Acute pyomyositis of the pelvis: the spectrum of clinical presentations and MR findings

Background: Acute pelvic pyomyositis is uncommon in non-tropical areas. Objective: To summarize the clinical and MR findings in children with acute pelvic pyomyositis. Materials and methods: We retrospectively identified 20 children (mean age 9.4 years) who were evaluated by MR and diagnosed with acute pelvis pyomyositis during the time period between January 2002 and June 2005. We reviewed clinical, laboratory, and imaging findings. Results: Fifteen of the 20 children had secondary pyomyositis associated with osteomyelitis (n=13), septic hip (n=4) or sacroiliitis (n=4); all were previously healthy except for one child with leukemia. Seven of the children with secondary pyomyositis underwent bone scintigraphy; three (43%) did not show pelvic abnormalities. Staphylococcus aureus was cultured in 13 of the 15 (87%) children. Five of the 20 children had primary pyomyositis. Three had underlying disease and two others were engaged in vigorous physical activity. Bone scintigraphies (n=2) were negative. Cultures were positive for S. aureus in three of the five (60%) children. Conclusion: Septic hip should be the first diagnostic consideration in children with fever and acute hip pain. Pyomyositis should be considered if art\hrocentesis is negative or there is clinical suspicion of infection outside the hip joint. MR is the preferred imaging modality for evaluating foci of pyomyositis, muscle abscesses, and additional foci of infection within the pelvis.     

Bacteremia in children at the University Hospital in Riyadh, Saudi Arabia

Background  Bacteremia is a major pediatric health care problem despite the availability of new modalities in the management of this disease. The aim of the present study was to determine the incidence and pattern of bacteremia in pediatric group at a tertiary hospital in Riyadh, Saudi Arabia. Methods  This retrospective study was conducted at the Department of Pediatrics, College of Medicine, King Khalid University Hospital, Riyadh in the period of January 2003 to January 2005. Positive culture was found in 259 patients aged below 15 years with a total of 8244 admissions in the period. Results  The highest incidence of bacteremia was found in patients aged less than 1 year (57.9%), and the majority of patients (30.5%) were infants aged less than 1 month. Staphylococcus aureus was the most common isolated pathogen (18.7%). Prematurity was associated with 13.2% of the cases, and respiratory tract infection (10.1%) and fever (76.1%) were chief complaints. Conclusions   Staphylococcus aureus is the most common isolated pathogen. The most common primary infections are respiratory tract infection and septic meningitis. Klebsiella pneumoniae and E. coli are the most common isolated Gram-negative organisms.     

Ilio-psoas abscess caused by methicillin-resistant Staphylococcus aureus (MRSA): a rare but potentially dangerous condition in neonates

We report a case of methicillin-resistant Staphylococcus aureus ilio-psoas abscess (IPA) in a neonate. This case has clinical importance because this neonate had toxic shock syndrome-like exanthematous disease, known as NTED, before developing IPA. A high index of suspicion is required for IPA if a neonate presents with limb disuse and fever of unknown origin. Our case required surgical drainage, since ultrasound-guided percutaneous needle aspiration failed.     

Neonatal orbital abscess

Orbital abscess is life‐threatening and rare in children. Reported herein is a term male neonate who had methicillin‐resistant Staphylococcus aureus orbital abscess, and a literature review of this disease. A total of 16 neonates diagnosed with neonatal orbital abscess are reported in the literature. There is a mild male predilection and two neonates were delivered prematurely. Leukocytosis, fever, ethmoiditis and associated upper respiratory tract infection were found in approximately half of them. Eight neonates had sepsis and 14 patients underwent surgical intervention. One patient died. Staphylococcus aureus was identified in 14 out of 17 patients. Neonatal orbital abscess is rarely encountered but may be fatal. Although streptococci are prevalent in childhood orbital infection, S. aureus was predominant in neonatal orbital abscess in the present series. Appropriate antimicrobial therapy against S. aureus is essential in treating neonatal orbital abscess. This case suggests that a higher initial dose of vancomycin may be an effective and safe strategy for severe S. aureus infection in neonates.     

Fatal infectious mononucleosis with staphylococcal pyoderma in a girl with hereditary immunological dysregulations

We describe a 14-year-old girl with fatal infectious mononucleosis with high fever, pancytopenia, and multiple skin ulcers due toStaphylococcus aureus. Immunological studies revealed low serum IgM, low natural killer (NK) activity, and high CD4/CD8 ratio. Her father had also low NK activity and high CD4/CD8 ratio. It is suggested that she had a dominantly inherited immunodeficiency predisposing to severe Epstein-Barr virus infection.     

Defective phagocytosis confined to Staphylococcus aureus in a female infant with recurrent infections

Defective chemotaxis and phagocytosis of Staphylococcus aureus was identified in a female infant with marked hepatosplenomegaly and recurrent infections. Neutrophil mobilization from the marrow and marginal pool; random mobility; phagocytosis of yeast particles, latex beads and carbon particles; phagocytosis and intracellular killing capacity of Streptococcus pyogenes and E. coli; and NBT dye reduction were normal. Infiltration of neutrophils was depressed in the skin window test. The complement system and cellular immunity were intact. The patient also had a persistent EB virus infection.Defective phagocytosis limited to Staphylococcus aureus seems to be caused by an intrinsic cellular defect, such as congenital defect in neutrophil receptors for Staphylococcus aureus.     

Methicillin‐resistant Staphylococcus aureus bacteraemia and epidural abscess in a neonate

A 24‐day‐old boy presented with fever, irritability and poor feeding. Blood culture grew methicillin‐resistant Staphylococcus aureus. Cerebrospinal fluid analysis showed pleocytosis, and methicillin‐resistant Staphylococcus aureus grew from enrichment broth. Magnetic resonance imaging revealed an epidural abscess extending from C2–3 to T8–9. Staphylococcal infections of the central nervous system are uncommon in neonates. This case demonstrates the importance of performing a lumbar puncture in isolated staphylococcal bacteraemia. The case also highlights that cerebrospinal fluid pleocytosis may indicate a parameningeal focus of infection.     

Primary obturator externus pyomyositis in a child presenting as hip pain: a case report

Hip pain in children often poses a diagnostic dilemma. Septic arthritis, Perthes disease, and slipped capital femoral epiphysis are among the most important causes. Pyomyositis involving muscles around the hip can present with similar features as septic arthritis and are difficult to diagnose because of their rarity and indolent presentation. Obturator internus and iliopsoas muscle abscess have been most commonly reported, with only 1 such report on isolated obturator externus muscle abscess. Routine laboratory investigations are nonspecific, and the diagnosis rests on imaging modalities. Magnetic resonance scan is the most useful investigation in the diagnosis and can pick up early changes in the muscle. Treatment involves appropriate antibiotic therapy with or without drainage. Most cases resolve completely. We report here a case of isolated obturator externus muscle abscess in an 11-year-old child illustrating the similarities with septic arthritis of hip and problems encountered during diagnosis and management.     

Antimicrobial susceptibility of Staphylococcus aureus in children with atopic dermatitis

Background: Skin infection and/or nasal carriage of Staphylococcus aureus in children with atopic dermatitis (AD) is a risk factor for exacerbating disease or subsequent recurrent S. aureus infection. The purpose of the study is to evaluate the antibiotic susceptibilities of S. aureus strains from AD children and determine the most appropriate choice of antibiotics. Methods: Nasal swabs from 168 healthy children with AD and 20 AD children with concurrent skin and soft‐tissue infections (SSTI) were collected in 2005–2008. S. aureus strains were further analyzed for and compared with antibiotic susceptibilities. Results: There were 78 (46.4%) healthy children with AD colonized with S. aureus, and 24 (30.8%) were methicillin‐resistant S. aureus (MRSA). Among the 20 SSTI‐infecting strains, 12 (60%) were MRSA. Antimicrobial susceptibility testing showed that, after penicillin, colonizing and SSTI‐infecting strains had the highest rates of resistance to erythromycin (50% and 70%, respectively). All isolated strains were susceptible to vancomycin, rifampin, and mupirocin. Multi‐drug resistance was found in 70% of the colonizing and 50% of the SSTI‐infecting strains. D‐test assay revealed inducible clindamycin resistance in 75% of the colonizing strains. The most prevalent resistance gene was ermB which was present in 94.9% and 92.9% of colonizing and SSTI‐infecting strains, respectively. Conclusions: This study found that colonizing and SSTI‐infecting strains of S. aureus from AD children had a high prevalence of MRSA and multi‐drug resistance. Trimethoprim‐sulfamethoxazole, rifampin, fusidic acid and mupirocin appear to be more suitable for treatment and decolonization of S. aureus in AD children.     

False aneurysm of the right ventricle due to endocarditis in a child

Summary An eight-year-old boy with supravalvular pulmonic stenosis, supravalvular aortic stenosis, and ventricular septal defect developedStaphylococcus aureus endocarditis. The infection was complicated by formation of a false aneurysm of the right ventricular outflow tract, which was demonstrated by contrast echocardiogram. Surgical treatment was successful. This is a unique case of false aneurysm of the outflow tract of the right ventricle, because it is secondary to endocarditis without known previous trauma to the right ventricular wall.     

Staphylococcus saprophyticus urinary tract infections in children

Staphylococcus saprophyticus commonly causes urinary tract infection (UTI) in young women: in males it is found mainly in the elderly. In this studyS. saprophyticus UTI occurred in 59 children (45 girls and 14 boys) below 16 years of age, of whom 20 were less than 13 years of age. The common presentation was dysuria and flank or back pain whereas fever 38.5°C was rare. Radiological investigation performed in 63% of the children revealed no anomalies of importance. Children withS. saprophyticus UTI appear to constitute a group with a low frequency of urinary tract anomalies and with a low risk of UTI caused by other bacteria.     

Primary sternal osteomyelitis due to community-associated methicillin-resistant<Emphasis Type="Italic"> Staphylococcus aureus</Emphasis>: case report and literature review

Primary sternal osteomyelitis is a rare infectious disease in paediatric patients. It has not been previously reported as caused by community-associated methicillin-resistant Staphylococcus aureus. We describe a 9-year-old boy with a painful erythematous mid-sternal mass diagnosed as primary sternal osteomyelitis. The aetiological agent was community-associated methicillin-resistant Staphylococcus aureus, carrying a type IV staphylococcal cassette chromosome for mec. Conclusion:Methicillin resistance should be taken into considered in patient with community-associated staphylococcal infections.     

Paravertebral streptococcal myositis complicated by an epidural abscess in a 5-year-old girl]

CASE REPORT: A 5-year-old girl was hospitalised for fever, abdominal and lumbar pain, associated with general impairment state and a whitlow. One of the blood cultures and CSF grew A beta haemolytic Streptococcus, muscular echography and MRI showed paravertebral myositis, which was complicated by an epidural abscess. The outcome was good with medical treatment alone. DISCUSSION: Streptococcal myositis is a rare and severe skeletal muscle infection caused by A beta haemolytic Streptococcus. It is characterized by a muscle necrosis, without abscess formation. It has to be distinguished from pyomyositis, usually caused by Staphylococcus aureus, where a muscle abscess occurs, which must be treated by surgical drainage and antibiotics. Prognosis of this infection is poorer than other muscle infections such as pyomyositis, with a high mortality rate. The diagnosis is difficult and often delayed. Practitioners should keep in mind this diagnosis, even if symptoms are non specific, in front of an undetermined infectious syndrome associated with pain, and make an echography or nuclear magnetic resonance imaging to confirm the diagnosis.     

Low prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in a southwestern region of Germany

Introduction Methicillin-resistant Staphylococcus aureus (MRSA) has developed into an important human pathogen and is increasingly being found to be the cause of skin and soft tissue infections or invasive infections in many communities. We have determined the prevalence of MRSA among S. aureus isolates from pediatric in- and outpatients of the University Children’s Hospital of Freiburg, from children attending primary care pediatricians and from healthy children entering school in a prospective study carried out in a southwestern region of Germany. Of the healthy children tested, all between 5 and 7 years of age, 25.8% were intra-nasally colonized with S. aureus. A total of 1455 S. aureus isolates were tested for antibiotic susceptibility. Apart from penicillin resistance (82.1%), an overall high susceptibility of S. aureus to antibiotics, including clindamycin, was common, while resistance among the S. aureus isolates to erythromycin and clindamycin had even significantly decreased from 2002 to 2004. Methicillin-resistance was exceedingly rare (0.3%).Conclusion In the southwestern region of Germany, about one quarter of the healthy children tested at school entry were found to be colonized with S. aureus. The prevalence of MRSA among healthy as well as hospitalized children colonized with S. aureus is still extremely rare in this region.     

Staphylococcus aureus epidemic in a neonatal nursery: a strategy of infection control

The risk of nosocomial infection due to Staphylococcus aureus in fullterm newborns is higher under hospital conditions where there are overcrowded nurseries and inadequate infection control techniques. We report on an outbreak of skin infection in a Maternity Nursery (May 21, 2000) and the measures undertaken to bring the epidemic under control. These measures included: separating neonates already present in the nursery on August 23, 2000 from ones newly arriving by creating two different cohorts, one of neonates born before this date and one of neonates born later; restricting healthcare workers caring for S. aureus- infected infants from working with non-infected infants; disallowing carrier healthcare workers from caring for patients; introducing contact and droplet precautions (including the routine use of gowns, gloves, and mask); ensuring appropriate disinfection of potential sources of contamination. A representative number of isolates were typed by genomic DNA restriction length polymorphism analysis by means of pulsed-field gel electrophoresis (PFGE). Among the 227 cases of skin lesions, microbiological laboratory analyses confirmed that 175 were staphylococcal infections. The outbreak showed a gradual reduction in magnitude when the overcrowding of the Nursery was reduced by separating the newborns into the two different Nurseries (two cohorts). The genotyping of the strains by PFGE confirmed the nurse-to-newborn transmission of S. aureus. The measures adopted for controlling the S. aureus outbreak can, in retrospect, be assessed to have been very effective.     

Staphylococcus aureus endocarditis and pyomyositis: Rare complications of rotavirus gastroenteritis

Rotavirus may cause life‐threatening complications in untreated patients during the course of gastroenteritis. Electrolyte imbalance, bacteremia and sepsis are the most common complications of rotavirus gastroenteritis (RG). It is believed that translocation of intestinal microorganisms as a result of intestinal epithelium dysfunction is the underlying mechanism of bacteremia in RG. Although Gram‐negative bacteremia has been noted as a complication in RG, Staphylococcus aureus bacteremia and endocarditis have not been reported previously. A 22‐month‐old boy was admitted with complaints of fever, diarrhea and dehydration. He was diagnosed with RG complicated with S. aureus bacteremia, pyomyositis and endocarditis. We call attention to these complications in patients with prolonged or late‐onset fever during RG as rare complications of the disease.     

Specific and nonspecific lymphadenitis in childhood: etiology, diagnosis, and therapy

Over a period of 4 years, 39 children with lymphadenitis were treated surgically; in 31 cases cervical lymph nodes were the main location. In 9 cases the lymphadenitis was caused by mycobacterial infection.Staphylococcus aureus was the most frequent causative organism of unspecific lymphadenitis (11 cases). The therapy of choice appears to be surgical treatment and medical care after operation. Especially in mycobacterial lymphadenitis, complete surgical excision of the lymph node is decisive for definitive healing. There was only 1 case of therapy-resistant, relapsing cervical lymphadenitis that needed a second operation. Causative organisms in this case wereMycobacterium avium andMycobacterium intracellulare. All other patients showed an uneventful postoperative clinical course. We believe that a consequent diagnostic process and cooperation between the pediatric surgeon and pediatrician are necessary for effective therapy.     

A case of milk-protein-induced enterocolitis associated with enterotoxigenic E. coli and MRSA infections

Food protein-induced enterocolitis (FPIE) is a severe, cell-mediated gastrointestinal food hypersensitivity typically provoked by cow’s milk [Joint Task Force of AAAAI and ACAAI Food allergy: a practice parameter. XVII. Differential diagnosis of adverse reaction to foods. Ann Allergy Asthma Immunol 96(3 Suppl 2):S40–S44 (2006)]. We present an infant who developed FPIE associated with enterotoxigenic E. coli (ETEC) and methicillin-resistant Staphylococcus aureus (MRSA) infections. The case suggests that enteral infection may have a role in the development of sensitization to food protein and the pathogenesis of FPIE.     

Acute Pericarditis in Childhood: A 10-Year Experience

Twenty children, aged 6 months to 13 years, with acute pericarditis admitted between 1987 and 1997 to a university hospital were analyzed retrospectively for their etiology, presentation, management, and prognosis. The most common types of pericarditis were purulent (40%), collagen vascular disease (30%), viral (20%), and neoplastic disease (10%). Most children presented with chest pain, fever, and tachypnea, but cardiac tamponade was not seen in any children. Staphylococcus aureus was the most frequent causative organism of purulent pericarditis and septic arthritis was the most common concurrent infection in the patients. Surgical drainage was performed for 11 cases, 9 underwent subxiphoid pericardial window, and 2 underwent thoracotomy. There was no constrictive pericarditis or reaccumulation of fluid after surgery. Two children died, one of staphylococcal septicemia and the other had a malignant mediastinal tumor. The remaining 18 made a complete recovery. We conclude that subxiphoid pericardial drainage is a simple, safe, and quick procedure and can be done easily in general hospitals by pediatric surgeons. The expensive facilities of cardiac surgeries are not needed.     

Infective endocarditis associated with acute leukemia: Report of two cases

There have been few reports regarding infective endocarditis (IE) in patients with leukemia. In the first case, a 15‐year‐old girl with Down syndrome was diagnosed with acute lymphoblastic leukemia. On admission, methicillin‐sensitive Staphylococcus aureus (MSSA) was detected on blood culture. Echocardiography was performed because MSSA was detected repeatedly even after treatment. Vegetation in all of the atria and ventricles met the Duke criteria defining IE. She died of multiple organ failure 21 days after diagnosis. In the second case, an 11‐year‐old boy with acute myeloid leukemia underwent peripheral blood stem cell transplantation (PBSCT). He had fever 68 days after PBSCT, and methicillin‐resistant S. aureus (MRSA) was detected on blood culture. Echocardiography showed vegetation in the right atrium and ventricle. Daptomycin was administered for 7 weeks, and recurrence was not observed. IE should be considered when S. aureus bacteremia is documented even in patients with leukemia.