clinic visit was 35.7 days. 53 of the 168 women presenting for prenatal care (32%) had STDs. Patients originally screened at the PPCC for STD, however, had a significantly lower prevalence of infection than the previously unscreened group. 22 of the group screened at the initial PPCC were infected, 12 of whom had been previously negative. The authors stress that primary care providers are missing an important therapeutic opportunity in this adolescent population by failing to identify and treat STDs at the initial diagnosis of pregnancy. The initial diagnosis of pregnancy in adolescents should always include screening for STD, with suspected infections treated immediately rather than waiting for definitive test results. Patients should also be given information on how to protect themselves from acquiring new STDs during pregnancy.

Delay in obstetrical care in newly diagnosed teenage pregnancy.

A retrospective study of 42 adolescent patients diagnosed as being pregnant between June 1987 and February 1990 at the Downtown Health Center (DHC), an inner city pediatric primary care clinic, was conducted to determine whether patients referred to a hospital-based Teen Pregnancy Clinic (TPC) were seen within a reasonable period of time. The frequency of sexually transmitted diseases (STDs) was also determined when these women were initially seen at TPC. Only 5 of the 42 patients seen at DHC had a pelvic exam prior to referral. Of the 40 patients seen at TPC, 20% were not seen until four weeks or more after initial diagnosis. Fifty percent had a STD. Pediatricians should recognize that pregnant teenagers may have a significant delay between diagnosis of pregnancy and entry into obstetrical care. Pelvic exam including cultures for STDs is recommended prior to referral.