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THE JOURNAL OF THE JAPAN PEDIATRIC SOCIETY
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Vol.117, No.6, June 2013
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Original Article
Title
Non-convulsive Seizures in Children with an Altered Mental State Associated with Influenza A (H1N1) pdm09 Infection
Author
Kyoko Fujita1) Hiroaki Nagase1) Taku Nakagawa2) Yohsuke Saji3) Azusa Maruyama1) and Yoshiyuki Uetani2)
1)Department of Neurology, Hyogo Prefectural Kobe Children's Hospital
2)Department of General Medicine, Hyogo Prefectural Kobe Children's Hospital
3)Department of Emergency and Critical Care Medicine, Hyogo Prefectural Kobe Children's Hospital
Abstract
Background
In the intensive care unit setting, children with an altered mental state often present with non-convulsive seizures (NCS). Children with influenza infection can occasionally show an altered mental state; however, the prevalence of NCS in children with influenza infection and an altered mental state remains unclear.
Objective
To clarify the prevalence of NCS in children with an altered mental state associated with influenza A (H1N1) pdm09 infection.
Methods
We retrospectively reviewed the cases of 15 children with influenza A (H1N1) pdm09 infection and an altered mental state. The presence of NCS was confirmed using continuous electroencephalogram (EEG) monitoring.
Results
Five children showed NCS on continuous EEG monitoring.
Conclusion
Thirty-three percent of the children with influenza A (H1N1) pdm09 infection and an altered mental state presented with NCS. Further study is needed to determine whether the detection and management of NCS improve outcomes.
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Original Article
Title
Clinical Characteristics of Human Herpesvirus-7-positive Patients Presenting with Seizure
Author
Shiho Yamamoto Shoko Tokutake Takafumi Honda Ayako Muto Hiromichi Hamada Kitami Hayashi and Masaru Terai
Department of Pediatrics, Tokyo Women's Medical University Yachiyo Medical Center
Abstract
We report our clinical findings obtained from the investigation of 6 hospitalized human herpesvirus (HHV)-7-positive patients presenting with seizure between December 2007 and March 2011. Typical clinical findings were obtained for all the patients, including skin rashes after the fever subsided, suggesting primary HHV infection. All the patients were confirmed to have HHV-7 DNA in acute sera by conventional PCR. Their median age at onset was 15.5 months, which was older than that in HHV-6-positive patients. Four patients developed acute encephalopathy. We compared HHV-7-associated encephalopathy (n=4) with HHV-6-associated encephalopathy (n=12). The average age of patients was higher in the HHV-7 group than in the HHV-6 group. The mean pediatric indexes of mortality were 4.6% in the HHV-6 group and 3.6% in the HHV-7 group. Magnetic resonance imaging showed abnormal findings in 50% of the patients in the HHV-6 group, but in none of the patients in the HHV-7 group. The pediatric cerebral performance category was higher in the HHV-6 group than in the HHV-7 group. These findings suggest that primary HHV-7 infection occurs later than primary HHV-6 infection, and that HHV-7-associated encephalopathy is not as severe as HHV-6-associated encephalopathy.
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Original Article
Title
Periorbital and Orbital Cellulitis in Children: A Retrospective Review of 32 Cases
Author
Kenji Kishimoto Takuya Tamura and Tsunekazu Haruta
Department of Pediatrics, Kobe City Medical Center General Hospital
Abstract
Objective: To clarify the clinical features of childhood periorbital and orbital cellulitis.
Methods: We retrospectively reviewed 32 medical records of children hospitalized for periorbital cellulitis (PC) or orbital cellulitis (OC) in our hospital.
Results: A total of 25 cases of PC and 7 cases of OC were reviewed. Patients with PC were significantly younger than patients with OC. There was no significant difference between the 2 groups in the proportion of patients with high fever, initial leukocyte counts, and maximum C-reactive protein values. Proptosis and ophthalmoplegia were documented in 3 (43%) and 6 (86%) of the patients with OC, respectively. The major predisposing factors in PC were sinusitis, upper respiratory tract infection, bacteremia, and eyelid trauma, whereas patients with OC were significantly more likely to have sinusitis. Three children (12%) with PC had Heamophilus influenzae type b bacteremia. All of the patients received intravenous antibiotics immediately after admission. Only 1 patient (14%) with OC had surgical drainage. Neither recurrence nor sequelae occurred.
Conclusions: Differentiation between PC and OC can be difficult in children. Prompt and accurate diagnosis through imaging studies is crucial. Early administration of antibiotics may reduce complications and sequelae.
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Original Article
Title
A Scale for Evaluating Difficulties in Daily and Social Life Based on the Children's Global Assessment Scale
Author
Yuko Yamauchi1)2) Takeo Fujiwara3) Makiko Okuyama1)2) and Hiroyuki Ida2)
1)Department of Psychosocial Medicine, National Center for Child Health and Development
2)Department of Pediatrics, Jikei University
3)Section of Social Medicine, National Center for Child Health and Development
Abstract
While treating children with mental disorders, it is important to evaluate improvements in functional and social abilities as well as any symptoms occurring as a result of treatment. The Children's Global Assessment Scale (CGAS) is a valuable tool to evaluate the social function of children, but the use of this scale is not convenient because of the numerous detailed questions and the inability of family members to administer it. An alternative scoring procedure for evaluating difficulties in daily and social life was created on the basis of the CGAS. This alternative scale is convenient because both doctors and the patients' family members can use it to evaluate the current condition of the patient. The score obtained from this scale correlates with that obtained from the CGAS (0.74 P<0.001), and it was found to be useful for evaluating difficulties in daily and social life.
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Original Article
Title
Treatment and Outcome of 22 Cases of Haemophilus influenzae Meningitis
Author
Natsuko Katsube Masako Nagashima Yukifumi Monden Tokiko Fukuda Yasuyuki Nozaki Masato Mori Hideo Sugie Takanori Yamagata and Mariko Y Momoi
Department of Pediatrics, Jichi Medical University
Abstract
We clarified the relation between drug treatment and outcome of H. influenzae meningitis by retrospectively analyzing the cases of 22 infant patients admitted to our hospital from 2000 to 2010. The patients were divided into the resistant group and the non-resistant group. Patients who were refractory to drug treatment comprised 40% (4/10) of the resistant group and 42% (5/12) of the non-resistant group. Infants under 12 months were significantly more refractory to treatment than the older patients in the non-resistant group (P=0.021). The interval between the onset of the disease and the initiation of treatment did not differ significantly between the 2 groups. Glucose levels in the cerebrospinal fluid (CSF) at the time of diagnosis were lower in the refractory group than in the responsive group only in the resistant group (P=0.021). Six of the 14 patients (42.9%) who had periods of monotherapy with either cefotaxime or meropenem during the first 7 days developed neurological sequelae. In contrast, only 1 of the 8 (12.5%) patients treated with the 2 antibiotics for more than 8 days developed neurological sequelae. Significant relations were observed between hearing difficulty and high CSF cell counts (P=0.031), and between mental retardation and onset at a young age (P=0.029). The initial response to the drug treatment was not related to the development of neurological sequelae. Chloramphenicol (CP) was effective in 1 patient with subdural empyema caused by drug-resistant H. influenzae, suggesting that CP can be a second-line treatment in refractory cases.
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Original Article
Title
A Case of Acne Fulminans in Which Magnetic Resonance Imaging Was Useful for Diagnosis
Author
Ken Saida1) Norimoto Kobayashi2) Yosuke Shima1) Kentaro Yoshikawa3) Takafumi Nishimura3) Tatsunori Sumi3) Fumio Morohashi1) Eizaburo Ishii3) Hiroshi Kawai3) and Kenichi Koike2)
1)Department of Pediatrics, Shinonoi General Hospital
2)Department of Pediatrics, Shinshu University School of Medicine
3)Department of Pediatrics, Division of General Medicine, Nagano Children's Hospital
Abstract
A 14-year-old boy with a 1-year history of mild acne vulgaris on the face suddenly developed multiple reddish papules accompanied by pustules, crust formation, sharp pain, and rapid ulceration. He had been prescribed antibiotics and a topical product for acne at a dermatology clinic, but there had been no marked improvement. One month later, he consulted an orthopedic surgeon because of a mild fever, back pain, and knee joint pain. Arthritis was suspected and he was hospitalized. Two days after hospitalization, his low back pain worsened. Intravenous infusion of antibiotics resulted in no improvement, and body movement became difficult because of severe pain. Magnetic resonance imaging (MRI) of the lumbar vertebrae showed contrast enhancement around the spinous process and adjacent soft tissue. His condition was diagnosed as acne fulminans (AF) based on the presence of an osteoarticular lesion with acute acne. Naproxen was not effective, but prednisolone improved his symptoms. AF is included in synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome. However, the MRI findings of the osteoarticular lesion in our patient differed from those of many previous reports of SAPHO syndrome. Thus, AF and SAPHO syndrome may be different clinical entities based on MRI findings and response to treatment.
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Original Article
Title
A Fatal Case of Neonatal Necrotizing Fasciitis Following Omphalitis
Author
Rie Kuge1) Nobuaki Inoue2) Naoki Shimizu2) and Yuho Horikoshi3)
1)Division of General Pediatrics, Tokyo Metropolitan Children's Medical Center
2)Department of Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center
3)Division of Infectious Diseases, Tokyo Metropolitan Children's Medical Center
Abstract
A full term 9-day-old-boy presented at a local hospital with poor feeding and abdominal distension. His perinatal history was unremarkable. He developed septic shock and was transferred to our hospital for further management. On physical examination, he had significant abdominal distension with periumbilical erythema. He developed ventricular tachycardia secondary to hyperkalemia and received chest compressions for 3 minutes. He was intubated and admitted to the Pediatric Intensive Care Unit. The care team initially suspected intestinal necrosis of unknown origin from the significant abdominal distension with shock status. Exploratory laparotomy showed no significant abnormalities of the intestinal tract. However, he continued to deteriorate and required extracorporeal membrane oxygenation (ECMO) for circulatory support. He was also noted to have progression of dark red discoloration of the periumbilical skin. At this point, necrotizing fasciitis following omphalitis was strongly suspected and a second surgery with debridement of subcutaneous tissue and peritoneal fascia of the periumbilical area was performed. However, even after the successful removal of infected tissues, intravascular volume could not be maintained despite aggressive fluid management and ECMO support. He died 17 hours after the initial hospitalization. The fascial tissue culture yielded Escherichia coli, Clostridium sordellii and Clostridium ramosum. Clostridium sordellii was suspected to produce lethal toxin (LT), as shown in a positive test using a commercial Clostridium difficile A/B toxin kit (enzyme immunoassay, Nissui, Japan). LT causes toxic shock syndrome and plays a major role in pathogenicity. LT is also known to resemble C. difficile toxin structurally. Pathological findings of the fascia were also compatible with necrotizing fasciitis. To the best of our knowledge, this is the first published case report in Japan. Omphalitis is a common infection in neonates. Physicians should be aware that necrotizing fasciitis can be a fatal complication of omphalitis. Early recognition and prompt surgical intervention are extremely important life saving measures for infants with necrotizing fasciitis.
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Original Article
Title
A Case of Pneumococcal Meningitis due to Oropharyngeal Injury
Author
Hisamitsu Tamaki Masahiro Otsuka Masahiro Ito Kosuke Nishiguchi Tae Omori and Masahiro Misawa
Department of Pediatrics, Tokyo Metropolitan Bokuto Hospital
Abstract
Oropharyngeal penetrating injuries are common in children, and every emergency room (ER) clinician encounters these injuries frequently. In most cases, these injuries are superficial and the vast majority of these injuries heal spontaneously without complications. However, a small minority of these injuries causes serious complications, such as carotid artery injury, penetrating head or spinal canal injury, deep neck infection, brain abscess, and meningitis. In this study, we present the case of a child with pneumococcal meningitis due to penetration of a chopstick into the oropharyngeal wall. A plastic chopstick accidently penetrated into the throat of a 2-year-old girl via her mouth; her father removed the chopstick immediately. The depth of this penetration wound was estimated to be approximately 3 cm. After 15 minutes, she was admitted our ER. She presented with a wound in the left soft plate. Plain computed tomography scan of the head and neck revealed no abnormal findings except for retropharyngeal mucosal swelling and free air. The following day, she had fever, consciousness disorder, and meningeal signs. Her cerebrospinal fluid (CSF) cell count was 3,786/3 μl with neutrophilic pleocytosis. Penicillin resistant Streptococcus pneumoniae (serotype 23) was isolated from her blood and CSF culture. For the pneumococcus, the minimal inhibitory concentrations of penicillin G, cefotaxime, meropenem, and vancomycin were 1.0 μg/ml, 1.0 μg/ml, 0.5 μg/ml, and 0.5 μg/ml, respectively. Intravenous antimicrobial therapies with ceftriaxone and vancomycin for 14 days were effective. We attributed the occurrence of meningitis in our patient to 2 probable causes: direct seeding of bacteria from the oropharynx into the central nervous system (via the direct infiltration of bacteria into the head or spinal canal), or infiltration of bacteria from the wounded mucosa into the circulation (via bacteremia). Patients with penetrating oropharyngeal injury require antimicrobial therapy to treat infection caused by oral flora (anaerobic species, coagulase-negative staphylococcus, streptococcal species, and Staphylococcus aureus) that cause traumatic meningitis, as seen in our case. Although every ER clinician encounters pediatric oropharyngeal injuries, serious complications are rare. However, a small minority of these injuries causes serious complications. Therefore, ER clinicians must carefully manage oropharyngeal injuries.
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Original Article
Title
Fulminant Hepatic Failure in a Child with Spinal Muscular Atrophy: A Case Report
Author
Rie Habuka1) Toshiaki Suzuki1) Hiroya Hasegawa1) Tamaki Karasawa1) Utako Kaneko1) Yohei Ikezumi1) Tsukasa Ohashi2) Noriyuki Akasaka2) Jun Toyama2) Hisahide Nishio3) and Akihiko Saitoh1)
1)Department of Pediatrics, Niigata Univesity Medical and Dental Hospital
2)Department of Pediatrics, Nishi-Niigata Central National Hospital
3)Department of Community Medicine and Social Healthcare Science, Kobe University Graduate School of Medicine
Abstract
Although the etiologies of fulminant hepatic failure are unknown in most children, metabolic diseases, viral infections, and drugs are probable etiologies. Herein, we describe a case of fulminant hepatic failure in a child with spinal muscular atrophy (SMA). A 3-year-old boy was admitted to a hospital because of repeated episodes of aspiration pneumonia. During the course of treatment, he developed hepatic dysfunction with markedly elevated levels of serum hepatic enzymes and was subsequently transferred to our institution for further evaluation and treatment. On admission, computed tomography scan revealed liver enlargement and fatty degeneration, and the next day, the patient rapidly progressed to stage III hepatic coma. After commencing intensive care, during which plasma exchange and continuous hemodiafiltration were performed, his hepatic function recovered gradually without the need for liver transplantation. Furthermore, he did not develop any chronic liver disease. To the best of our knowledge, this is the first case report of acute hepatic failure accompanied by SMA type 1. Although the pathogenesis in this case was unknown, previous reports suggested that patients with severe SMA in the fasting state develop abnormal dicarboxylic aciduria and abnormal fatty acid metabolism. Moreover, metabolic disorders such as defects in beta-oxidation of fatty acids have often been associated with hepatic failure. Therefore, on the basis of these reports, we speculate that abnormal fatty acid metabolism may have led to fulminant hepatic failure and Reye syndrome-like clinical presentation in our patient. In conclusion, patients with SMA, particularly those in a fasting state, should be treated carefully to avoid progression to fulminant hepatic failure.
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Original Article
Title
Acquired Bronchoesophageal Fistula Caused by an Esophageal Foreign Body in a Patient with Severe Motor and Intellectual Disability
Author
Junnpei Mukai Masayuki Shimohira Masato Nishioka Risa Nomura and Ruri Satomi
Department of Pediatrics, Kawaguchi Municipal Medical Center
Abstract
Acquired bronchoesophageal fistula (BEF) is a rare entity. One cause of this disorder is the presence of an esophageal foreign body. We present a case of acquired BEF with left bronchial stenosis caused by such a foreign body. The patient was an 11-year-old girl who suffered from shaken baby syndrome at the age of 3 months. She underwent tracheotomy and gastrostomy and received medical care at home. She was referred to our hospital for a low breath sound in her left lung. Chest computed tomography revealed an esophageal foreign body and left bronchial stenosis. Her condition was diagnosed as BEF by esophagography. Esophageal endoscopy was performed and we removed the foreign body which was identified as the tip of a low-pressure continuous suction unit used for saliva ejection. We initially planned on conservative management, but it was difficult to control the increased tracheal secretions. In addition, no spontaneous closure of the fistula had occurred 2 months after the foreign body was removed. Surgical closure was difficult because of the patient's general condition. To prevent aspiration of mucus from the esophagus through the fistula, cervical esophagostomy was performed as palliative management. The tracheal secretions then markedly decreased. We are currently planning to perform Nissen fundoplication. BEF caused by an esophageal foreign body is rare and difficult to diagnose. We should consider the possibility that ingestion of a foreign body may lead to serious complications.
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Title
Current Status of Vitamin K Prophylaxis in Hokkaido after Publication of "Revised Guidelines for Vitamin K Deficiency Bleeding in Infants and Newborns (Modified Version)"
Author
Satoko Noguchi Hideomi Asanuma Shuku Ishikawa Junya Iida and Yuichi Niida
Department of Neonatology, Hokkaido Medical Center for Child Health and Rehabilitation
Abstract
The Japan Pediatric Society Newborn Committee published the "Revised Guidelines for Vitamin K Deficiency Bleeding in Infants and Newborns (Modified Version)" in March 2011. To review the current situation of oral vitamin K prophylaxis regimens in maternity hospitals in Hokkaido after the publication of these revised guidelines, we carried out a questionnaire survey in January 2012.
A total of 71 hospitals responded to the survey. Nine out of 49 hospitals with pediatricians and 2 out of 22 hospitals without pediatricians, for a total of 11 hospitals have adopted "an oral dose of vitamin K2 of 2 mg at birth, and 2 mg every week from 1 week to 3 months old" for full-term healthy infants as recommended in the guidelines. The revised guidelines (modified version) do not clearly state the strength of the recommendation for a continuous prophylaxis until 3 months old, and therefore the decision was made by each hospital. As a result, only 16% (11 out of the 71 hospitals) employ the new method. The other 78% (55 out of the 71 hospitals) have used the conventional method, "a 3 oral doses of 2 mg (at birth, on the 7th day, and at 1 month)" as recommended.
To avoid the risk of vitamin K deficiency bleeding during infancy for more infants, particularly breastfed babies, the diffusion of a "weekly oral dose of 2 mg until 3 months old" method is advisable. It is believed that understanding the accurate incidence rate of vitamin K deficiency bleeding, presenting a clear statement of the strength of the recommendation, and providing current information to obstetricians are required.
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