CLINICAL AND LABORATORY OBSERVATIONS
Arcanobacterium haemolyticum in children with presumed streptococcal pharyngotonsillitis or scarlet fever Themistocles Karpathios, MD, Sophia Drakonaki, MD, A n a s t a s i a Z e r v o u d a k i , MD, G e o r g i a C o u p a r i , MD, A n d r e w Fretzayas, MD, J e n n y Kremastinos, MD, a n d T h e o d o r e Thomaidis, MD From the Second Department of Pediatrics and the Department of Microbiology, "'A. P. Kyriakou" Children's Hospital, and Athens' School of Public Health, Athens, Greece
Arcanobacterium haemolyticum was cultured from p h a r y n g e a l s p e c i m e n s obt a i n e d from 12 of 129 children with pharyngotonsillitis, s o m e of w h o m h a d a scarlatiniform rash. This organism should be c o n s i d e r e d to be a c a u s e of infections that are clinically similar to those c a u s e d by B-hemolytic streptococci. (J PEDIATR 1992;121:735-7)
Corynebacterium haemolyticum was first isolated, characterized, and named by MacLean et a l l but has been reclassified with the name Areanobacterium haemolyticum. 2 This microorganism causes throat infections in young adults and occasionally in children; it may also cause severe infections such as septicemia, 3, 4 pneumonia,4 osteomyelitis, s and endocarditis,6 usually in immunocompromised individuals or those with a chronic disease. This prospective investigation evaluated the significance and frequency of Ah as an etiologic agent in children with clinical manifestations reminiscent of streptococcal throat infection or scarlet fever. METHODS Patients. We studied 129 children with clinical findings consistent with streptococcal pharyngotonsillitis or scarlet fever seen in the emergency outpatient service during the period from Jan. 1, 1988, through Dec. 31, 1989. A prerequisite for inclusion in the study was not to have taken antibiotics for the preceding 7 days. Written informed consent from the accompanying parent was routinely obtained. Age distribution of these 73 boys and 56 girls ranged from 5 months to 13 years 8 months (mean age, 6.9 _+ 3.1 years). Culture specimens of the throat and both tonsils were ob-
Submitted for publication July 12, 1991; accepted June 8, 1992. Reprint requests: Themistocles Karpathios, MD, Associate Professor and Director, Second Department of Pediatrics, ~ Kyriakou" Children's Hospital, Athens 115 27, Greece. 9/22/40117
tained from all patients. Complete blood cell counts and antistreptolysin O titers (hemolysis inhibition method) were also determined. Penicillin, at a dose of 100,000 IU/kg body weight per 24 hours, was administered orally for 10 days to all of these children. Additional throat cultures of spefimens from 12 children from whom Ah had been isolated were established after completion of penicillin therapy. An additional ASO titer was obtained 1 month after the first visit for six of those children from whom Ah had been isolated, because their cultures also grew a few colonies of group A r streptococcus. Compliance with treatment of patients who had Ah infection was evaluated on the basis of empty bottles that parents brought at follow-up. Throat culture specimens were taken from 308 age- and
Ah ASO GABHS
Arcanobacterium haemolyticum Antistreptolysin O Group A B-hemolytic streptococcus
sex-matched children used as conl(rol subjects. They had a mean age of 8.7 _+ 3.4 years, and were randomly selected from the emergency outpatient service of the orthopedic clinic of the same hospital. Their main complaints were joint sprains or bone fractures. Prerequisites for inclusion in the control group were not to have taken any antibiotic during the preceding 7 days and to have no clinical evidence of infection. Isolation and identification of A. haemolytieum. Throat swabs were transported in Stuart medium and were plated in the laboratory on two double-layered human blood agar plates, the bottom layer containing blood agar base (Oxoid) 735
736
Clinical and laboratory observations
The Journal of Pediatrics November 1992
Table. Symptoms and signs in 12 patients with infection caused by Ah Symptoms
n
Signs
n
Fever Chills Headache Cough Hoarsness of voice Vomiting Abdominal pain
9 6 3 7 7 4 2
Cervicallymphadenitis Exanthem Face Trunk Extremities Pharyngeal injection Tonsillar exudates Palatal petechiae Glossitis
9 7 0 7 3 10 8 4 3
n, Number of patients with the symptom or sign.
and the top layer containing, in addition, 5% human blood. The plates were incubated at 37 ~ C. One plate from each swab was incubated anaerobically and the other in an atmosphere containing 95% air and 5% carbon dioxide. The plates were examined after 24 and 48 hours. Colonies characteristic of Ah, (i.e., with strong hemolysis appearing after 48 hours of incubation and typical pitting of the agar beneath the colony), as well as having characteristic morphologic features in a Gram stain, were identified with biochemical and other tests according to Cowan and Steel, 7 Coyle et al., 8 and Banck and Nyman. 9 Results of the catalase test were negative by conventional methods. The key tests that distinguish Ah from Corynebacterium pyogenes (i.e., inability of Ah to hydrolyze gelatin and ferment xylose) were also performed. The Ah strains isolated from our patients had reactions identical to those of the National Collection of Type Cultures reference strain NCTC 9697. Susceptibility tests were performed by the Bauer-Kirby disk 9diffusion method on Mueller-Hinton agar medium with 5% human blood. All throat cultures were also processed on chocolate, MacConkey, Chapman, and Sabouraud agars for further investigation of pharyngeal flora. Pathogens and potential pathogens were subcultured and identified according to routine methods. 7, 10 Haemophilus influenzae isolates were not serogrouped. RESULTS
Patients Clinicalfindings. The symptoms and signs in the 12 children who had growth of Ah on throat cultures are shown in the Table, with their corresponding frequency of occurrence. Pharyngeal injection and cervical lymphadenitis were the most common findings; rash was present in seven of them. Symptoms in the remaini~ag 117 children (among whom 72 had growth of GABHS and 30 had growth of normal flora) did not differ significantly. Throat cultures. Ah was isolated from culture specimens of 12 children. In 4 of them, Ah was the only microbial growth, in 6 there were also rare colonies of GABHS, and
another 2 had rare colonies of H. influenzae. In 2 of the 12 children with Ah growth, additional cultures were still positive for Ah after completion of penicillin treatment. A S O titer. In the six children with additional rare growth of GABHS, follow-up determinations of ASO did not disclose any increase of titer ( m e a n A S O titers at initial and follow-up determinations were 106.8 + 37.9 and 123.5 _+ 24.2, respectively). Complete blood cell counts. Mean total leukocyte count of the 12 children with Ah infection was 13,108 _+ 3503/ mm 3 and mean total count of polymorphonuclear granulocytes was 8,554 ___ 3,950/mm 3. Antibiotic treatment and in vitro sensitivity o f Ah. After completion of penicillin treatment, 10 of 12 children had no signs and symptoms, and their throat cultures did not grow any pathogens. In two children, clinical improvement was not satisfactory and throat cultures still yielded Ah. Erythromycin was administered to these two children for 10 days at a dose of 50 mg/kg body weight per 24 hours; signs and symptoms disappeared and throat cultures became sterile. In vitro antibiotic susceptibility tests for Ah were done in eight of the children, among whom were the two who did not respond to penicillin. In these two children Ah was resistant to penicillin, whereas in all eight children Ah was susceptible to erythromycin. Control subjects. From 308 control children, 267 throat cultures grew normal flora; 27 had rare colonies of B-hemolytic streptococci of various groups (i.e., A, B, C, F, G); 2 had H. influenzae that was not serotyped; and in 10 Staphylococcus aureus was found. None of the control subjects had Ah. DISCUSSION That Ah is a human pathogen is evidenced by (1) its isolation in pharyngeal secretions of some patients with upper respiratory tract infection, (2) the uniformity of clinical presentation of pharyngotonsillitis when Ah is isolated, (3) a prompt rerhission of the disease after administration of antibiotics to which Ah is susceptible, and (4) the presence of Ah for 4 to 6 weeks after its inoculation into the pharynx of volunteers.9, 11, 12 The findings in our 12 patients were in accordance with these data, though the presence of specific antibodies to this microbe, proving its pathogenicity, was not tested. The rare colonies of GABHS isolated simultaneously in six of the patients are unlikely to have been the causative microorganism of the disease, and there was no subsequent increase of ASO titer. Frequently Ah has been isolated along with both /3-hemolytic streptococci and Corynebacterium diphtheriae; these high rates of additional isolates have been observed mainly in tropical countries, whereas Ah is usually exclusively isolated (90%) in the United Kingdom and the United States. IH3 Streptococcal and Ah infections involving the tonsils and
Volume 121 Number 5, Part 1
pharynx do not differ substantially in terms of clinical presentation, as confirmed by our findings. A scarlatiniform rash was present in 7 of the 12 children with Ah infection, involving mainly the trunk and less often the extremities. This incidence is high, but it may be spurious because about half of all patients studied had a scarlatiniform rash; probably the presence of a rash in both streptococcus- and Ahinfected children caused parents to take the children to the hospital. The rash is reported as a frequent manifestation of Ah throat infection in the United Kingdom and the United States but is rare in tropical countries.l 1, 12 Frequency of the rash is higher in the second decade of life. We conclude that in children with pharyngotonsillitis or a scarlatiniform rash whose throat culture is negative for G A B H S , Ah infection should be sought. Erythromycin may be administered if the organism is resistant to penicillin, but for most patients penicillin is the drug of choice.
REFERENCES 1. MacLean PD, Liebow AA, Rosenberg AA. A herr ~lytic eorynebacterium resembling Corynebaeterium ovis and Corynebacterium pyogenes in man. J Infect Dis 1946;79:6990. 2. Collins MD, Jones D, Schofield GM. Reclassification of Corynebacterium haemolyticum (MacLean, Liebow & Rosenberg) in the genus Areanobacterium gen.nov, as Areanobacterium haemolytieum nom.rev., comb.nov. J Gen Microbiol 1982;128:1279-81. 3. Goudswaard J, van de Merwe DW, van der Sluys P, Doorn H.
Clinical and laboratory observations
737
Corynebacterium haemolyticum septicemia in a girl with mononucleosis infectiosa. Seand J Infect Dis 1988;20:339-40. 4. Jobanputra RS, Swain CP. Septicemia due to Corynebaeterium haemolytieum. J Clin Pathol 1975;28:798-800. 5. Ceilley RI. Foot ulceration and vertebral osteomyelitis with Corynebacterium haemolytieum. Arch Dermatol 1977; l 13:646-7. 6. Worthington MC, Daly BDT, Smith FE. Corynebacterium haemolytieum endocarditis on a native valve. South Med J 1988;78:1261-2. 7. Cowan ST, Steel KJ. Manual for identification of medical bacteria, 2rid ed. Cambridge: Cambridge University Press, 1974. 8. Coyle M, Hollis D, Groman N. Corynebacterium spp and other coryneform organisms. In: Lennette EH, Balows A, Hausler WJ Jr, Shadomy H J, eds. Manual of clinical microbiology. 4th ed. Washington, D.C.: American Society for Microbiology, 1985:193. 9. Banek G, Nyman M. Tonsillitis and rash associated with Corynebaeterium haemolyticum. J Infect Dis 1986; 154:103740. 10. Lennette EH, Balows A, Hausler WJ Jr, Shadomy HJ. Manual of clinical microbiology. 4th ed. Washington, D.C.: American Society for Microbiology, 1985. 11. Fell HWK, Nagington J, Naylor GRE. Corynebaeterium haemolyticum infections in Cambridgeshire. J Hyg (Cambridge) 1977;79:269-74. 12. Miller RA, Brancato F, Holmes KK. Corynebaeterium haemolyticum as a cause of pharyngitis and scarlatiniform rash. Ann Intern Med 1986;105:867-72. 13. Wickremesinghe RSB. Corynebaeterium haemolytieum infections in Sri Lanka. J Hyg (Cambridge) 1981;87:271-7.
Soft tissue swelling and acute skull fractures Paul K. Kleinman, MD, a n d Melissa R. S p e v a k , MD From the Department of Radiology, Universityof Massachusetts Medical Center, Worcester
To determine whether soft tissue swelling, as identified by computed tomography, invariably accompanies acute calvarial fracture, the computed tomography scans of 35 children a g e d 3 months to 8 years with acute skull fractures were evaluated. Bone window settings revealed at least 4 mm of soft tissue swelling in all instances. We conclude that a skull fracture without overlying soft tissue swelling demonstrable by computed tomography is probably inconsistent with an acute injury. (J PEDIATR4992;424:737-9) Although reasonable criteria exist for assessing the age of fractures involving the long bone shafts and the rib arcs, other bony injuries pose problems in accurate dating. 1 The Submitted for publication Feb 26, 1992; accepted June 16, 1992. Reprint requests: Paul K. Kleinman, MD, Department of Radiology, University of Massachusetts Medical Center, 55 Lake Ave., North, Worcester, MA 01655. 9/22/40276
skull is one important region for which reliable criteria for dating injuries are not available. Infants may undergo substantial blunt injury to the head, have no clinically evident soft tissue swelling, and yet have scalp and subgaleal hemorrhage at autopsy. 2 Thus the absence of clinically detectable soft tissue swelling overlying a skull fracture does not necessarily indicate that the fracture is old. Computed tomography provides a more sensitive assessment of the scalp and the subgaleal space, and this technique might therefore
Arcanobacterium haemolyticum in children with presumed streptococcal pharyngotonsillitis or scarlet fever Themistocles Karpathios, MD, Sophia Drakonaki, MD, A n a s t a s i a Z e r v o u d a k i , MD, G e o r g i a C o u p a r i , MD, A n d r e w Fretzayas, MD, J e n n y Kremastinos, MD, a n d T h e o d o r e Thomaidis, MD From the Second Department of Pediatrics and the Department of Microbiology, "'A. P. Kyriakou" Children's Hospital, and Athens' School of Public Health, Athens, Greece
Arcanobacterium haemolyticum was cultured from p h a r y n g e a l s p e c i m e n s obt a i n e d from 12 of 129 children with pharyngotonsillitis, s o m e of w h o m h a d a scarlatiniform rash. This organism should be c o n s i d e r e d to be a c a u s e of infections that are clinically similar to those c a u s e d by B-hemolytic streptococci. (J PEDIATR 1992;121:735-7)
Corynebacterium haemolyticum was first isolated, characterized, and named by MacLean et a l l but has been reclassified with the name Areanobacterium haemolyticum. 2 This microorganism causes throat infections in young adults and occasionally in children; it may also cause severe infections such as septicemia, 3, 4 pneumonia,4 osteomyelitis, s and endocarditis,6 usually in immunocompromised individuals or those with a chronic disease. This prospective investigation evaluated the significance and frequency of Ah as an etiologic agent in children with clinical manifestations reminiscent of streptococcal throat infection or scarlet fever. METHODS Patients. We studied 129 children with clinical findings consistent with streptococcal pharyngotonsillitis or scarlet fever seen in the emergency outpatient service during the period from Jan. 1, 1988, through Dec. 31, 1989. A prerequisite for inclusion in the study was not to have taken antibiotics for the preceding 7 days. Written informed consent from the accompanying parent was routinely obtained. Age distribution of these 73 boys and 56 girls ranged from 5 months to 13 years 8 months (mean age, 6.9 _+ 3.1 years). Culture specimens of the throat and both tonsils were ob-
Submitted for publication July 12, 1991; accepted June 8, 1992. Reprint requests: Themistocles Karpathios, MD, Associate Professor and Director, Second Department of Pediatrics, ~ Kyriakou" Children's Hospital, Athens 115 27, Greece. 9/22/40117
tained from all patients. Complete blood cell counts and antistreptolysin O titers (hemolysis inhibition method) were also determined. Penicillin, at a dose of 100,000 IU/kg body weight per 24 hours, was administered orally for 10 days to all of these children. Additional throat cultures of spefimens from 12 children from whom Ah had been isolated were established after completion of penicillin therapy. An additional ASO titer was obtained 1 month after the first visit for six of those children from whom Ah had been isolated, because their cultures also grew a few colonies of group A r streptococcus. Compliance with treatment of patients who had Ah infection was evaluated on the basis of empty bottles that parents brought at follow-up. Throat culture specimens were taken from 308 age- and
Ah ASO GABHS
Arcanobacterium haemolyticum Antistreptolysin O Group A B-hemolytic streptococcus
sex-matched children used as conl(rol subjects. They had a mean age of 8.7 _+ 3.4 years, and were randomly selected from the emergency outpatient service of the orthopedic clinic of the same hospital. Their main complaints were joint sprains or bone fractures. Prerequisites for inclusion in the control group were not to have taken any antibiotic during the preceding 7 days and to have no clinical evidence of infection. Isolation and identification of A. haemolytieum. Throat swabs were transported in Stuart medium and were plated in the laboratory on two double-layered human blood agar plates, the bottom layer containing blood agar base (Oxoid) 735
736
Clinical and laboratory observations
The Journal of Pediatrics November 1992
Table. Symptoms and signs in 12 patients with infection caused by Ah Symptoms
n
Signs
n
Fever Chills Headache Cough Hoarsness of voice Vomiting Abdominal pain
9 6 3 7 7 4 2
Cervicallymphadenitis Exanthem Face Trunk Extremities Pharyngeal injection Tonsillar exudates Palatal petechiae Glossitis
9 7 0 7 3 10 8 4 3
n, Number of patients with the symptom or sign.
and the top layer containing, in addition, 5% human blood. The plates were incubated at 37 ~ C. One plate from each swab was incubated anaerobically and the other in an atmosphere containing 95% air and 5% carbon dioxide. The plates were examined after 24 and 48 hours. Colonies characteristic of Ah, (i.e., with strong hemolysis appearing after 48 hours of incubation and typical pitting of the agar beneath the colony), as well as having characteristic morphologic features in a Gram stain, were identified with biochemical and other tests according to Cowan and Steel, 7 Coyle et al., 8 and Banck and Nyman. 9 Results of the catalase test were negative by conventional methods. The key tests that distinguish Ah from Corynebacterium pyogenes (i.e., inability of Ah to hydrolyze gelatin and ferment xylose) were also performed. The Ah strains isolated from our patients had reactions identical to those of the National Collection of Type Cultures reference strain NCTC 9697. Susceptibility tests were performed by the Bauer-Kirby disk 9diffusion method on Mueller-Hinton agar medium with 5% human blood. All throat cultures were also processed on chocolate, MacConkey, Chapman, and Sabouraud agars for further investigation of pharyngeal flora. Pathogens and potential pathogens were subcultured and identified according to routine methods. 7, 10 Haemophilus influenzae isolates were not serogrouped. RESULTS
Patients Clinicalfindings. The symptoms and signs in the 12 children who had growth of Ah on throat cultures are shown in the Table, with their corresponding frequency of occurrence. Pharyngeal injection and cervical lymphadenitis were the most common findings; rash was present in seven of them. Symptoms in the remaini~ag 117 children (among whom 72 had growth of GABHS and 30 had growth of normal flora) did not differ significantly. Throat cultures. Ah was isolated from culture specimens of 12 children. In 4 of them, Ah was the only microbial growth, in 6 there were also rare colonies of GABHS, and
another 2 had rare colonies of H. influenzae. In 2 of the 12 children with Ah growth, additional cultures were still positive for Ah after completion of penicillin treatment. A S O titer. In the six children with additional rare growth of GABHS, follow-up determinations of ASO did not disclose any increase of titer ( m e a n A S O titers at initial and follow-up determinations were 106.8 + 37.9 and 123.5 _+ 24.2, respectively). Complete blood cell counts. Mean total leukocyte count of the 12 children with Ah infection was 13,108 _+ 3503/ mm 3 and mean total count of polymorphonuclear granulocytes was 8,554 ___ 3,950/mm 3. Antibiotic treatment and in vitro sensitivity o f Ah. After completion of penicillin treatment, 10 of 12 children had no signs and symptoms, and their throat cultures did not grow any pathogens. In two children, clinical improvement was not satisfactory and throat cultures still yielded Ah. Erythromycin was administered to these two children for 10 days at a dose of 50 mg/kg body weight per 24 hours; signs and symptoms disappeared and throat cultures became sterile. In vitro antibiotic susceptibility tests for Ah were done in eight of the children, among whom were the two who did not respond to penicillin. In these two children Ah was resistant to penicillin, whereas in all eight children Ah was susceptible to erythromycin. Control subjects. From 308 control children, 267 throat cultures grew normal flora; 27 had rare colonies of B-hemolytic streptococci of various groups (i.e., A, B, C, F, G); 2 had H. influenzae that was not serotyped; and in 10 Staphylococcus aureus was found. None of the control subjects had Ah. DISCUSSION That Ah is a human pathogen is evidenced by (1) its isolation in pharyngeal secretions of some patients with upper respiratory tract infection, (2) the uniformity of clinical presentation of pharyngotonsillitis when Ah is isolated, (3) a prompt rerhission of the disease after administration of antibiotics to which Ah is susceptible, and (4) the presence of Ah for 4 to 6 weeks after its inoculation into the pharynx of volunteers.9, 11, 12 The findings in our 12 patients were in accordance with these data, though the presence of specific antibodies to this microbe, proving its pathogenicity, was not tested. The rare colonies of GABHS isolated simultaneously in six of the patients are unlikely to have been the causative microorganism of the disease, and there was no subsequent increase of ASO titer. Frequently Ah has been isolated along with both /3-hemolytic streptococci and Corynebacterium diphtheriae; these high rates of additional isolates have been observed mainly in tropical countries, whereas Ah is usually exclusively isolated (90%) in the United Kingdom and the United States. IH3 Streptococcal and Ah infections involving the tonsils and
Volume 121 Number 5, Part 1
pharynx do not differ substantially in terms of clinical presentation, as confirmed by our findings. A scarlatiniform rash was present in 7 of the 12 children with Ah infection, involving mainly the trunk and less often the extremities. This incidence is high, but it may be spurious because about half of all patients studied had a scarlatiniform rash; probably the presence of a rash in both streptococcus- and Ahinfected children caused parents to take the children to the hospital. The rash is reported as a frequent manifestation of Ah throat infection in the United Kingdom and the United States but is rare in tropical countries.l 1, 12 Frequency of the rash is higher in the second decade of life. We conclude that in children with pharyngotonsillitis or a scarlatiniform rash whose throat culture is negative for G A B H S , Ah infection should be sought. Erythromycin may be administered if the organism is resistant to penicillin, but for most patients penicillin is the drug of choice.
REFERENCES 1. MacLean PD, Liebow AA, Rosenberg AA. A herr ~lytic eorynebacterium resembling Corynebaeterium ovis and Corynebacterium pyogenes in man. J Infect Dis 1946;79:6990. 2. Collins MD, Jones D, Schofield GM. Reclassification of Corynebacterium haemolyticum (MacLean, Liebow & Rosenberg) in the genus Areanobacterium gen.nov, as Areanobacterium haemolytieum nom.rev., comb.nov. J Gen Microbiol 1982;128:1279-81. 3. Goudswaard J, van de Merwe DW, van der Sluys P, Doorn H.
Clinical and laboratory observations
737
Corynebacterium haemolyticum septicemia in a girl with mononucleosis infectiosa. Seand J Infect Dis 1988;20:339-40. 4. Jobanputra RS, Swain CP. Septicemia due to Corynebaeterium haemolytieum. J Clin Pathol 1975;28:798-800. 5. Ceilley RI. Foot ulceration and vertebral osteomyelitis with Corynebacterium haemolytieum. Arch Dermatol 1977; l 13:646-7. 6. Worthington MC, Daly BDT, Smith FE. Corynebacterium haemolytieum endocarditis on a native valve. South Med J 1988;78:1261-2. 7. Cowan ST, Steel KJ. Manual for identification of medical bacteria, 2rid ed. Cambridge: Cambridge University Press, 1974. 8. Coyle M, Hollis D, Groman N. Corynebacterium spp and other coryneform organisms. In: Lennette EH, Balows A, Hausler WJ Jr, Shadomy H J, eds. Manual of clinical microbiology. 4th ed. Washington, D.C.: American Society for Microbiology, 1985:193. 9. Banek G, Nyman M. Tonsillitis and rash associated with Corynebaeterium haemolyticum. J Infect Dis 1986; 154:103740. 10. Lennette EH, Balows A, Hausler WJ Jr, Shadomy HJ. Manual of clinical microbiology. 4th ed. Washington, D.C.: American Society for Microbiology, 1985. 11. Fell HWK, Nagington J, Naylor GRE. Corynebaeterium haemolyticum infections in Cambridgeshire. J Hyg (Cambridge) 1977;79:269-74. 12. Miller RA, Brancato F, Holmes KK. Corynebaeterium haemolyticum as a cause of pharyngitis and scarlatiniform rash. Ann Intern Med 1986;105:867-72. 13. Wickremesinghe RSB. Corynebaeterium haemolytieum infections in Sri Lanka. J Hyg (Cambridge) 1981;87:271-7.
Soft tissue swelling and acute skull fractures Paul K. Kleinman, MD, a n d Melissa R. S p e v a k , MD From the Department of Radiology, Universityof Massachusetts Medical Center, Worcester
To determine whether soft tissue swelling, as identified by computed tomography, invariably accompanies acute calvarial fracture, the computed tomography scans of 35 children a g e d 3 months to 8 years with acute skull fractures were evaluated. Bone window settings revealed at least 4 mm of soft tissue swelling in all instances. We conclude that a skull fracture without overlying soft tissue swelling demonstrable by computed tomography is probably inconsistent with an acute injury. (J PEDIATR4992;424:737-9) Although reasonable criteria exist for assessing the age of fractures involving the long bone shafts and the rib arcs, other bony injuries pose problems in accurate dating. 1 The Submitted for publication Feb 26, 1992; accepted June 16, 1992. Reprint requests: Paul K. Kleinman, MD, Department of Radiology, University of Massachusetts Medical Center, 55 Lake Ave., North, Worcester, MA 01655. 9/22/40276
skull is one important region for which reliable criteria for dating injuries are not available. Infants may undergo substantial blunt injury to the head, have no clinically evident soft tissue swelling, and yet have scalp and subgaleal hemorrhage at autopsy. 2 Thus the absence of clinically detectable soft tissue swelling overlying a skull fracture does not necessarily indicate that the fracture is old. Computed tomography provides a more sensitive assessment of the scalp and the subgaleal space, and this technique might therefore
