Complicated nosocomial pneumonia due to Legionella pneumophila in an immunocompromised child.

An immunocompromised child developed necrotizing pneumonia with BAL cultures growing Legionella pneumophila resistant to treatment, including erythromycin and rifampicin. Ciprofloxacin and clarithromycin reversed the clinical course; their use as first-line drugs is justifiable and a high index of suspicion for the occurrence of legionellosis is warranted.

The effect of buphthalmos on orbital growth in early childhood: increased orbital soft tissue volume strongly correlates with increased orbital volume.

PURPOSE: Our purpose was to evaluate the effect of increased orbital soft tissue volume on orbital growth. METHOD: Patients with unilateral or significantly asymmetric bilateral buphthalmos as determined by axial computed tomography scan were recruited. Volumetric determinations of the bony orbit with use of axial 1.5 mm sections on computed tomography were undertaken. Statistical analysis of the paired ocular length measurement and bony orbital volume measurements for each patient were performed. RESULTS: Eight patients (mean age 41 months) with a 15% or greater difference in axial length were enrolled. The mean axial length of the buphthalmic globes was 23% greater than that of the contralateral globes. Orbits harboring a buphthalmic globe had an orbital volume 11% greater than on the contralateral side. CONCLUSION: Increased orbital soft tissue volume as evidenced by buphthalmos was significantly associated with enlarged bony orbital volume. This indicates that soft tissue volume is a determinant of orbital volume and suggests that orbital tissue expanders might enhance bony development in patients with anophthalmos or microphthalmos and after early enucleation.

The effect of maturation on the ability to stimulate orbital growth using tissue expanders in the anophthalmic cat orbit.

Tissue expanders were used to stimulate orbital growth at different stages of maturity in the immature anophthalmic cat orbit. Twelve cats had the right globe enucleated at 2 weeks of age and tissue expanders implanted in the orbit. The cats were randomized into four groups (A, B, C, and D). The tissue expanders remained in the nonexpanded state for a preassigned length of time. Orbital volume was determined on each cat using computed tomography (CT) immediately prior to expansion of the implant. Expansion began at age 10 weeks for group A, 15 weeks for group B, and 25 weeks for group C and involved 0.7 cc injections of saline at 2-week intervals until a final volume of 4.5 cc was obtained. Group D remained as a nonexpansion control group. Four to 5 weeks after expansion was completed, a second orbital volume CT was obtained on each animal and compared with the pre-expansion CT. The right orbits of group A, had pre-expansion (week 10) orbital hypoplasia with a volume 26.2% smaller than the left control orbits. Postexpansion (week 25), the right orbital hypoplasia had decreased to a volume 10.3% less than the left control orbits. The right orbits of group B had pre-expansion (week 15) orbital hypoplasia with a volume 35.6% smaller than the left control orbits. Postexpansion (week 31), the right orbital hypoplasia had decreased to a volume 25.9% less than the left control orbits. The right orbits of group C had a preexpansion (week 25) orbital hypoplasia with a volume 39.8% smaller than the left control orbits. Postexpansion (week 41), the right orbital hypoplasia had decreased to a volume 29.3% less than the left control orbit. Tissue expanders, expanded in the hypoplastic immature cat orbit stimulated orbital growth and reversed orbital bony hypoplasia to varying degrees. The amount of growth stimulated was inversely proportional to the age at which expansion began. Orbital growth, stimulated by tissue expander expansion, was also demonstrated after the normal age of cat orbit maturation (weeks 28-30).

Traumatic chiasmal syndrome associated with midline basilar skull fractures.

We studied two young males who had visual field defects consistent with optic chiasmal injury after blunt frontal head trauma. One patient also had a unilateral optic neuropathy. Long-term follow-up disclosed complete bi-temporal hemianopsias in these patients. Both patients had midline basilar skull fractures that traversed the midclivus through the sella turcica floor, dorsum sellae, and sphenoid sinus. Magnetic resonance images did not identify intrachiasmal hemorrhage as the cause of the visual field defect. We believe this fracture pattern, in conjunction with the magnetic resonance image findings, suggests tearing of the optic chiasm on a microscopic, if not macroscopic, scale as the cause of the complete bitemporal hemianopsia.

Eccrine adenocarcinoma of the eyelid in a young patient.

Malignant eccrine adenocarcinoma of the lower eyelids is described in a 16-year-old girl. This rare tumor has previously been reported only in males, whose average age was 64 years. Our patient remains tumor free 7 years after wide resection of the eyelid and reconstruction.

Gadolinium magnetic resonance imaging dacryocystography.

A 1:100 solution of 48% gadopentolate in liquid tear solution was used in magnetic resonance dacryocystography to image the canaliculi, nasolacrimal sac, and nasolacrimal duct. It was administered as an eyedrop, one drop every minute for five minutes, immediately before scanning in six normal and five abnormal nasolacrimal outflow systems. In cases of nasolacrimal obstruction, the dilute gadolinium solution was injected through the canaliculus immediately before scanning. A three-inch surface coil enhanced the detail of soft-tissue structures such as the canaliculi and lacrimal sac. In the evaluation of complex tearing disorders such as congenital, neoplastic, postsurgical, and posttraumatic nasolacrimal obstruction, gadolinium lacrimal contrast adds useful information to magnetic resonance images of the lacrimal outflow system. Because of the expense of the test, we do not recommend it as a routine examination.

Exposure rate of hydroxyapatite spheres in the anophthalmic socket: histopathologic correlation and comparison with silicone sphere implants.

We retrospectively reviewed enucleations and secondary anophthalmic socket sphere implantations for a 3 year period. We compared the incidence of exposure of hydroxyapatite implants to the incidence of exposure of silicone implants. We found that the incidence of hydroxyapatite exposure following enucleation was 3 of 27 (11.1%), and following secondary anophthalmic socket implantation was 3 of 32 (9.4%). The incidence of silicone sphere exposure following enucleation was 0 of 48 (0%), and following secondary implantation was 1 of 30 (3.3%). The difference in exposure rate between hydroxyapatite and silicone reached statistical significance in the enucleation group (p = 0.043) and in the combined enucleation and secondary implantation group (p = 0.033), but not in the secondary implantation group when considered separately. Osteoinduction and fibrovascular infiltration were found in all hydroxyapatite specimens examined histopathologically. In the exposed implants, liquefaction necrosis of the implant occurred. In the nonexposed implant, complete fibrovascular ingrowth was noted at 7 months. We believe that the hydroxyapatite anophthalmic sphere is associated with a higher incidence of exposure and postoperative inflammation when compared to silicone anophthalmic spheres. Patient selection and technique modification may reduce the incidence of hydroxyapatite implant exposure.

The association of cigarette smoking with clinical subtypes of ophthalmic Graves' disease.

We retrospectively reviewed the smoking habits of 124 patients with Graves' ophthalmopathy. We divided these patients into those without restrictive myopathy (type I) and those with restrictive myopathy (type II). Sixty-three percent of type I and 83% of type II patients were smokers at the time of diagnosis. The incidence of smoking in an age- and gender-matched randomly selected control population in the same geographic area was 30% for controls matched to our type I group and 26.6% for controls matched to our type II group. We believe smoking is an important factor in the development of both clinical subtypes of Graves' ophthalmopathy.

Extrusion rate of silicone spherical anophthalmic socket implants.

The most popular technique of placement of an anophthalmic spherical implant was first described by Frost and Lange in 1886, and has remained essentially unchanged since that time. That technique incorporates imbrication of recti muscles over an 18 mm spherical implant, and purse stringing of conjunctiva and Tenon's fascia in a single layered closure. The Frost-Lange technique has led to previously reported extrusion rates as high as 11.3%. The technique is also associated with superotemporal implant migration and poor prosthetic motility. Our technique modification includes suturing recti muscles independently to a 20 mm spherical implant reinforced with autogenous fascia or preserved sclera. We then close Tenon's fascia and conjunctiva independently as separate layers. The extrusion rate for our patients during a 10 year study period was 0.84% (1 of 119). We found no implant migration, no painful socket, and prosthetic motility was good. We recommend our technique modification to replace the traditional Frost-Lange technique.

Ocular manifestations of the lacrimo-auriculo-dento-digital syndrome.

We studied a mother and daughter with an extremely rare constellation of signs and symptoms. One or both had absent lacrimal puncta, nasolacrimal duct obstruction, chronic dacryocystitis, dry eyes, and epiphora. Systemic findings included salivary gland hyposecretion, dental hypoplasia and dysplasia, cup-shaped ears with hearing loss, and digital anomalies. These findings are consistent with those of the lacrimo-auriculo-dento-digital syndrome, a genetic disorder. Our study supports the autosomal dominant inheritance of this syndrome, delineates the ophthalmic manifestations, and provides evidence that renal anomalies are part of the disorder.

The influence of chlordecone and oestrogen on the secretion of proteinaceous molecules of the mouse uterus.

Ovariectomised mice were treated with sesame seed oil, oestradiol, or one of three different levels of the insecticide chlordecone (1, 1a, 3, 3a, 4, 5, 5a, 6-decachloro-octahydro-1, 3, 4-metheno-2H-cyclobuta[cd] pentalen-2-one). After 9 days of treatment, the uteri were injected with (35)S-methionine and radiolabelled proteins were flushed from uteri 4 h later. Reproductive tract weights and the total amount of radioactivity in uterine flushings were measured. Reproductive tract weights increased significantly only in animals treated with the highest dose of chlordecone tested and oestradiol-treated animals. Trichloroacetic acid (TCA) precipitated radioactivity was increased by all doses of insecticide chlordecone tested but increases were significant only at one level. The greatest stimulation of (35)S-methionine incorporation occurred in ovariectomised animals treated with oestradiol. Radioactive proteins were analysed by fluorography of two-dimensional gels. The fluorograms showed that the proteinaceous uterine secretions, as influenced by chlordecone, were greatly reduced in number as compared with those secreted under the influence of oestradiol. Chlordecone appears to cause the secretion of proteinaceous material from the uteri of mice in a qualitatively different manner than does oestradiol.