Biliary pseudolithiasis in childhood: a case report.

Cholelithiasis is uncommon in childhood and usually associated with any predisposing factors such as congenital abnormalities of biliary tract, hemolytic diseases, TPN administration and diseases of terminal ileum. Recent studies demonstrated ceftriaxone inducing reversible precipitations in gallbladder that mimic cholelithiasis. This complication is termed "biliary pseudolithiasis" or "reversible cholelithiasis". In this paper we describe a patient who developed biliary pseudolithiasis after six days of ceftriaxone therapy which completely resolved eleven days after the end of the treatment, and discuss the indication for cholecystectomy.     

Clinical and pathological characteristics of cystic lesions of extrahepatic bile duct in neonates

Aim: To investigate the differences in clinical and pathological manifestations between biliary atresia with extrahepatic biliary cyst and choledochal cyst in neonates. Methods: Symptoms and clinical signs in 5 neonates with biliary atresia with extrahepatic biliary cyst (4 of type I and 1 of type III) and 17 neonates with choledochal cyst were recorded. The levels of serum alkaline phosphatase, bilirubin, direct bilirubin, transaminase, gamma-glutamyl transpeptidase were analysed. Width and length of gallbladder and choledochal cyst were measured on B-mode ultrasound before surgery. Intrahepatic or extrahepatic biliary ducts were visualized with intraoperative cholangiography. The pathologic features in specimens of the liver were studied with light- and electron transmission microscopy. Results: All malformations occurred more commonly in girls, and obstructive jaundice was the main manifestation in both groups. Laboratory tests showed similar results for all patients in this study. With regard to pathological features, no significant difference was seen in either light microscopy or transmission electron microscopy, but it was shown with ultrasound that the length and width of the cysts and the gallbladder in neonates with biliary atresia were all shorter than the measurements in patients with choledochal cyst. The intrahepatic bile ducts could not be visualized on intraoperative cholangiography in type III biliary atresia. Deformation of the biliary ducts within the liver and stricture of the portal bile duct were the predominant features in type I biliary atresia, while the bile duct within the liver was normal or dilated in neonates with choledochal cyst.

Conclusions: Cystic lesions of the extrahepatic bile duct might be a common manifestation of biliary atresia and choledochal cyst. Intraoperative cholangiography is a precise and effective technique in the differential diagnosis of those lesions and helps decide on the most rational method of treatment.     

Pharmacokinetics of ceftriaxone in neonates and infants with meningitis

The pharmacokinetics of ceftriaxone was studied in the plasma, urine, and cerebrospinal fluid of seven neonates and seven infants with meningitis. In addition, plasma and urine data were obtained in five neonates and one infant receiving ceftriaxone for other serious infections. All neonates younger than 14 days received daily doses of 50 mg/kg ceftriaxone; all other patients but two received 100 mg/kg. The average weight-corrected values for total body clearance (ClT), volume of distribution (Vdss), and biologic half-life (t 1/2) were 0.37 ml/min/kg, 0.45 L/kg, and 16.2 hours in neonates younger than 1 week; 0.77 ml/min/kg, 0.48 L/kg, and 9.2 hours in neonates older than 1 week; and 1.03 ml/min/kg, 0.39 L/kg, and 7.1 hours in older infants, respectively. There was a significant difference in ClT and t 1/2 between the neonates younger and both neonates older than 1 week, and infants. The Vdss was not significantly different among the three age groups. The average renal clearance in neonates younger than 1 week (0.28 ml/min/kg was 70%, in neonates older than 1 week (0.54 ml/min/kg) was 77%, and in older infants (0.49 ml/min/kg) was 47% of ClT, indicating that nonrenal elimination was less developed in neonates. The quantitation of CSF diffusion of ceftriaxone was assessed by comparison of the areas under the CSF and plasma concentration-time curve. The mean ceftriaxone penetration into the CSF in neonates and infants with bacterial meningitis was 17%. On the other hand, penetration in patients with aseptic meningitis amounted to only 4%. Mean ceftriaxone concentrations in the CSF in patients with bacterial meningitis were 2.8 mg/L after 24 hours, exceeding by many times the minimum inhibitory concentration of the common meningitis pathogens at this time.     

Ceftriaxone-associated nephrolithiasis and biliary pseudolithiasis

Biliary pseudolithiasis has been reported in patients who received ceftriaxone therapy. In addition to biliary sludge formation occasional reports of ceftriaxone-induced nephrolithiasis have been published. In general, these adverse effects will develop after seven to ten days of treatment. We report on a seven-year-old boy with ceftriaxone-associated biliary pseudolithiasis and nephrolithiasis four days after initiation of treatment. Patients receiving a high dose of ceftriaxone and developing colicky abdominal pain should be considered for ultrasound and a change in antibiotic therapy if appropriate. Received: 16 February 1999 / Accepted: 9 June 1999     

Transient biliary lithiasis associated with the use of ceftriaxone

Up to 40% of ceftriaxone is excreted unchanged into the bile and, due to its high calcium-binding affinity, it may form a salt that can provoke biliary lithiasis. Echography revealed that biliary lithiasis was present in 12-45% of patients treated with ceftriaxone as early as the second day of treatment. Lithiasis is usually asymptomatic and disappears in less than 2 months. Symptomatic cases and patients requiring cholecystectomy have been described in the literature. We present four children, evaluated in 1999, who presented asymptomatic cholelithiasis between the second and fourth day of ceftriaxone treatment. Biliary lithiasis was found after 2-4 days of treatment, with resolution of the lithiasis between 1-4 months after the end of therapy.     

肾脏疾病合并头孢曲松相关假性胆结石患儿的临床分析

目的 探讨肾脏疾病患儿合并头孢曲松相关假性胆结石的临床特点.方法 回顾性分析3例合并头孢曲松相关假性胆结石的肾脏疾病患儿临床资料.结果 病例1,男,11岁,诊断"肾病综合征",因"胃肠炎"予头孢曲松2g/d[50 mg/(kg·d)]抗感染,3 d后发现胆囊内泥沙样沉积,伴纳差、恶心;停药16 d后胆囊结石消失.病例2,男,10岁,诊断"急性链球菌感染后肾小球肾炎、肾功能不全",因"胃肠炎"予头孢曲松1.5 g/d[30 mg/(kg·d)],疗程6 d时发现胆囊结石,伴恶心、呕吐和腹痛,Murphy's征阳性;停药18 d后胆囊结石消失.病例3,男,12岁,诊断"肾病综合征",因"胃肠炎?"给予头孢曲松2g/d[40 mg/(kg·d)]联合甲硝唑抗感染、疗程2周,感染控制,但有中上腹压痛,停药3 d后发现胆囊结石;停药2个月后复查结石回声消失.结论 上述3例患儿出现胆囊结石时头孢曲松治疗剂量较低、结石出现早、临床表现相对重,可能与肾脏疾病患儿同时存在血液浓缩、高凝状态、肾功能不全或补充钙剂等高危因素有关.     

微创手术治疗小儿尿路结石

目的探讨微创手术治疗小儿尿路结石的可行性与临床效果。方法应用输尿管镜经尿道碎石或经皮肾造瘘碎石取出尿路结石。结果52例患儿所有结石均一次取净,无明显并发症。结论微创手术治疗小儿尿路结石安全可行,并发症少。     

Ceftriaxone-associated biliary sludge and pseudocholelithiasis during childhood: A prospective study

BACKGROUND: Cholelithiasis is a rare condition seen during childhood. The aim of this study was to determine frequency of biliary sludge and cholelithiasis with ceftriaxone therapy. METHODS: Thirty-eight children aged between 1 month and 17 years were evaluated with ultrasonographic examination at the initiation of the ceftriaxone therapy and 10th day of therapy, consecutively. If biliary sludge or cholelithiasis were demonstrated, scans were repeated monthly until pathology disappeared. RESULTS: Abnormal gallbladder sonograms were demonstrated in 36.8% (n = 14) of patients at the 10th day of therapy. Cholelithiasis was detected in 28.9% (n = 11) of patients and biliary sludge was detected in 7.9% (n = 3). Two children still had cholelithiasis at the 30th day after therapy and one had cholelithiasis after the 60th day. The 9-year-old girl who still had cholelithiasis after 60 days of therapy also had nausea, vomiting and abdominal pain at 7 days after cessation of therapy. Her 90th day sonographic examination was normal. CONCLUSION: Reversible biliary sludge or pseudocholelithiasis due to ceftriaxone treatment is not a rare condition. Therefore it is benign, spontaneously resolved and clinical signs are usually absent.     

Treatment of depressed skull fractures in neonates using percutaneous microscrew elevation

Depressed skull fractures in neonates involve the inward buckling of the skull bones to resemble a cup shape or "ping-pong ball" shape. In the past, several methods have been used to treat these fractures for cosmetic effect, including the use of vacuum extraction. The aim of this study was to demonstrate the use of a novel treatment method for these skull fractures. All patients presented to Hershey Medical Center between May 2007 and March 2010. All underwent treatment of their ping-pong skull fracture using a novel technique of percutaneous screw elevation with self-tapping microscrews (4 or 5 mm) typically used in neurosurgery for cranial plating. Four patients were treated, all between the ages of 2 days and 4 months. Two of the patients were treated under general anesthesia and 2 with local anesthesia only. All patients had good cosmetic results and experienced no adverse events. Percutaneous screw elevation of the ping-pong type, simple depressed skull fracture in neonates is a feasible method of treatment with a low complication rate associated with the procedure and no risk from anesthesia.     

Nephrolithiasis associated with ceftriaxone therapy: a prospective study in 51 children

Background: Background: Ceftriaxone, a third generation cephalosporin, is widely used for treating infection during childhood. The kidneys eliminate approximately 33–67% of this agent, and the remainder is eliminated via the biliary system. Ceftriaxone may bind with calcium ions and form insoluble precipitate leading to biliary pseudolithiasis. The aim of this study was to assess whether ceftriaxone associated nephrolithiasis develops by the same mechanism, and whether this condition is dose related. Methods: The study involved 51 children with various infections. Of these, 24 were hospitalized with severe infection and received 100 mg/kg/day ceftriaxone divided into two equal intravenous doses. The other 27 patients received a single daily intramuscular injection of 50 mg/kg/day. Serum and urine parameters were evaluated before and after treatment, and abdominal ultrasonographic examinations were also carried out before and after treatment. Results: Serum urea, creatinine, and calcium levels were normal in all patients before and after treatment. Post-treatment ultrasound identified nephrolithiasis in four (7.8%) of the 51 subjects. The stones were all of small size (2 mm). Comparison of the groups with and without nephrolithiasis revealed no significant differences with respect to age, sex distribution, duration of treatment, or dose/route of administration of ceftriaxone. The renal stones disappeared spontaneously in three of the four cases, but were still present in one patient 7 months after ceftriaxone treatment. Conclusions: Conclusions: The study showed that children taking a 7 day course of normal or high dose ceftriaxone may develop small sized asymptomatic renal stones. The overall incidence of nephrolithiasis in this study was 7.8%.     

Nephrolithiasis associated with ceftriaxone therapy: a prospective study in 51 children.

BACKGROUND: Ceftriaxone, a third generation cephalosporin, is widely used for treating infection during childhood. The kidneys eliminate approximately 33-67% of this agent, and the remainder is eliminated via the biliary system. Ceftriaxone may bind with calcium ions and form insoluble precipitate leading to biliary pseudolithiasis. The aim of this study was to assess whether ceftriaxone associated nephrolithiasis develops by the same mechanism, and whether this condition is dose related. METHODS: The study involved 51 children with various infections. Of these, 24 were hospitalized with severe infection and received 100 mg/kg/day ceftriaxone divided into two equal intravenous doses. The other 27 patients received a single daily intramuscular injection of 50 mg/kg/day. Serum and urine parameters were evaluated before and after treatment, and abdominal ultrasonographic examinations were also carried out before and after treatment. RESULTS: Serum urea, creatinine, and calcium levels were normal in all patients before and after treatment. Post-treatment ultrasound identified nephrolithiasis in four (7.8%) of the 51 subjects. The stones were all of small size (2 mm). Comparison of the groups with and without nephrolithiasis revealed no significant differences with respect to age, sex distribution, duration of treatment, or dose/route of administration of ceftriaxone. The renal stones disappeared spontaneously in three of the four cases, but were still present in one patient 7 months after ceftriaxone treatment. CONCLUSIONS: Conclusions: The study showed that children taking a 7 day course of normal or high dose ceftriaxone may develop small sized asymptomatic renal stones. The overall incidence of nephrolithiasis in this study was 7.8%.     

Albuterol-induced myocardial ischemia in sickle cell anemia after hemolysis from ceftriaxone administration

Hemolysis induced by ceftriaxone is a complication that has been described in sickle cell anemia. Albuterol is known to induce myocardial ischemia. We describe a case of albuterol-induced cardiac dysfunction in a patient with sickle cell anemia who developed severe anemia after administration of ceftriaxone.     

Ceftriaxone-associated nephrolithiasis and biliary pseudolithiasis in a child

Ceftriaxone is a widely used third-generation cephalosporin. It is generally very safe, but complications of biliary pseudolithiasis and, rarely, nephrolithiasis have been reported in children. These complications generally resolve spontaneously with cessation of the ceftriaxone therapy; however, they may symptomatically mimic more serious clinical problems, such as cholecystitis. We report a case of both ceftriaxone-induced biliary pseudolithiasis and nephrolithiasis.     

Incidence of ceftriaxone-associated gallbladder pseudolithiasis

We prospectively evaluated the incidence of gallbladder pseudolithiasis in children treated with high doses of ceftriaxone for a variety of serious infections. We also monitored the time interval needed for this phenomenon to develop and resolve completely after initiation and cessation of treatment, respectively. Included in this study are 44 children treated with ceftriaxone 100 mg/kg/d divided into 2 equal intravenous doses and followed by serial abdominal sonography. Eleven children developed pseudolithiasis of gallbladder 2-9 d after initiation of ceftriaxone therapy. Six children (54.5%) developed this complication within the first 3 d. Lithiasis completely resolved 8-23 d after the end of treatment. In conclusion, pseudolithiasis of the gallbladder developed in 25% of sick children and completely resolved in all patients. Early development of this complication was not exceptional. It occurred in more than half of these children.     

Hepatobiliary scintigraphy with technetium-99m disofenin in the evaluation of neonatal cholestasis

To assess the reliability of technetium-99m disofenin scanning in evaluating neonatal cholestasis, 33 neonates (less than 3 months of age) with direct hyperbilirubinemia were evaluated prospectively by cholescintigraphy. Results of this test were compared to those of standard serum tests of liver function, ultrasonography, and liver biopsy. The diagnosis of biliary atresia was suggested by a serum gamma-glutamyl transpeptidase (gamma-GTP) greater than 300 units/L, absence of the gallbladder on ultrasonography, and a lack of detectable radioisotope in the gastrointestinal and/or extrahepatic biliary tract on cholescintigraphy. Each of these tests lacked sensitivity and/or specificity when compared to liver biopsy. Of the nine neonates with biliary atresia, three had gallbladders identified by ultrasonography and two had gamma-GTP less than 300 units/L. Of the 24 neonates without biliary atresia, eight had cholescintigraphy without detectable radioisotope excretion, four had ultrasonography that failed to visualize the gallbladder, and nine had gamma-GTP greater than 300 units/L. Cholescintigraphy excluded the diagnosis of biliary atresia when gut and/or extrahepatic biliary excretion of isotope was seen. However, cholescintigraphy required more time, 6-8 days, and was less specific than ultrasonography and liver biopsy. We recommend that cholescintigraphy should not be routinely used in evaluating neonatal cholestasis, especially if it delays surgical intervention.     

Biliary atresia syndrome and splenic malformation. A case report

Biliary atresia is a severe neonatal malformation in which the entire extrahepatic biliary tract or part of it is absent and replaced by fibrosclerotic tissue. Having been described for the first time by Thomson in 1891, biliary atresia has an incidence of 1:10,000-15,000 live neonates with a slight predominance in the female sex; it is associated with other malformations in 25% of cases. In 1993 Davenport et al. identified a subgroup of patients with biliary atresia who presented a splenic malformation. This condition was known as biliary atresia and splenic malformation syndrome (BASM). The cases of biliary atresia and BASM are still not clear and a number of etiopathogenetic hypotheses have been put forward. The treatment is surgical and includes a first stage of hepatic-porto-enteroanastomosis using a defunctionalised Roux loop (Kasal), followed by the definitive operation comprising liver transplant. We report the case of a boy who was brought to our attention with jaundice, polypnea and hepatosplenomegalia; instrumental tests allowed the diagnosis of biliary atresia, median liver, stomach and spleen on the right, polysplenia, atresia of the intrahepatic tract of the inferior vena cava, presence of a superior vena cava to the left that drained into the upper left portion of the common atrium. Moreover, the cardiac apex was present on the right, extensive DIA of the common atrium type, extensive DIV and right aortic arch.     

Multiple gastrointestinal atresias: sonography of associated biliary abnormalities

The pre-operative finding of biliary ductal dilatation in the setting of multiple gastrointestinal atresias has not been previously reported. This paper illustrates the sonographic findings in two neonates with multiple gastrointestinal atresias from the prepyloric region to the rectum. Biliary ductal dilatation was seen in both patients and highly echogenic, mobile intraluminal bowel debris secondary to calcified meconium was evident in one. Postoperative biliary gas was demonstrated on sonography in one case.     

Intravenous-intramuscular bioequivalency of ceftriaxone in newborn infants

In 6 neonates over 7 days of life, comparison of maximum and residual serum concentrations of ceftriaxone after intra-venous or intra-muscular administration showed the bio-equivalence of both ways. In both cases a single daily injection obtained bacterial serum levels on most of the strains responsible for secondary bacterial infections in neonates.     

Biliary precipitation during ceftriaxone therapy: frequency and risk factors

Ceftriaxone, a third-generation cephalosporin, is widely used for treating infection during childhood. It is mainly eliminated in the urine, but approximately 40% of a given dose is unmetabolized and secreted into bile. The aim of this study was to investigate the frequency, clinical characteristics, and outcome of biliary sludge (BS) in addition to potential contributing risk factors in children who receive ceftriaxone. Biliary ultrasonography was performed at the time of randomization before ceftriaxone treatment was started, on the 5th and 10th days, and at the end of the treatment. If BS was detected, patients were followed-up weekly by sonographic examination until the BS or biliary lithiasis (BL) disappeared. A total of 114 children (56 girls, 58 boys; age range: 2-180 months, mean 47.5 +/- 46.3 mos) were enrolled in the study. Fourteen (12%) subjects developed BS and 10 (9%) developed BL on the 5th day of treatment. On the 10th day of treatment, 20 (18%) subjects developed BS and 15 (13%) developed BL. In total, 35 (31%) of all subjects developed biliary precipitation (BP), of whom 20 (57%) were diagnosed as BS and 15 (43%) as BL. All subjects who developed BP were found to be asymptomatic during the course of therapy. Patient age over 12 months, daily total dose of ceftriaxone of more than 2 g, and duration of treatment longer than five days were found to be associated with BP. Ceftriaxone frequently causes transient BPs and its probability increases if the child is over 12 months of age, the dose is over 2 g/day, or the duration is over five days. Neither radiologic investigation nor the discontinuation of treatment with ceftriaxone is necessary as long as the patient is asymptomatic.     

Treatment with linezolid in a neonate with meningitis caused by methicillin-resistant Staphylococcus epidermidis

Recent findings have focused on the possible role of linezolid (LZD) as a suitable candidate for the treatment of central nervous system infections. LZD treatment for meningitis has been sporadically reported in adults, but there are no reports in neonates or infants. We report a case of meningitis caused by methicillin-resistant Staphylococcus epidermidis (MRSE) in a neonatal girl. The patient had intraventricular hemorrhage on postnatal day 1 and was treated with ventricular drainage. Twenty-two days after drainage, the patient developed a fever and seizure. Although ampicillin and ceftriaxone were given empirically for meningitis, an increased cell count and protein were observed in cerebrospinal fluid (CSF). Vancomycin (VCM) was administered intravenously because MRSE was detected from CSF 2 days after the administration of ampicillin and ceftriaxone. However, intravenous administration of VCM did not show any effect. Subsequent treatment of LZD successfully reduced the cell count and protein in CSF. Conclusion: LZD may be a treatment option for neonates and infants for drain-associated meningitis caused by MRSE.