Course and outcome of chronic fatigue in children and adolescents.

PURPOSE: To describe the epidemiology, symptoms, and psychosocial characteristics of children and adolescents evaluated in a chronic fatigue program and determine the course and outcome of the syndrome in these patients. METHODS: During the summer of 1994, chart review was performed for the 58 patients evaluated between 1990 and 1994 and a telephone follow-up was conducted with 42 of the 58 families. Patients were predominantly female (71%) and white (94%), with 50% between the ages of 7 and 14 years and 50% between the ages of 15 and 21 years (mean age 14.6 years). RESULTS: At time of presentation, 50% of patients had been fatigued for 1 to 6 months and 50% had been fatigued for 7 to 36 months. Sixty percent indicated the fatigue had begun with an acute illness and 60% had a history of allergies. Most commonly reported symptoms were fatigue (100%), headache (74%), sore throat (59%), abdominal pain (48%), fever (36%), and difficulties with concentration and/or memory (33%). Most patients had a worsening of school performance and a decrease in social activities. On follow-up, there was significant improvement in many patients during the summer after the first visit, with continued improvement in most patients during the second and third years. At time of the follow-up telephone call, 43% of families considered their child "cured" and 52% considered their child "improved," whereas only 5% considered their child to be "the same." Statistical analyses demonstrated no demographic or clinical factors that distinguished between those who did or did not participate in the follow-up study, or between those who did or did not do well on follow-up. CONCLUSIONS: These data demonstrate that children and adolescents with chronic fatigue have a syndrome that is similar to that described in adults, but that the syndrome differs in several ways, most specifically, presentation earlier in the course of the illness and a more optimistic outcome.

Evaluation of a rapid diagnostic test for respiratory syncytial virus (RSV): potential for bedside diagnosis.

OBJECTIVE: Rapid detection of respiratory syncytial virus (RSV) infection can assist clinicians in decisions regarding antiviral therapy with ribavirin as well as instituting infection control measures. The Abbott TestPack RSV is a rapid RSV detection immunoassay that can be performed on respiratory secretions in 20 to 30 minutes without special laboratory equipment. The purpose of this study was to evaluate housestaff performance of the TestPack RSV at bedside as compared with laboratory testing of aliquots of the same specimen by tissue culture inoculation, direct fluorescent antibody (DFA) testing and TestPack RSV. METHODS: During the 1991 through 1992 RSV season, 137 nasopharyngeal aspirates or washes obtained from pediatric patients < 4 years of age suffering from acute respiratory disease were assayed by the Food and Drug Administration-approved TestPack RSV as well as conventional tube culture and DFA testing. RESULTS: 66 of 137 (48%) specimens were positive for RSV as defined by: isolation and DFA-positive (n = 48) and DFA testing positive with negative culture (n = 18); blocking assay experiments using TestPack RSV confirmed culture-negative DFA-positive specimens as positive in 8/8 instances in which material for retesting was available. Using these definitions, the sensitivity and specificity for the assays were: housestaff TestPack RSV: 92%, 93%; laboratory TestPack RSV: 97%, 98%; virus isolation: 72%, 100%. CONCLUSION: From these data, it appears that the TestPack RSV EIA in the field setting is reliable, although laboratory confirmation of results is important.

Inactivation of respiratory syncytial virus by detergents and disinfectants.

The activity of a number of detergents and disinfectants against respiratory syncytial virus (RSV) was evaluated in an in vitro assay system. Equal volumes of RSV and serial 10-fold dilutions of the test agents were mixed at 4 degrees C for 5 minutes. The RSV titer in each mixture was compared with that of untreated RSV alone. In 14 experiments with input RSV titers ranging from 2.6 x 10(3) to 2 x 10(7) plaque-forming units/ml, a 10-fold dilution of 5.25% sodium hypochlorite (generic bleach) inactivated (> or = 3-log reduction in titer) the virus. With lower RSV titers inactivation was also observed at a 100-fold dilution of bleach. Fetal calf serum concentrations up to 50% as an organic load did not diminish the bleach effect. The degree of RSV inactivation was also defined for Lysol, povidone-iodine, Amphyl, Hibiclens, Osyl, ethanol and Listermint. The short contact time, the reproducible nature of the findings and the continued effectiveness with increasing organic loads all suggest that detergents and disinfectants can potentially play an important role in decreasing the spread of RSV infection.

Pediatric acquired immunodeficiency syndrome-related complex: clinical and immunologic features.

The long term clinical outcome for infants and children with the pediatric acquired immunodeficiency syndrome-related complex is unknown. This report describes our experience with 14 patients with acquired immunodeficiency syndrome-related complex who have been followed for 11 to 71 months since the onset of their symptoms. The most frequent clinical features at presentation were persistent generalized lymphadenopathy (14 of 14), hepatosplenomegaly (11 of 14) and a history of recurrent otitis media (7 of 14). Except for hypergammaglobulinemia (14 of 14) and reversed T4/T8 ratios (9 of 14), immunologic analyses, including in vitro responses to mitogens and antibody responses following immunization, revealed no consistent abnormalities. Over the course of follow-up, none of the patients have developed serious or opportunistic infections and 12 of 14 have shown catch up or age-appropriate growth. The T4/T8 ratios have remained stable in 8 of 11 and improved in 2 of 11 patients. Gradual regression of hepatosplenomegaly and lymphadenopathy has been noted patients. Although follow-up studies over a longer period are needed to confirm our observations to date, acquired immunodeficiency syndrome-related complex may represent a prolonged plateau in the course of human immunodeficiency virus infection in many infected children. Detailed immunologic evaluation of these patients may help to identify a subset of children that could benefit from periodic gamma-globulin or chronic antibiotic therapy.

Varicella zoster immunoglobulin after postnatal exposure to varicella: survey of experts.

A questionnaire based on a hypothetical 6-day-old infant exposed to a sibling with varicella was mailed to 316 Pediatric Infectious Diseases Society members to determine their recommendations for administration of varicella zoster immunoglobulin (VZIG). Of the 137 faculty members who responded 20% would recommend VZIG for the infant described (13% were undecided). When further information including a negative maternal history for varicella, prematurity or maternal varicella infection occurring 1 week after delivery was considered, the numbers who recommended VZIG (43, 46 and 52%, respectively) rose significantly (P less than 0.01). Twenty-two physicians had knowledge of a severe case of varicella following postnatal exposure. Only 33% of faculty members surveyed feel there are no indications for VZIG in infants exposed after 48 hours of age.

Reduced environmental exposure to aerosolized ribavirin using a simple containment system.

To minimize the exposure of health care workers to aerosolized ribavirin, we designed a double tent containment system with circulating mist and suction applied between the tents and we evaluated the ability of this system to contain and evacuate aerosolized ribavirin. While the drug was administered with this system at three institutions, three air sampling pumps at different locations in the room and one worn by the investigator (personal breathing zone) collected air samples onto filters for assay of ambient ribavirin. Ribavirin determinations were made by high performance liquid chromatography. A 5- to greater than 20-fold decrease in ambient ribavirin concentrations was observed with the containment system compared with those detected with a single oxyhood in use. The personal breathing zone concentration was 566.0 micrograms/m3 with the oxyhood alone and fell to a mean concentration of 43.81 +/- 33.40 micrograms/m3 with the containment system. Though the risk to exposed health care workers is unknown, this system offers a simple way to decrease significantly occupational exposure to ribavirin.

Follow-up of children with respiratory syncytial virus bronchiolitis in 1986 and 1987: potential effect of ribavirin on long term pulmonary function. The Bronchiolitis Study Group.

BACKGROUND: Hospitalization for respiratory syncytial virus (RSV) bronchiolitis is considered a risk factor for reactive airway disease and/or abnormal pulmonary function tests (PFTs) later in childhood. This study attempted to assess this observation with newer PFTs and to determine whether ribavirin therapy of initial RSV infection may affect the long term outcome. METHODS: Medical records of all infants hospitalized with RSV infection in 1986 and 1987 at six institutions (North Shore University Hospital, Children's Hospital of Buffalo, University Florida-Gainesville, University of Connecticut, Children's Hospital National Medical Center, Denver Children's Hospital) were requested. Patients who could be contacted were recalled in 1993 and 1994 for PFTs and given a pulmonary status questionnaire. RESULTS: One hundred patients were evaluated. Overall PFTs were within normal ranges. There was less "bronchitis" over the interval years in the ribavirin-treated patients (13 of 33) vs. those who did not receive ribavirin (44 of 67, P < 0.01). There was no difference for the diagnosis of reactive airway disease (15 of 33 ribavirin vs. 36 of 67 no ribavirin). Patients who received ribavirin were then matched by age (within 2 weeks) at initial RSV infection and underlying risk factor (bronchopulmonary dysplasia, heart disease). Of the 27 patients matched, the ribavirin patients had longer intensive care unit stays (median (25 to 75% interquartile range): 2 (0 to 7) vs. 0 (0 to 0), P < 0.05). On follow-up evaluation there were no significant differences in PFTs or reactive airway disease between the 2 groups. There was a trend toward lower forced expiratory volume at 1 s and midexpiratory flow rate (25 to 75%) in the ribavirin-treated group, and there were more reported pneumonias on follow-up in the ribavirin patients. CONCLUSION: During our 5- to 6- year follow-up of children, status post bronchiolitis, we noted a good long term prognosis. No long term adverse effects on pulmonary function were detected. Despite being potentially sicker at presentation as assessed by intensive care unit stay, ribavirin recipients were doing equally well at the time of follow-up.

Impact of an infection control program in a specialized preschool.

BACKGROUND: The purpose of this study was to design and implement a comprehensive infection control program and measure its effects on the number and types of infectious illnesses experienced by children attending a specialized preschool program. METHODS: Participants in the study were children with Down syndrome enrolled in a school-based early intervention program. The ages of the children ranged from 6 weeks to 5 years. Through a series of parental questionnaires, the number and types of infections in the children were chronicled for a year before and a year after the implementation of an infection control intervention program. Interventions included infection control lectures, handouts, posters, and attention to environmental cleaning and disinfection, with an emphasis on toys. Compliance with these measures was monitored and recorded. RESULTS: During the interventional year the median number of total illnesses/child/month decreased significantly from the baseline year (0.70 vs 0.53, p < 0.05), with a trend toward a decrease in the number of respiratory illnesses (0.67 vs 0.42, p < 0.07). Significant decreases were also seen for the median number of physician visits (0.50 vs 0.33, p < 0.05), courses of antibiotics administered (0.33 vs 0.28, p < 0.05), and days of school missed as a result of respiratory illness (0.75 vs 0.40, p < 0.05). CONCLUSIONS: This study demonstrates a decrease in infection rates with the implementation of a comprehensive educational and environmental infection control program in a day care setting.

The differentiation of classic Kawasaki disease, atypical Kawasaki disease, and acute adenoviral infection: use of clinical features and a rapid direct fluorescent antigen test.

OBJECTIVE: To compare the clinical and laboratory features of children with Kawasaki disease with those with acute adenoviral infection, which may mimic Kawasaki disease. DESIGN: We retrospectively compared the medical records of children with Kawasaki disease and atypical Kawasaki disease with those of children with acute adenoviral infection. All children included were initially evaluated because their primary care physicians were concerned that they might have Kawasaki disease. The utility of a rapid direct fluorescent antigen test for adenovirus was evaluated. Thirty-six children with Kawasaki disease (23 with classic and 13 with atypical presentations) and 7 patients with acute adenoviral infection were studied. SETTING: A tertiary care pediatric hospital. RESULTS: Children with Kawasaki disease were more likely to have conjunctivitis (36 of 36 vs 4 of 7), strawberry) tongues (23 of 36 vs 1 of 7), perineal peeling (19 of 36 vs 0 of 7), and distal extremity changes (22 of 36 vs 0 of 7) than those with acute adenoviral infection. Children with acute adenoviral infection were more likely to have purulent conjunctivitis (3 of 7 vs 1 of 36) and exudative pharyngitis (3 of 7 vs 1 of 35). In addition to pyuria (13 of 26 vs 0 of 6), patients with Kawasaki disease had higher mean white blood cell counts (15.3 +/- 3.5 vs 11.5 +/- 6.0 x 10(9)/L), erythrocyte sedimentation rates (56 vs 42 mm/h), platelet counts (426 vs 259 x 10(9)/L), and levels of alanine aminotransferase (101 vs 18 U/L) than those with acute adenoviral infection. Children with Kawasaki disease had lower mean albumin levels (32 vs 36 g/L). A rapid antigen test for adenovirus had a specificity and sensitivity of 100% compared with viral culture. CONCLUSIONS: Kawasaki disease and acute adenoviral infection can present with many of the same clinical characteristics. A rapid direct fluorescent antigen assay for adenovirus may be a helpful adjunctive test for distinguishing acute adenoviral infection from Kawasaki disease.

Efficacy of Directigen RSV testing in patient management following admission from a paediatric emergency department.

We investigated the use of the Directigen Respiratory Syncytial Virus test performed under 'Stat Laboratory' conditions, in the management of infants after admission from the Paediatric Emergency Department (ED). The study group consisted of 242 consecutive paediatric ED patients tested by Directigen in the Stat laboratory during the winter 1995-1996 respiratory virus season. Specimens were submitted to the Virology Laboratory for confirmatory consensus testing utilizing in part, an in-house multiplex immunofluorescence assay (IFA) and conventional virus isolation methodologies. The sensitivity, specificity, positive and negative predictive values for Directigen, IFA, and isolation, were 71, 91, 85, 80%; 98, 100, 100, 99%; and 51, 100, 100, 72% respectively. Re-testing of 17 discordant original NP aspirates using Directigen, suggested that errors were due to technologist interpretation as well as to overt assay failure. The low analytical sensitivity and specificity of Directigen precludes its use in the clinical setting described in this study. Evening or weekend specimen collection, followed by IFA testing in a centralized Virology Laboratory at the start of the next working day, produces reliable test results. Among the small number of pediatric patients who might be candidates for antiviral therapy IFA testing should be made available on an on-call basis by Virology Laboratory.

Influenza and respiratory syncytial virus. Update on infection, management, and prevention.

This article is an overview of the epidemiology and spectrum of clinical disease attributed to influenza and respiratory syncytial virus in children. It separately discusses the pathogenesis of the two diseases and the host responses to the viruses to emphasize each infection's significance and need for a vaccine. Updates on current preventive measures and a preview of potential future vaccine developments are presented.

Psychosocial correlates of chronic fatigue syndrome in adolescent girls.

Behavior problems and family functioning were investigated in a sample of 10 adolescent girls with chronic fatigue syndrome (CFS), 10 matched healthy adolescent girls, and 10 adolescents with childhood cancer in remission. Based on the adolescent girls' reports, the CFS group had significantly higher scores than the cancer and healthy comparison adolescent girls on somatic complaints and also significantly higher scores than the cancer controls on internalizing symptoms and depression. Parent reports resulted in significantly higher scores in the CFS group than the adolescent girls from the healthy comparison groups on internalizing scores and somatic complaints. There were no significant differences on any family variables.

Neurobehavioral manifestations and sequelae of HIV and other infections.

Central nervous system infections in children and adolescents involve a wide spectrum of illnesses, ranging from acute self-limited diseases, such as enteroviral meningitis, to severe diffuse or focal infections (i.e., arboviral encephalitis) resulting in devastating neurologic sequelae. All the clinical manifestations of CNS infections occur to some degree secondary to toxic mediators such as cytokines. These factors are neurotoxic and produce clinical manifestations such as encephalopathy, motor abnormalities, and seizures. Many of these diseases also produce radiculoneuropathies and vasculopathies (stroke). As a result, chronic neurologic conditions may result and are frequently associated with psychiatric disturbances and situational depression.

Lemierre's and Lemierre's-like syndromes in association with infectious mononucleosis.

OBJECTIVE: This study aimed to review cases of Lemierre's and Lemierre's-like syndromes in paediatric patients, to examine a possible association with Epstein-Barr virus as a predisposing factor, and to assess the impact of this virus on the severity of illness. METHODS: We performed a retrospective analysis of data from the in-patient database at Winthrop University Hospital, from January 2001 to October 2007. We reviewed clinical and laboratory findings as well as the outcome of infection in patients aged 21 years or less with a diagnosis of Lemierre's syndrome. An additional case of Lemierre's-like syndrome was also included. The illness severity and duration of in-patient management of those testing positive for heterophile antibody were then compared with the same parameters in patients who tested negative. RESULTS: Of the five patients diagnosed with Lemierre's syndrome, two had concomitant acute infection with Epstein-Barr virus. Additionally, a 19-year-old adolescent was admitted during this period with acute infectious mononucleosis, Fusobacterium necrophorum sepsis, sinusitis, frontal lobe abscess and ophthalmic vein thrombosis. The clinical presentation of all patients included fever, sore throat, and ear or neck pain. The duration of symptoms ranged from two days to three weeks prior to admission. The patients with acute Epstein-Barr virus infection had been diagnosed with infectious mononucleosis prior to admission, and tested positive for heterophile antibody. These patients subsequently underwent more extensive in-patient treatment, including intensive care management and ventilator support. The patients who tested negative for heterophile antibody experienced a milder course of illness, with a shorter duration of in-patient management. CONCLUSION: Two patients diagnosed with Lemierre's syndrome, and a third with Fusobacterium necrophorum sepsis, had coexisting acute Epstein-Barr virus infection. Patients who tested positive for heterophile antibody experienced a more severe course of illness. These observations suggest a possible association between Epstein-Barr virus infection and the severity of concomitant Lemierre's syndrome.