Biomedical subjects
Publications and source records attributed to G S Marshall.
A 3 year old girl with hepatosplenic cat scratch disease developed prolonged fever unresponsive to treatment with multiple antibiotics, including gentamicin, azithromycin, rifampin, and ciprofloxacin. Fever resolved with corticosteroid treatment.
A 4-week-old female newborn developed ascending flaccid paralysis and radiologic evidence of myelitis; the diagnosis of congenital toxoplasmosis was confirmed by the presence of Toxoplasma gondii-specific immunoglobulins in both mother and infant, and detection of Toxoplasma sequences in the infant's cerebrospinal fluid by polymerase chain reaction analysis. Treatment with pyrimethamine, sulfadiazine, and methylprednisolone resulted in improvement.
The induction of autoantibodies to U1 small nuclear ribonucleoprotein (U1 snRNP) complexes is not well understood. We present evidence that healthy individuals with cytomegalovirus (CMV) infection have an increased frequency and quantity of antibodies to ribonucleoprotein, directed primarily against the U1-70k protein. A significant association between the presence of antibodies to CMV and antibodies to the total RNP targeted by the immune response to the spliceosome (to both the Sm and RNP; Sm/RNP) was found for patients with systemic lupus erythematosus (SLE) but not those with mixed connective-tissue disease. CMV thus may play a role in inducing autoimmune responses in a subset of patients with systemic lupus erythematosus.
The end of the 20th century saw the realization of a goal that was previously only dreamed about: the near elimination of many deadly infectious diseases through universal vaccination. As one disease after another has been driven from memory, it is vaccination programs themselves that have come to occupy the public's mind. With increased scrutiny comes the promise that vaccines will become even safer, but there is also the threat that ill-founded concerns will result in reduced immunization rates, and diseases will resurge. This article reviews scientific data relating to current vaccine safety concerns.
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Neutrophilic dermatoses such as pyoderma gangrenosum are characterized by sterile, neutrophilic cutaneous infiltrates. Extracutaneous neutrophilic infiltrates can occur, primarily in the joints, lungs, heart, central nervous system, gastrointestinal tract, and eyes. Pulmonary disease is the most frequently reported extracutaneous manifestation of pyoderma gangrenosum and is characterized by patchy infiltrates or interstitial pneumonitis. We describe an adolescent with typical pyoderma gangrenosum who presented with cavitary pneumonia and responded completely to oral corticosteroids. In patients with inflammatory ulcers, extracutaneous neutrophilic disease should be considered, once an infectious process has been excluded.
The gB protein (gpUL55) of human cytomegalovirus (CMV) contains C-terminal (AD-1) and N-terminal (AD-2) linear immunodominant neutralizing domains. To measure antibodies to these epitopes, a modified protein (delta-gB) lacking heavily glycosylated intervening regions, the transmembrane domain, and the cytoplasmic domain, was expressed in recombinant baculovirus-infected cells. Eighty-six percent of 600 naturally CMV-seropositive individuals and 93% of 121 gB vaccine recipients had antibodies to delta-gB as detected by enzyme-linked immunosorbent assay (ELISA). The antibody level in vaccinees (median optical density [OD] = 1.73) exceeded that in natural seropositives (median OD = 0.94; p < .0001). Eleven percent of 95 natural seropositives and 7% of 120 gB vaccinees lacked A-gB antibodies but had neutralizing activity. Among subjects with delta-gB antibody, there were weak correlations between antibody level and neutralizing titer. These data suggest that antibodies to linear neutralizing gB domains are highly prevalent in naturally-infected individuals and regularly develop in gB vaccinees. However, for some individuals, discontinuous and/or linear epitopes not represented on delta-gB may be more important in the generation of neutralizing responses.
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BACKGROUND: The diagnosis of Kawasaki disease (KD) is made by fulfillment of clinical criteria. The dramatic effectiveness of intravenous immune globulin in this disease might lead to treatment of cases that do not meet those criteria. METHODS: A retrospective review was conducted of all cases of KD treated at Kosair Children's Hospital between January 1993 and July 1997. RESULTS: Fifty-six patients were identified. Demographic features were similar to reports from other regions of the country. Forty-eight children fulfilled criteria for typical or atypical KD and 8 (14%) did not. The latter children were not distinguished from those meeting criteria by standard laboratory test results. Echocardiographic abnormalities were found in 17 cases, including 3 with coronary artery aneurysms, but all abnormalities eventually resolved. CONCLUSIONS: The treatment of 14% of patients despite incomplete diagnostic criteria illustrates the tendency to be liberal in treatment decisions regarding KD. Whether this proportion of patients has a forme fruste of the illness that warrants treatment will await definitive biological markers for the syndrome.
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OBJECTIVE: To determine if psychological morbidity in youth with chronic fatigue is caused by the stress of coping with a chronic illness. STUDY DESIGN: Case-control study comparing pediatric patients with debilitating chronic fatigue and matched subjects with juvenile rheumatoid arthritis, a chronic medical illness with similar functional sequelae. SETTING: Pediatric Infectious Diseases Clinic and Juvenile Rheumatoid Arthritis Clinic of Kosair Children's Hospital. PARTICIPANTS: Nineteen children and adolescents with debilitating chronic fatigue and 19 age- and sex-matched peers with juvenile rheumatoid arthritis. Outcome. Structured Interview, Kaufman Brief Intelligence Test, Child Behavior Checklist, and Youth Self-Report. RESULTS: Intellectual functioning on the Kaufman Brief Intelligence Test Composite was average (103, standard score) for both groups. Pediatric patients with chronic fatigue had higher levels of internalizing psychological distress than patients suffering from juvenile rheumatoid arthritis, despite the fact that both groups had a similar pattern of decline in social and physical activities. Duration of illness did not explain the difference in psychological symptoms. CONCLUSIONS: Psychological factors may play a more active role in debilitating chronic fatigue in pediatric patients than can be explained by the stress of coping with a similar chronic, non-life-threatening illness.
Pseudoaneurysm formation of the cervical internal carotid artery (ICA) is a rare, potentially lethal complication of deep neck space infection. This entity typically occurs following otolaryngological or upper respiratory tract infection. The pseudoaneurysm is heralded by a pulsatile neck mass, Homer's syndrome, lower cranial neuropathies, and/or hemorrhage that may be massive. The recommended treatment includes prompt arterial ligation. The authors present a case of pseudoaneurysm of the cervical ICA complicating a deep neck space infection. A parapharyngeal Staphylococcus aureus abscess developed in a previously healthy 6-year-old girl after she experienced pharyngitis. The abscess was drained via an intraoral approach. On postoperative Day 3, the patient developed a pulsatile neck mass, lethargy, ipsilateral Horner's syndrome, and hemoptysis, which resulted in hemorrhagic shock. Treatment included emergency endovascular occlusion of the cervical ICA and postembolization antibiotic treatment for 6 weeks. The patient has made an uneventful recovery as of her 18-month follow-up evaluation. Conclusions drawn.from this experience and a review of the literature include the following: 1) mycotic pseudoaneurysms of the carotid arteries have a typical clinical presentation that should enable timely recognition; 2) these lesions occur more commonly in children than in adults; 3) angiography with a view to performing endovascular occlusion should be undertaken promptly; and 4) endovascular occlusion of the pseudoaneurysm is a viable treatment option.
OBJECTIVE: To study the effect of an educational intervention on the management of hospitalized infants with bronchiolitis. DESIGN: Sequential, prospective cohort study. SETTING: A 235-bed children's hospital with nearly all private rooms. PATIENTS: Consecutively admitted, previously healthy children younger than 24 months with symptoms of bronchiolitis. The first cohort was enrolled between January 1 and January 21, 1996; the second cohort between January 29 and February 18, 1996, following a 1-week intervention period; the third (follow-up) cohort between December 1996 and February 1997. INTERVENTION: Educational program and practice guidelines aimed at appropriate utilization of diagnostic tests, decreased antibiotic and bronchodilator use, increased compliance with isolation, decreased length of stay, and maintenance of quality care. MAIN OUTCOME MEASURES: Utilization of respiratory syncytial virus (RSV) enzyme immunoassay, initiation and duration of parenteral antibiotic therapy, number of nebulized bronchodilator treatments, isolation orders, length of stay, and readmission rate. RESULTS: A total of 90 patients were studied preintervention, 63 postintervention, and 90 during the follow-up period. The groups were comparable in demographic and clinical features. No patient had a documented serious bacterial infection; however, almost half in each group received parenteral antibiotics, despite recommendations against this. Immediately postintervention, children with positive RSV test results received antibiotics on fewer days than other children (median 0.6 vs 2.4 days; P=.004), suggesting that physicians stopped treatment with antibiotics once a viral diagnosis was confirmed. This effect did not persist into the follow-up period. Viral testing was reduced and isolation orders increased. Use of bronchodilators was reduced from 91% preintervention to 80% during the follow-up period (P=.046), and the median number of treatments was reduced from 15.0 to 10.0 (P=.005). There was no change in length of stay, which was 2 to 3 days, or in readmission rate, which was 1% to 4%. CONCLUSION: Educational efforts centered around practice guidelines can improve some aspects of the treatment of patients hospitalized with bronchiolitis.
In patients with infectious mononucleosis, abdominal pain is usually attributed to visceral enlargement. A teenage girl with symptoms of appendicitis was found at laparotomy to have mesenteric adenitis. Postoperatively, she developed classic features of Epstein-Barr virus (EBV)-induced mononucleosis. The lymphoproliferation characteristic of EBV infection can cause severe localized abdominal pain that predates the onset of mononucleosis.
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BACKGROUND: Although rapid viral tests are commonly used in children with lower respiratory tract infection, their effect on patient management has not been studied. OBJECTIVES: To examine how physicians utilize an enzyme immunoassay for respiratory syncytial virus (RSV EIA) and a centrifugation-enhanced cellular immunofluorescence assay for multiple viral pathogens [viral respiratory panel (VRP)] in children hospitalized with respiratory illness; to determine the effect of testing on length of stay, antibiotic use and costs; and to determine physician attitudes toward RSV testing. DESIGN AND SETTING: Prospective study and survey at a large children's hospital. PATIENTS: Previously healthy children < 24 months of age consecutively admitted between January 1 and February 11, 1995, with symptoms of lower respiratory tract infection. RESULTS: Of 200 patients 160 were tested by RSV EIA; 92 were positive and 68 were negative. Tested children were younger, more tachypneic and more likely to require oxygen than those not tested. Overall the length of stay was similar in RSV-positive and -negative patients. Although equal proportions of each group were given antibiotic therapy, RSV-positive children received antibiotic therapy for fewer days than RSV-negative children (median 2 vs. 3 days; P = 0.0387). However, a crude cost analysis did not support a strategy of testing all bronchiolitis patients for RSV. Sixty-five of the 68 RSV-negative children were tested for RSV and other pathogens by VRP. In 55 cases the results were not available until after patient discharge and could not have influenced their management. One hundred three physicians caring for children in the study were surveyed. Of 75 respondents almost all thought that RSV EIA results influenced their management of patients and were important to parents. CONCLUSIONS: Most children hospitalized with symptoms of lower respiratory tract infection were tested for viral pathogens. The VRP provided little clinically useful information. In contrast RSV EIA results may have been used by clinicians to make antibiotic decisions. Physicians felt that rapid testing for RSV was important.