Intrathecal tetanus immunoglobulins in the management of tetanus

Objective To study the clinical profile, treatment and outcome of tetanus in children treated with intrathecal tetanus immunoglobulin. (TIG) Methods Retrospective analysis of hospital records of tetaus cases admitted to the pediatric ICU during the five year period between 1999 to 2004 was done. Results There were 66 cases of tetanus treated with intrathecal TIG. Children below 5 years formed 53% of cases and 47% were above 5 years. Totally unimmunized children constituted 82% of cases and 18% partially immunized children. The portal of entry was otogenic in 58% of cases and injury in 30% of cases. The common complications observed included thrombophlebitis, aspiration pneumonia, laryngospasm and autonomic system involvement. There were no complications specific to intrathecal administration of TIG. The mortality due to tetanus was 9%. Discussion Mortality and morbidity due to tetanus was less in the present study compared to other centers where TIG is given intramuscularly. Conclusion Intrathecal TIG is effective in the treatment of mild and moderate tetanus. Randomized controlled clinical trials are needed to evaluate the efficacy of intrathecal TIG in the management of severe tetanus.     

The management of choledochal cysts in the newborn

Choledochal cysts are now being diagnosed before birth on routine maternal sonography (US). There is no report in the literature outlining the management of newborns with choledochal cysts, many of whom are asymptomatic. Our study details the diagnosis, treatment and outcome of six such children, four girls and two boys. Five had antenatal US revealing cystic abdominal masses. One had intermittent vomiting and US suggested a choledochal cyst. Four of six had normal serum bilirubin levels; two had elevations. In five babies the choledochal cyst was correctly diagnosed from the preoperative studies; in one the preoperative diagnosis was an ovarian cyst. The children underwent an operation at an average of 6 weeks of age (range 5 days to 17 weeks). At exploration, cholangiography showed Alonso-Lej type I cysts in all cases. Treatment consisted of resection of the cyst with Roux-en-Y choledochojejunostomy in five and with a valved jejunal choledochoduodenal conduit in one. In no case was the dissection of the choledochal cyst off the portal vein and hepatic artery difficult. There were no intra- or early postoperative complications. Mean hospital stay was 8 days (range 5 to 9 days). Presently, all 6 patients have normal bilirubin levels at an average length of follow-up of 35 months (range 16 to 70 months) after operation. We conclude that operative treatment of choledochal cysts in early infancy, even in asymptomatic children, is safe and effective and may prevent serious complications later in life.     

Ulcerated rhabdomyosarcoma as portal of entry for tetanus in a previously nonimmunized child

Infectious diseases represent one of the most important secondary problems related to the treatment of childhood cancer, being the leading cause of death in this population. They are predominantly of bacterial and fungal etiology. The association between tetanus, a bacterial vaccine-preventable disease, and cancer is virtually undescribed. The authors present the case of a previously nonimmunized child, due to his parents' choice, who developed severe tetanus with an ulcerated rhabdomyosarcoma as portal of entry. Due to an unfavorable evolution, the child underwent a hip disarticulation to provide tetanus control. The ulterior tumor management was successful: the child has been off therapy for more than 108 months with no evidence of disease.     

Complications of diphtheria seen during the 1978 outbreak in Khartoum

Twenty-nine cases of complicated diphtheria infection occurring during an epidemic in Khartoum are reviewed. The organism was a Corynebacterium diphtheriae subsp. gravis with an unusual property of fermenting sucrose. Eighteen patients were detected during prospective follow-up, where as 11 presented initially with a complication. Complications were mostly seen among pre-school children (65.5%). A routine immunization course had been completed in only two of the patients. Neurological complications were the commonest, lasting for more than two weeks, and five of the six deaths were due to cardiovascular complications.     

Long term outcome after surgery for extrahepatic portal vein thrombosis.

The long term outcome of 21 children with extrahepatic portal hypertension secondary to portal vein thrombosis managed by surgical intervention was evaluated. Portosystemic shunts, used primarily in nine patients (eight central splenorenal, one mesocaval) after conservative treatment had failed, had no associated mortality and a 56% patency rate. Five of these shunted patients had no further bleeding episodes and did not show encephalopathic impairment. Direct attack procedures-portoazygos operation (four patients) was associated with significant complications, including one fatality. Other direct approaches-oesophageal transection and variceal plication (five patients) had variable outcome. Splenectomy alone (three patients) ameliorated hypersplenism; however, further surgery for recurrent haemorrhage (two patients) was necessary. Endoscopic sclerotherapy controlled recurrent variceal bleeding (three patients) when it became available to the unit. Conservative treatment practised in five children had little success: two patients survived, two died from further haemorrhage, and one was lost to follow up. These results suggest that in centres without endoscopic expertise, and for patients who are sclerotherapy 'failures', surgery can be performed safely and achieve reasonable long term success rates in childhood extrahepatic portal hypertension.     

Extent of occurrence of the six vaccine preventable diseases in vaccinated/unvaccinated children.

Sixty two children who were diagnosed to be suffering from any of the six vaccine preventable diseases were studied to know their vaccination status prior to the occurrence of these diseases. A total of 33.9% of these children had developed these diseases inspite of full immunization. Nearly 75% of immunized children had received the vaccine from Government sources. The break-up diseases among the children studied was tetanus (35.5%), poliomyelitis and pulmonary tuberculosis (22.6% each), measles (11.3%), diphtheria (6.4%) and pertussis (1.6%). The vaccinated children who developed poliomyelitis belonged to a relatively higher age group. Seventy one per cent of measles cases developed bronchopneumonia as a complication. Seventy five per cent of the mortality in the children studied was due to tetanus neonatorum. Since one third of the children studied had developed diseases inspite of full immunization, it is inferred that closer monitoring of the Cold Chain System and intensive surveillance at peripheral levels are required.     

小儿门静脉高压治疗新进展

门静脉高压(portal hypertension,PH)是各种原因导致门静脉系统压力升高引起的一组临床综合征,是儿童发病率较低的严重并发症.小儿门静脉高压症的病因和治疗有别于成人.本文综合近五年小儿PH治疗的文章,总结历年国际及国内范围对该病的病案报道,分别从药物、内镜、介入、手术、肝移植等方面做了详细的描述,理清了门静脉高压治疗的最新进展,有助于提高各种病因门静脉高压患儿的治疗效果.     

Transileocolic venous balloon dilatation for the management of primary and recurrent portal venous stenosis after living donor liver transplantation in children

Portal venous stenosis is relatively a rare complication after liver transplantation in children and it sometimes leads to life threatening event due to gastrointestinal bleeding or graft failure. Recently, balloon dilatation has been widely accepted as a treatment of choice for the management of portal venous stenosis. The purpose of this study was to evaluate the feasibility of transileocolic venous balloon dilatation for the management of primary and recurrent portal venous stenosis after living donor liver transplantation (LDLT) in children. The records of 57 pediatric liver transplants were retrospectively reviewed. Nine patients (15.8%) with portal venous stenosis were identified. Seven symptomatic children with portal venous stenosis underwent balloon dilatation. Two approaches were employed for balloon dilatation; the transileocolic venous approach and the percutaneous transhepatic approach. In patients with recurrent stenosis, careful follow-up was carried out while they were asymptomatic. Twelve balloon dilatations were performed in seven children with primary or recurrent portal venous stenoses. The initial technical success rate was 91.7% (11/12), while 6 out of 12 (50.0%) procedures resulted in recurrent stenosis. Five out of six recurrent stenoses required repeated balloon dilatation. The clinical success rate of balloon dilatation in our study was 85.7% (6/7). Other than recurrent stenosis, two procedure-related complications occurred. In conclusion, transileocolic venous balloon dilatation was a safe and effective procedure for portal venous stenosis after LDLT in children.     

Infections in Children with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome: An Autopsy Study of 30 Cases in South Florida, 1990-1993

Thirty autopsies performed on infants and children with HIV infection and/or AIDS were reviewed for the presence and type of infection. Twenty-six (87%) demonstrated evidence of infection in addition to HIV at the time of postmortem examination. Pathogenic bacterial infections were the most frequently encountered, seen in 15 of the cases. Nine of the 15 (60%) were due to gram-negative rods, most commonly Pseudomonas aeruginosa. Infections with gram-negative organisms often involved multiple organ systems and were frequently undiagnosed both pre -and postmortem because of variability in culture results and difficulties in identification both clinically and in tissue sections. Discussion is presented of unusual staining characteristics and filamentous morphology found with these pathogens. Other pathogenic bacteria encountered were Klebsiella pneumoniae, Escherichia coli, Enterobacter sp., and Staphylococcus. Fungal infections due to Candida species were present in nine cases (31 %) but were invasive in only two of these. One instance of Aspergillus meningo-encephalitis was noted. Proven viral infections were present in five children (three cytomegalovirus, one herpes simplex, and one adenovirus). Pneumocystis carinii pneumonia was diagnosed in five of the patients (17%), and one instance of disseminated Mycobacterium avium-intracellulare was encountered.     

Pediatric liver transplantation using left hepatic segments from living related donors: surgical experience in 100 recipients at Saint-Luc University Clinics

Living-related liver transplantation was developed in the context of deceased donor organ shortage, which is particularly acute for pediatric recipients. This retrospective study analyzes the surgical technique and complications in the first 100 pediatric liver transplantation using left segmental liver grafts from living donors, performed at Saint-Luc University Clinics between July 1993 and April 2002. Pre-operative evaluation in donors and recipients, analysis of the surgical technique, and postoperative complications were reviewed. After a median follow-up period of 2526 days, no donor mortality was encountered, with a minimal morbidity and no long-term sequelae. At one and five yr post-transplantation, the actuarial patient survival rates were 94% and 92%, the corresponding figures being 92% and 89% for graft survival. The incidences of portal vein and hepatic artery thromboses, and of biliary complications were 14%, 1%, and 27%, respectively. Living-related liver transplantation in children constitutes an efficient therapy for liver failure to face the increased demand for liver grafts. Donor morbidity was kept to acceptable incidence, and surgical technique in the recipient needs to be tailored to minimize postoperative complications.     

Tetanus in children: an 11-year review

One hundred and three cases of tetanus in children 1-12 years of age were reviewed. Sixty-six per cent had severe disease, half of whom required management with total muscle paralysis and intermittent positive pressure ventilation (IPPV), and 70% in this group developed signs of sympathetic overactivity (SOA). Control of SOA with morphia 0.5-1 mg/kg/dose given 1-4 times a day appears to have decreased the mortality rate from this complication of severe tetanus. There was a relative resistance to drug control of SOA in the youngest children. High output renal failure developed in two children, an incidence much the same as reported in severely affected adults. The overall mortality rate of this series was 14.5%: all the deaths were amongst those severely affected. The cause of death could be attributed to tetanus in half, while in the remainder it resulted from complications of intensive therapy. Tetanus in children resembles the disease in adults.     

Liver abscesses in children: a single center experience in the developed world

OBJECTIVES: The aim of this study was to investigate the clinical and radiologic features, predisposing risk factors, and complications of children with pyogenic liver abscess (PLA) referred to a tertiary pediatric hepatology center. METHODS: We analyzed our database of all children referred to our unit over a 10 year period and performed a case note review of all patients with a radiologically proven PLA. RESULTS: PLA was diagnosed in 15 children (7 boys), 0.5% of all referrals. They presented at a median age of 10 years (range 2 months-15 years). In three children (2 boys), PLA was the first manifestation of chronic granulomatous disease. Among the others, five had radiologic evidence of other intra-abdominal pathology (1 with subsequently proven appendicitis), and four developed portal vein thrombosis with portal hypertension. The commonest isolated pathogen was Staphylococcus aureus. Combined treatment with guided aspiration and prolonged intravenous antibiotics was successful in all patients. CONCLUSION: PLA is a rare diagnosis in children in the developed world. It may be caused by primary neutrophil disorders even in the absence of a previous history of infection. Co-existent appendicitis, intra-abdominal sepsis, and ascending pylephlebitis must be sought because these children are at risk of developing portal vein obstruction and portal hypertension. Prolonged intravenous antibiotic treatment guided by microbiologic sensitivities is highly effective.     

Portal cavernoma in congenital hepatic fibrosis

A retrospective pediatric study of 30 angiograms in congenital hepatic fibrosis (CHF) was undertaken to analyze the different aspects of the portal venous system in this disease. Besides the classical angiographic signs (hepatofugal veins and intrahepatic duplications), a hepatopetal venous network was present in ten children, contrasting with the patency of the portal venous system. Analysis of the medical charts for these ten patients showed that the clinical signs and outcome were similar to classical CHF. Liver biopsies were available in six cases and, in addition to the diagnostic features of CHF, demonstrated paucity or absence of portal venules. This unusual association of hepatopetal and hepatofugal collateral veins in an intrahepatic block could be explained by hypoplasia or thrombosis of portal venules. Thus, the association between hepatomegaly and hepatopetal collateral veins without portal obstruction should be suggestive of CHF.     

Endodermal sinus (yolk sac) tumor in infants and children. A clinical and pathologic study: an 11 year review

We reviewed the clinical features, treatment, and results of children with gonadal and extragonadal yolk sac (endodermal sinus) tumors seen in the King Faisal Specialist Hospital and Research Centre between 1976 and 1987. There were nine children (seven girls and two boys) with ages ranging from 7 months to 12 years (median of 3.5 years). Sites of origin included the vagina (two cases), face (two cases), sacrum (two cases), mediastinum (one case), ovary (one case), and testicle (1 case). All children had elevated alpha-fetoprotein (AFP) at diagnosis. One girl had complete surgical excision of an ovarian tumor at the time of diagnosis, and one boy had surgical excision of the testis. In the remaining seven children, the tumor was unresectable. Surgery was limited to a biopsy in six children. All patients received different combinations of chemotherapy, including vincristine (VCR), actinomycin D (Act-D), cyclophosphamide (Cyclo), adriamycin (Adria), bleomycin (Bleo), cis-platinum (CDDP), vinblastine (VBL), and VP-16. Of the nine patients, one was lost to follow-up while in remission, five died, one was lost to follow-up, and three are alive and disease-free at 15, 55, and 67 months from diagnosis. This review demonstrates an unusual preponderance of the extragonadal form of endodermal sinus tumor among our patients.     

Herpes simplex virus esophagitis in immunocompetent children

OBJECTIVES: To review clinical, laboratory, endoscopic and histologic features, treatment and outcome of immunocompetent children with Herpes simplex virus esophagitis. METHODS: Retrospective analysis of the medical records of six children (five males) referred to our unit between 1997-2001. RESULTS: The median age at presentation was 4 years. Fever was present in all, odynophagia/dysphagia in five, retrosternal pain in four, vomiting in three, drooling in two and irritability and drowsiness in one. The median time between the onset of symptoms and the diagnosis was 6.5 days. Endoscopy, performed in all, showed friable mucosa and erosive-ulcerative involvement, with histology showing inflammation and ulcerated esophagitis. Tissue viral culture was performed in five patients and was positive in three, and polymerase chain reaction was positive in two of four tested. Serology was consistent with primary Herpes simplex virus infection in all. All received nasogastric feeding and acyclovir. The outcome was very good. CONCLUSIONS: This is an uncommon and under-recognized condition in the immunocompetent child. The most common symptoms are sometimes not diagnostic, particularly in very young children. The presence of unusual clinical signs may lead to a difficult and delayed diagnosis. Treatment with acyclovir may have hastened the resolution of symptoms, but a controlled clinical study was not performed.     

Multidetector CT findings of splenic artery aneurysm in children with chronic liver disease

BACKGROUND: Splenic artery aneurysm (SAA) is a well-known complication of chronic liver disease and portal hypertension in adults. The incidence of SAA in children undergoing selective hepatic angiography prior to liver transplantation is reported as 4%, but there are few systematic studies. OBJECTIVE: To investigate the SAAs detected by multidetector CT angiography (MDCTA) among children with chronic liver disease. MATERIALS AND METHODS: A total of 124 children (71 girls, 53 boys; mean age 118 months; age range 5 days to 204 months) with chronic liver disease underwent MDCTA to display the vascular anatomy and any vascular complications during the pretransplantation period. Of these children, 23 also underwent coeliac angiography. The digital subtraction angiography (DSA) and MDCTA findings were compared. RESULTS: SAAs were detected in 13 children (10.4%); none was detectable by US. All patients had more than one aneurysm; ten patients had more than three. In all except one patient, the SAAs were located only in the intraparenchymal branches of the splenic artery; in one patient they were located in the intraparenchymal segment and in the distal third of the splenic artery. The mean size of the aneurysms was 6.5 mm (range 2.5-18 mm). All patients with aneurysms had splenomegaly and vascular collaterals. Nine of the children with SAAs had portal vein pathologies (two occlusions, two stenoses, five dilatations). A statistically significant difference existed with regard to the size of spleen (P < 0.05) and patient age (P < 0.05) between children with SAAs and children without SAAs. There was an increased risk of SAAs in patients with portal vein pathologies. In 19 patients without SAAs on MDCTA, no SAAs were seen on DSA. CONCLUSIONS: It is likely that the incidence of SAA in children with chronic liver disease will increase with improved survival of children with long-standing portal hypertension and chronic liver disease. MDCTA with multiplanar reconstruction is a noninvasive and effective means of imaging paediatric patients with SAAs, especially during the peritransplantation period, which is considered to be a time of significant risk for SAA rupture in this patient population.     

Splenic salvage in children with blunt pancreatic transection

Delayed recognition of pancreatic transection after blunt abdominal trauma contributes significantly to the high morbidity and mortality of this lesion. The classical treatment of this injury has been distal pancreatectomy and splenectomy. Over the past 5 years, we have treated six children with complete transection of the pancreas due to blunt trauma to the abdomen. Computed tomography (CT) was useful in defining the site of transection in two of three patients. Three children had a delay in diagnosis of 3–49 days; they all developed complications (e. g. pseudocyst, abscess, fistula) prior to definitive surgery. The spleen was salvaged in all sic patients: five had partial pancreatectomy and one had cystogastrostomy. Following pancreatic resection, there was no morbidity or pancreatic insufficiency over an average follow-up period of 40 months. The mortality in this series was 0%. When pancreatic injury is suspected in blunt abdominal trauma, CT is recommended for early diagnosis of pancreatic transection. In stable patients with this injury, distal pancreatectomy with splenic salvage is a feasible and effective treatment that preserves adequate pancreatic function and lowers the incidence of complications. Offprint requests to: A. J. Razzouk     

Nissen fundoplication and Boix-Ochoa antireflux procedure: comparison between two surgical techniques in the treatment of gastroesophageal reflux in children.

Over a period of 19 years an antireflux procedure was performed for gastroesophageal reflux in 59 children. Thirty-two patients underwent Nissen fundoplication and 27 children underwent the Boix-Ochoa antireflux procedure. Six patients died between two and 15 months post surgery of unrelated causes. Follow-up period from six months to 18 years was available in 45 (85%) of the surviving patients. This report summarizes the complications and long-term results with the two surgical procedures and their comparisons. The follow-up evaluation included parental interview and physical examination. Upper GI series and pH monitoring were performed only in children with signs and symptoms of recurrent GER or other post-operative complications. At follow-up with a mean period of 8.7 years following Nissen fundoplication, 87.5% showed good results without any residual symptoms. However, the overall complication rate was as high as 50%. Following the Boix-Ochoa antireflux procedure, 17 (81%) children showed excellent results while four children had recurrent GER. This occurred in two neurologically impaired children and two patients following esophageal atresia repair. No other post-operative complications were encountered with the Boix-Ochoa antireflux procedure. In our experience, the Boix-Ochoa antireflux procedure should be the procedure of choice in the surgical treatment of GER in otherwise normal children while the Nissen fundoplication is preferable in neurologically impaired children and in patients with GER following esophageal atresia repair.     

Sclerotherapy for extrahepatic portal hypertension in childhood

Ten children with extrahepatic portal hypertension who had major bleeding from esophageal varices were treated with sclerotherapy of esophageal varices by means of flexible fiberoptic endoscopy and intravenous sedation. Four had had no previous therapy, five had had previous surgery for variceal bleeding, and five had received propranolol orally. During therapy and follow-up monitoring of 1.4 to 7.1 years (mean 4.7 years), only two patients bled again from esophageal varices, one before complete obliteration of varices and one who temporarily defaulted on follow-up. The few complications were easily managed, and only three required any specific therapy. No child bled from gastric varices. Frequency of sclerotherapy sessions and quantity of sclerosant could be decreased with time, usually after 3 years of sclerotherapy, suggesting that the natural history of decreased bleeding with time in extrahepatic portal hypertension may be accelerated by sclerotherapy. Esophageal varices in children with extrahepatic portal hypertension may be treated safely with sclerotherapy, which is effective in preventing chronic and recurrent gastrointestinal bleeding.     

Infective endocarditis in black South African children: report of 10 cases with some unusual features

Ten black South African children with infective endocarditis seen over a 2-year period are reported. In five cases, including two neonates, the infection was nosocomial and in five cases it occurred in children with previously normal hearts. Of the bacteria isolated from nine cases, five were Staphylococcus aureus (all from nosocomial cases), one was Haemophilus influenzae and three were corynebacteria. The unusual aspects of this series are discussed, with an emphasis on preventing nosocomial cases and on making the diagnosis in children without underlying heart disease.