Infective endocarditis in infants and children

Due to changing characteristics of infective endocarditis in the past two decades, we, retrospectively analysed 28 cases of infective endocarditis in children of age less than 15 years at Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar from December, 1983 to November, 1993. The incidence of disease was observed as 1.5 cases/1000 children admitted with a M:F ratio of 2∶1. Three patients were of age less than 2 years (group I) as 25 were above 2 years of age (group II). The two groups had significant difference in portal of entry of infection, infective microorganisms, echocardiography and prognosis. Congenital heart disease was the commonest underlying cardiac lesion in 24 (85.71%) patients. Portal of entry of infection was apparent in 35.71% only; dental route being more frequent in group II. Streptococcus viridans (in 9 cases) followed by staphylococcus aureus (in 4 cases) were the two common organisms isolated. Patients were treated, for a period of 4–6 weeks with a over all mortality rate of 25%. Factors associated with poor prognosis were age <2 years, staphylococcal infection ad negative blood cultures. Heart failure resistant to medical therapy was a leading cause of death.     

Infective endocarditis: experience of a paediatric emergency department

OBJECTIVES: To determine the clinical features at presentation of children with infective endocarditis to a tertiary centre and review the role of the emergency department in these cases. The subsequent course and outcomes are briefly discussed. METHODS: Retrospective audit of children with endocarditis presenting to a tertiary children's hospital over a 16-year period. RESULTS: Twenty-three cases of infective endocarditis were identified. Initial presentation via the paediatric emergency department occurred in 78% of cases and was associated with the least delay to commencement of appropriate treatment. The average duration of illness at the time of presentation was 6 days. Prior medical care had been sought in 65% of the cases, with antibiotics prescribed for an alternate diagnosis in 73%. Children with and without cardiac anomalies were equally represented. Of the group with normal cardiac anatomy, 45% presented without a murmur. Staphylococcus aureus was the most frequent causative organism (43%) and accounted for 64% of cases in children with no pre-existing cardiac abnormalities. Permanent sequelae were more likely to occur with S. aureus. The overall mortality rate was 9%. CONCLUSIONS: Infective endocarditis is a rare illness in children and represents a diagnostic challenge. The majority of cases will present via the paediatric emergency department with a non-specific febrile illness, having frequently commenced antibiotics for an alternate diagnosis. Specific expertise in paediatric emergency care can assist in early diagnosis and management. Morbidity remains significant, particularly in cases caused by S. aureus.     

Infective endocarditis (IE) in children receiving treatment for cancer

Infective endocarditis (IE) is rare in children but is associated with substantial morbidity/mortality. Medical records of 161 new patients admitted to the Pediatric Oncology Unit in a 2 years period were reviewed to identify patients with a diagnosis of IE following the Duke criteria. Nine patients developed IE; their ages ranged from 2.4 to 11.3 years. The patients received treatment according to the results of blood cultures. TIPs are associated with a high rate of IE. The diagnosis of IE should be considered in children with cancer who have major/minor criteria as defined by the Duke criteria.     

Glioblastoma in long‐term survivors of acute lymphoblastic leukemia: Report of two cases

Acute lymphoblastic leukemia (ALL) is the most common form of cancer in children. Second neoplasms as late effects of therapy for ALL have been recognized as a significant clinical issue given the increasing number of long‐term survivors of ALL, because they can be the cause of death in such cases. In contrast, glioblastoma (GBM) is the most common primary brain tumor in adults. It is a malignant brain tumor that most often occurs in elderly patients, and GBM in young adults or adolescents appears to be rare. Here, we describe our experience of two cases of GBM in young long‐term survivors of ALL, and emphasize the necessity of careful follow up of patients treated for ALL for the potential occurrence of central nervous system second neoplasms, especially when the patients have previously undergone cranial radiotherapy.     

儿童感染性心内膜炎35例分析

目的了解儿童感染性心内膜炎(IE)的临床特点、病原谱特征、耐药状况及预后。方法回顾性分析2007年6月1日至2014年12月31日确诊为IE患儿的临床及病原学资料。结果研究年限内共确诊IE 35例,男15例、女20例,平均年龄为(6.56±0.81)岁。原有先天性心脏病23例(65.7%)。赘生物形成24例(68.6%)。57.4%的患儿有长期发热。血培养阳性19例,占54.3%;其中83.3%为革兰阳性球菌,包括凝固酶阴性葡萄球菌、草绿色链球菌和肠球菌。所有阳性球菌均对万古霉素敏感。结论先天性心脏病是IE的易感因素,感染细菌以革兰阳性球菌为主,对万古霉素敏感。     

Langerhans cell histiocytosis and acute leukemia: Unusual association in two cases

Langerhans cell histiocytosis (LCH) is a non-malignant disorder, whether localized or disseminated, and usually has a favourable prognosis. A possible relationship between LCH and neoplastic diseases has not been assessed up to now even if a few cases have been recorded. We report two new cases of acute leukemia in children with LCH. The first child had acute lymphoblastic leukemia after untreated LCH; the second developed acute promyelocytic leukemia after LCH treated with vinblastine and etoposide. To our knowledge, this is the first case of secondary leukemia after exposure to an epipodophyllotoxin derivative in a child with benign disease. Cooperative studies of large numbers of LCH patients are needed to evaluate a possible association between LCH and acute leukemia, and to identify common risk factors or predisposing agents if such be present. © 1993 Wiley-Liss, Inc.     

Acute lymphoblastic leukemia in Noonan syndrome: Report of two cases

Only two cases of Noonan Syndrome (NS) associated with tumor have previously been reported. The authors describe two new cases of NS with acute lymphoblastic leukemia (ALL), which were part of a series of 370 consecutive ALL untreated patients. © 1993 Wiley-Liss, Inc.     

Follow-up Study on Children with Infective Endocarditis

ABSTRACT. A follow-up study on 36 children having had infective endocarditis during the time period 1971–80 was performed. All answered a questionnaire and 33 underwent a complete noninvasive cardiac examination including exercise test. The study comprised 406 patient years. During this time there were four late deaths and three recurrent attacks of endocarditis. Seventeen (47 %) took prophylactic antibiotics. Two patients had been operated on because of the initial infection and another five had developed intracardiac sequelae. An ability index given to each patient before the infection and at the follow-up showed that as a group these patients were doing well.     

Phase II study of gemcitabine in children with relapsed acute lymphoblastic leukemia or acute myelogenous leukemia (ADVL0022): a Children's Oncology Group Report

BACKGROUND: To determine the response rate and toxicity to gemcitabine administered as 10 mg/m2/min x 360 min weekly for 3 weeks in children with relapsed acute lymphoblastic leukemia (ALL) or acute myelogenous leukemia (AML). Gemcitabine is a deoxycytidine analog that inhibits DNA synthesis and repair and has a broad spectrum of antitumor activity. PROCEDURE: From April 2001 to April 2003, 23 male and 9 female eligible patients were recruited for the Children's Oncology Group (COG) phase II study of Gemcitabine (ADVL0022). RESULTS: One of 20 evaluable patients with ALL and none of 10 evaluable patients with AML had complete responses to gemcitabine; there were no partial responses. Grade 3 or 4 hematologic toxicity and liver toxicity were common during therapy. Only one patient was alive 1 year after entry. The estimated 1-year overall survival probability for the 32 patients was 4% (SE = 3%). CONCLUSIONS: Gemcitabine at the dose and schedule in this trial was not effective for children with relapsed AML or ALL.     

急性白血病患儿中性粒细胞减少合并感染诊治分析

中性粒细胞减少症合并感染是儿童急性白血病(A L)化疗的主要并发症之一,尽管有效的抗感染药物、粒细胞集落刺激因子(G C SF)及其他支持疗法,大大降低了死亡率,但仍严重危害患儿的生命犤1～2犦。临床上大约30%的患儿可发现明确的病原体,主要是细菌、真菌和病毒。但大部分患儿找不到病原体,因此以经验用药为主。现对我院小儿血液科急性白血病(A L)患儿中,发生中性粒细胞减少合并感染353例次的诊治问题进行分析探讨如下。1对象及方法1.1对象自2003年1月～2004年12月共收治A L105例,其中急性淋巴细胞性白血病(A LL)82例,急性非淋巴细胞性…     

儿童急性淋巴细胞性白血病ALL-2005方案治疗失败病例分析

目的分析ALL-2005方案治疗儿童急性淋巴细胞性白血病(ALL)失败的原因。方法将初治ALL失败病例分为诱导治疗失败、复发和依从失败以及治疗相关死亡三类,回顾性分析失败的原因。结果 2005年5月1日至2009年4月30日,共388例初治ALL患儿,随访时间中位数48个月(24～72个月)。101例患儿治疗失败,总失败率为26.0%;其中诱导治疗失败6例,复发69例,依从失败17例,治疗相关死亡9例。骨髓复发率为13.2%,单纯中枢神经系统复发率为2.4%,男性患儿睾丸复发率为3.9%。388例ALL患儿中,300例B系ALL患儿在诱导治疗第35天监测微小残留病(MRD),MRD≤0.01%患儿的复发率为15.4%,而MRD>0.01%患儿为28.8%,两者间差异有统计学意义(χ2=5.818,P=0.016)。结论复发是导致ALL-2005方案治疗ALL失败的主要原因,诱导治疗第35天MRD水平可以预测患儿的预后。     

Hemophagocytic lymphohistiocytosis associated with precursor B acute lymphoblastic leukemia

We report a case of a child with precursor-B acute lymphoblastic leukemia (ALL) who experienced refractory thrombocytopenia and massive splenomegaly during standard induction chemotherapy. He was diagnosed with hemophatocytic lymphohistiocytosis (HLH) during induction. Clinical and laboratory evaluation showed no evidence of infectious cause to HLH. Pancytopenia and HLH persisted after consolidation therapy even with remission from leukemia. After failure to control HLH with ALL-directed therapy and HLH-directed therapy, the patient underwent unrelated donor hematopoietic stem cell transplantation 8 months after diagnosis. He is 34 months post-transplant and in remission from leukemia and HLH.     

Development of acute lymphoblastic leukemia following treatment for acute myeloid leukemia in children with Down syndrome: A case report and retrospective review of Children's Oncology Group acute myeloid leukemia trials

Children with Down syndrome have a 150‐fold increased risk of developing acute myeloid leukemia (AML) and 20‐fold increased risk of developing acute lymphoblastic leukemia (ALL). Although the risk of developing AML and ALL is significantly increased in children with Down syndrome, the development of both malignancies in the same patient is very rare. We describe a patient with Down syndrome who developed ALL 6 years after being diagnosed with AML. We performed a literature review and Children's Oncology Group query and discovered eight published cases and five cases of ALL following AML in pediatric patients with Down syndrome, as well as six cases of ALL following AML in non‐Down syndrome patients. There was a similar cumulative incidence of ALL after treatment for AML in the Down syndrome and non‐Down syndrome populations. Overall survival in patients with Down syndrome who developed ALL after treatment for AML was comparable to overall survival for patients with Down syndrome with de novo ALL with an average follow‐up of 7 years after ALL diagnosis. Clinical data collected were used to discuss whether this phenomenon represents a secondary leukemia, second primary cancer, or mixed‐lineage leukemia.     

Treatment of infective endocarditis with recombinant tissue plasminogen activator

Infective endocarditis (IE) caused by microbial infection is virtually always fatal if untreated. High-dose and long-term antibiotic treatment is required to eradicate microorganisms. If increased risk of embolic events, persistent infection, and progressive cardiac failure are present, surgery is indicated. However, surgery can carry an increased risk of mortality and morbidity in critically ill children of whom other treatment options such as administering, a thrombolytic agent; recombinant tissue plasminogen activator (r-tPA) could be an alternative choice. Here, we report a 14-year-old male with Down syndrome and acute myeloblastic leukemia, diagnosed with IE characterized by two large vegetations on aortic and mitral valves, who was successfully treated with r-tPA.     

Infective endocarditis in newborn infants with structurally normal hearts

Mecrow IK, Ladusans EJ. Infective endocarditis in newborn infants with structurally normal hearts. Acta Pædiatr 1994;83:35–9. Stockholm. ISSN 0803–5253.
Twelve infants with structurally normal hearts were demonstrated to have intracardiac vegetations on echocardiography and diagnosed as having infective endocarditis. All were found in the right side of the heart, most frequently at the junction of the superior vena cava and the right atrium and in no case involved the tricuspid or pulmonary valves. Most were diagnosed in the course of investigation of repeatedly positive blood cultures, despite appropriate antibiotic therapy. Coagulase-negative staphylococci were isolated from blood culture in nine infants, and Streptococcus sanguis and Candida albicans from one each. All infants had had intracardiac central lines inserted to facilitate venous access, either by a percutaneous technique or as a formal surgical procedure. Eight (67%) were successfully treated and made a full recovery. Cardiac murmurs were absent in all of the cases. Echocardiography should be included in the investigation of all neonates with persistently positive blood culture, particularly when intracardiac lines have been sited. Right-sided, non-valvar lesions and infection with coagulase-negative staphylococci may carry a better prognosis than previously reported.     

Immunocompetence and prognosis in children with acute lymphoblastic leukemia: Combination of two different maintenance therapies

Intensive chemotherapy in patients with leukemia produces immunosuppression. The level of immunocompetence correlates with prognosis. The immunological function of 29 children with acute lymphoblastic leukemia (ALL) in complete remission and on 2 different maintenance therapies was evaluated and compared with 16 normal children (Group A). Sixteen children (Group B) with ALL received 6 mercaptopurine (6MP) daily and methotrexate (MTX) twice a week, and 13 children (Group C) received 6MP and MTX weekly for maintenance. There was depression of both cellular immunity, measured by the number of T cells and skin tests, and humoral immunity, measured by number of B cells, primary antibody production to typhoid vaccine, and levels of immunoglobulins. However, continuous maintenance therapy (Group B) produced significantly more severe immunosuppression of cellular immunity than the intermittent therapy (Group C). Humoral immunity was equally depressed in both groups of leukemia patients, but was less altered than cellular immunity. Concomitantly, patients with intermittent maintenance chemotherapy had less hematologic depression, fewer episodes of infection, and fewer died in complete remission. Patients of both groups with higher levels of immunocompetence had better prognosis with longer duration of complete remission than patients with severe immunosuppression. Out of 6 patients with “favorable immunocompetence” only 1 relapsed at 7 months and the other 5 remain in complete remission from 8 to 31 months. Among 23 leukemic patients with “unfavorable immunocompetence,” 15 relapsed and 8 remain in complete remission from 9 to 26 months.     

Secondary acute non-lymphoblastic leukemia in two children following treatment with a cis-diamminedichloroplatinum-II-based regimen for osteosarcoma

Acute nonlymphocytic leukemia (ANLL) developed in 2 of 142 pediatric patients with osteosarcoma treated with a cis-diamminedichloroplatinum-II (CDP)-based regimen: acute monomyelogenous leukemia (M₄) with a normal female karyotype in one and acute myelogenous leukemia (M₂) with t (8,21) in the other. The ANLLs occurred, respectively, in each patient 3 and 4 years after the initial diagnosis of osteosarcoma. In contrast to most of the adult experience and consistent with the majority of reported ANLL in children, the disease was characterized by an absence of the smoldering phase and cytogenetic findings similar to those seen in de novo ANLL.     

A 28-year trend of infective endocarditis associated with congenital heart diseases: A single institute experience

BACKGROUND: Infective endocarditis (IE) is still one of the major complications of congenital heart disease and, therefore, prevention has always been an important issue. But there has been no large scale investigation of IE in Japan. METHODS: Clinical and microbiological features in 183 patients with congenital heart diseases complicated with infective endocarditis (IE), which were treated in our institute in the last 28 years, were reviewed. RESULT: During the period, the age distribution of the patients shifted to an older age; 80% were older than 15 years in the latest 7 year period. In the underlying diseases more complex conditions increased, such as the post Rastelli operation. Dental or oral diseases were the major preceding events and Streptococcus was the major pathogen throughout the study periods in the data. CONCLUSION: The result indicates the importance of continuing education for the prevention of IE and oral hygiene especially in adult patients with a risk for IE.