Volume 93 Number 3
Clinical notes
and identification of Haemophilus spp. from unusual lesions in children, J C1in Pathol 13:519, 1960. 4. Feigin RD, Shackelford PG, and Keeney R: Hemophilus infiuenzae abscess associated with septicemia, Am J Dis Child 121:534, 1971. 5. Waldman LS, Kosloske AM, and Parsons DW: Acute epididymo-orchitis as the presenting manifestation of Hemophilus influenzae septicemia, J PEDlATR 90:87, 1977.
533
Health laboratory. A survey of household members revealed that her father was excreting S. typht in his stools. On the third day of treatment, the fever subsided. Simultaneously, her behavior returned to normal. An audiogram on the fifth day of treatment showed a moderate (40 to 50 dB) low-frequency sensorineural hearing loss. Follow-up audiogram 6 weeks later was normal. DISCUSSION
Typhoid fever: Unusual presentation The reported incidence of typhoid fever in the United States has fallen steadily over the past 30 years from 3 to 0.2 cases/ 100,000.' The disease now occurs in scattered outbreaks, usually traceable to a single carrier. Sporadic cases occur mainly in travelers to parts of the world where typhoid is endemic. Because of its rarity, the diagnosis is usually made by chance. Of the nine cases seen in children at University Hospital of Jacksonville in the past ten years, typhoid was included in the initial differential diagnosis in only one. The patient reported here presented with psychosis and hearing loss. CASE REPORT
A 14-year-old girl was admitted to the hospital for changes in behavior. Two weeks before admission, she became withdrawn and uncommunicative, refusing to eat, drink, or walk. She was generally unresponsive to her environment, particularly to sound. She began to sleep more, and had vomiting and pain in the legs and abdomen. There were no previous episodes of unusual behavior and no known exposure to toxins or drugs. All members of her household were well. On examination, she was withdrawn and passive. Vital signs were normal. At times she did not seem to hear. Her speech was slurred and slow, and her responses to simple questions incoherent. Her face was expressionless. The pharynx was injected. Initial impression was of (I) behavior disorder, cause unknown, (2) pharyngitis, and (3) possible hearing loss. The hemoglobin concentration was 8.5 gm/dl, and peripheral blood smear revealed slight anisocytosis, poikilocytosis, and few microcytes, Results of urinary screening for toxic substances, serum electrolytes, lumbar CSF, and chest radiograph were normal. Initial cultures of throat, urine, and blood were negative. Findings of radionuclide brain scan and computerized axial tomograms of the brain were normal. Stool examination for occult blood was positive. A bone marrow cytologic examination was unremarkable. Serum creatinine phosphokinase was 2,850 Ilf /I, with electrophoretic fractionation showing all of the enzyme to be of skeletal muscle origin. Lactic acid dehydrogenase was greater than 600 (shown by electrophoresis to be of hepatic origin), and glutarnic-oxaloacetic transaminase was 279 lUll. On the second day her temperature rose to 104.3°F, and she remained febrile. Her affect remained blunted, and on one occasion she was found wandering aimlessly. On the seventh day, Salmonella typhi was isolated from the bone marrow (four blood cultures having been negative). Salmonella H antibodies were present in a dilution of 1:200. She was treated intravenously with ampicillin (200 rag/kg/day). The identity of the organism was confirmed in the State Board of
0022-3476178/0393-0533$00.1010 © 1978 The C. V. Mosby Co.
Alterations of central nervous system function are not uncommon in typhoid fever. Osuntokin et aI' found confusion or delirium in 57% and schizophreniform psychosis in 0.7% of a large series of patients in Nigeria. Workers in the field have long recognized transient deafness as a manifestation of typhoid fever." • Thiamine deficiency has been invoked as a possible mechanism,' but our patient's normal nutritional state and her recovery without vitamin supplementation argue against this explanation. The purpose of this note is to rem ind the clinician that typhoid fever continues to occur in this country and that its variability of presentation and rarity tend to delay diagnosis. Blood cultures may fail to yield the organism, especially if the patient has received antibiotics:' Clifford B. David, M.D. Chief Resident Asad Tolaymat, M.D. Assistant Professor Department of Pediatrics University Hospital of Jacksonville 655 W. Eighth St. Jacksonville, FL 32209 REFERENCES 1. Morbid Mortal Wk Rep, Annual Suppl. 24:59, 1975. 2. Osuntokun BO, Bademosi 0, Ogunrerni K, and Wright SC: Neuro-psychiatric manifestations of typhoid fever in 959 cases, Arch Neural 27:7, 1972. 3. Huckstep RL: Typhoid fever and other Salmonella infections, Edinburgh, 1962, E. & S. Livingstone, Ltd., pp 57-59. 4. Osler W: Modern medicine, its theory and practice, Vol. 2, Infectious diseases, Philadelphia and New York, 1907, pp 105, 152-154. 5. Gilman RH, Terminel M, Levine MM, Hernandez-Mendoza P, and Hornick, RB: Relative efficacy of blood, urine, rectal, swab, bone marrow and rose-spot cultures for recovery of Salmonella typhi in typhoid fever, Lancet 1:1211, 1975.
Balance studies in newborn infants Nutritional studies often require balance techniques in which intake is controlled and output is monitored through careful collection of urine and feces over a designated period of time. This necessitates adequate separation of urine and feces, a
0022·3476178/0393-0533$00.2010
e
1978 The C. V. Mosby Co.
534
Clinical notes
The
difficult procedure in newborn infants. This report describes a method which allows such collection without contamination. METHOD The neonate is placed on a metabolic bed, similar to one described previously.' A urine collection bag (U-BAG, No. 7515. Hollister, Inc., Chicago. Ill.) is accurately weighed and applied to the perineum. covering the anal orifice. Careful attention is paid to ensure adequate contact between the skin and the adhesive portion of the bag all around the anal orifice. The infant is generally nursed in the prone position. When supine, the penis in male infants is taped gently to the scrotum to direct the urinary stream into the metabolic bed. Urine is collected through the protruding spout at the foot end of the bed into silicone ClipS. It is measured accurately by a syringe and transferred to an appropriate specimen container, which can be refrigerated. A record of the amount transferred is kept by the bedside. The stools passed by the infant are collected in the urine collection bag. After passage of a stool, the bag in removed and the lips at the opening of the bag are sealed. The bag is weighed accurately, numbered, and placed in the freezer. A new bag is then applied for collection of the next stool. During analysis, the bag is cut open at the seam. The frozen mass of stool inside the bag is usually recovered with ease. If any fecal material is trapped in the crevices of the bag, it can be recovered by rinsing with sterile water from a squirt bottle with a fine opening. The recovered stool is thoroughly mixed with water in a previously weighed flask and then lyophilized.
of Pediatrics September 1978
JOIIl'/1a{
in very low-birth-weight infants conducted at the University of Oregon Health Sciences Center. In 26 infants studied, the only problem noted has been accidental dislodgement of the bag in one infant, necessitating a repeat balance procedure. The method allows complete separation of urine and feces. The nylon netting of the metabolic bed is totally free of fecal contamination, ensuring cleanliness; frequent changing of s toolsoiled netting is avoided. Recovery of semisolid or liquid stools is possible. Accurate records of urine volumes and stool weights can be maintained. Stools are stored easily till the time of analysis. Recovery of stools from the bag during analysis is easy. The potential problem of skin irritation can be minimized by utilizing one bag for collection of more than one stool. This can easily be accomplished in premature neonates with small amounts of feces. My gratitude to all the nurses in the Neonatal Intensive Care Center and 4 NE nursery for their excellent cooperation. and to Drs. R. C. Neerhout, S. G. Babson, and 1. W. Reynolds for their critical review of this manuscript. Jayant P. Shenai, M.D.. D.C.H., M.B.B.S. Research Fellow ill Neonatology University of Oregon Health Sciences Center 3181 S. W. Sam Jackson Park Ref. Portland, OR 97201 REFERENCE
1. Hepner R, and Lubchenco LO: A method for continuous urine and stool collection in young infants, Pediatrics 26:828, 1960.
RESULTS AND DISCUSSION The method described has been successfully used over a nine-month period of time in 96-hour nutritional balance studies
Information for authors Most of the provisions of the Copyright Act of 1976 became effective on January 1, 1978. Therefore. all manuscripts must be accompanied by the following statement. signed by each author: "The undersigned authorts) transfers all copyright ownership of the manuscript entitled (title of article) to The C. V. Mosby Company in the event the work is published. The authorts) warrants that the article is original. is not under consideration by another journal. and has not been previously published." Authors will he consulted. when possible. regarding republication of their material.
Clinical notes
and identification of Haemophilus spp. from unusual lesions in children, J C1in Pathol 13:519, 1960. 4. Feigin RD, Shackelford PG, and Keeney R: Hemophilus infiuenzae abscess associated with septicemia, Am J Dis Child 121:534, 1971. 5. Waldman LS, Kosloske AM, and Parsons DW: Acute epididymo-orchitis as the presenting manifestation of Hemophilus influenzae septicemia, J PEDlATR 90:87, 1977.
533
Health laboratory. A survey of household members revealed that her father was excreting S. typht in his stools. On the third day of treatment, the fever subsided. Simultaneously, her behavior returned to normal. An audiogram on the fifth day of treatment showed a moderate (40 to 50 dB) low-frequency sensorineural hearing loss. Follow-up audiogram 6 weeks later was normal. DISCUSSION
Typhoid fever: Unusual presentation The reported incidence of typhoid fever in the United States has fallen steadily over the past 30 years from 3 to 0.2 cases/ 100,000.' The disease now occurs in scattered outbreaks, usually traceable to a single carrier. Sporadic cases occur mainly in travelers to parts of the world where typhoid is endemic. Because of its rarity, the diagnosis is usually made by chance. Of the nine cases seen in children at University Hospital of Jacksonville in the past ten years, typhoid was included in the initial differential diagnosis in only one. The patient reported here presented with psychosis and hearing loss. CASE REPORT
A 14-year-old girl was admitted to the hospital for changes in behavior. Two weeks before admission, she became withdrawn and uncommunicative, refusing to eat, drink, or walk. She was generally unresponsive to her environment, particularly to sound. She began to sleep more, and had vomiting and pain in the legs and abdomen. There were no previous episodes of unusual behavior and no known exposure to toxins or drugs. All members of her household were well. On examination, she was withdrawn and passive. Vital signs were normal. At times she did not seem to hear. Her speech was slurred and slow, and her responses to simple questions incoherent. Her face was expressionless. The pharynx was injected. Initial impression was of (I) behavior disorder, cause unknown, (2) pharyngitis, and (3) possible hearing loss. The hemoglobin concentration was 8.5 gm/dl, and peripheral blood smear revealed slight anisocytosis, poikilocytosis, and few microcytes, Results of urinary screening for toxic substances, serum electrolytes, lumbar CSF, and chest radiograph were normal. Initial cultures of throat, urine, and blood were negative. Findings of radionuclide brain scan and computerized axial tomograms of the brain were normal. Stool examination for occult blood was positive. A bone marrow cytologic examination was unremarkable. Serum creatinine phosphokinase was 2,850 Ilf /I, with electrophoretic fractionation showing all of the enzyme to be of skeletal muscle origin. Lactic acid dehydrogenase was greater than 600 (shown by electrophoresis to be of hepatic origin), and glutarnic-oxaloacetic transaminase was 279 lUll. On the second day her temperature rose to 104.3°F, and she remained febrile. Her affect remained blunted, and on one occasion she was found wandering aimlessly. On the seventh day, Salmonella typhi was isolated from the bone marrow (four blood cultures having been negative). Salmonella H antibodies were present in a dilution of 1:200. She was treated intravenously with ampicillin (200 rag/kg/day). The identity of the organism was confirmed in the State Board of
0022-3476178/0393-0533$00.1010 © 1978 The C. V. Mosby Co.
Alterations of central nervous system function are not uncommon in typhoid fever. Osuntokin et aI' found confusion or delirium in 57% and schizophreniform psychosis in 0.7% of a large series of patients in Nigeria. Workers in the field have long recognized transient deafness as a manifestation of typhoid fever." • Thiamine deficiency has been invoked as a possible mechanism,' but our patient's normal nutritional state and her recovery without vitamin supplementation argue against this explanation. The purpose of this note is to rem ind the clinician that typhoid fever continues to occur in this country and that its variability of presentation and rarity tend to delay diagnosis. Blood cultures may fail to yield the organism, especially if the patient has received antibiotics:' Clifford B. David, M.D. Chief Resident Asad Tolaymat, M.D. Assistant Professor Department of Pediatrics University Hospital of Jacksonville 655 W. Eighth St. Jacksonville, FL 32209 REFERENCES 1. Morbid Mortal Wk Rep, Annual Suppl. 24:59, 1975. 2. Osuntokun BO, Bademosi 0, Ogunrerni K, and Wright SC: Neuro-psychiatric manifestations of typhoid fever in 959 cases, Arch Neural 27:7, 1972. 3. Huckstep RL: Typhoid fever and other Salmonella infections, Edinburgh, 1962, E. & S. Livingstone, Ltd., pp 57-59. 4. Osler W: Modern medicine, its theory and practice, Vol. 2, Infectious diseases, Philadelphia and New York, 1907, pp 105, 152-154. 5. Gilman RH, Terminel M, Levine MM, Hernandez-Mendoza P, and Hornick, RB: Relative efficacy of blood, urine, rectal, swab, bone marrow and rose-spot cultures for recovery of Salmonella typhi in typhoid fever, Lancet 1:1211, 1975.
Balance studies in newborn infants Nutritional studies often require balance techniques in which intake is controlled and output is monitored through careful collection of urine and feces over a designated period of time. This necessitates adequate separation of urine and feces, a
0022·3476178/0393-0533$00.2010
e
1978 The C. V. Mosby Co.
534
Clinical notes
The
difficult procedure in newborn infants. This report describes a method which allows such collection without contamination. METHOD The neonate is placed on a metabolic bed, similar to one described previously.' A urine collection bag (U-BAG, No. 7515. Hollister, Inc., Chicago. Ill.) is accurately weighed and applied to the perineum. covering the anal orifice. Careful attention is paid to ensure adequate contact between the skin and the adhesive portion of the bag all around the anal orifice. The infant is generally nursed in the prone position. When supine, the penis in male infants is taped gently to the scrotum to direct the urinary stream into the metabolic bed. Urine is collected through the protruding spout at the foot end of the bed into silicone ClipS. It is measured accurately by a syringe and transferred to an appropriate specimen container, which can be refrigerated. A record of the amount transferred is kept by the bedside. The stools passed by the infant are collected in the urine collection bag. After passage of a stool, the bag in removed and the lips at the opening of the bag are sealed. The bag is weighed accurately, numbered, and placed in the freezer. A new bag is then applied for collection of the next stool. During analysis, the bag is cut open at the seam. The frozen mass of stool inside the bag is usually recovered with ease. If any fecal material is trapped in the crevices of the bag, it can be recovered by rinsing with sterile water from a squirt bottle with a fine opening. The recovered stool is thoroughly mixed with water in a previously weighed flask and then lyophilized.
of Pediatrics September 1978
JOIIl'/1a{
in very low-birth-weight infants conducted at the University of Oregon Health Sciences Center. In 26 infants studied, the only problem noted has been accidental dislodgement of the bag in one infant, necessitating a repeat balance procedure. The method allows complete separation of urine and feces. The nylon netting of the metabolic bed is totally free of fecal contamination, ensuring cleanliness; frequent changing of s toolsoiled netting is avoided. Recovery of semisolid or liquid stools is possible. Accurate records of urine volumes and stool weights can be maintained. Stools are stored easily till the time of analysis. Recovery of stools from the bag during analysis is easy. The potential problem of skin irritation can be minimized by utilizing one bag for collection of more than one stool. This can easily be accomplished in premature neonates with small amounts of feces. My gratitude to all the nurses in the Neonatal Intensive Care Center and 4 NE nursery for their excellent cooperation. and to Drs. R. C. Neerhout, S. G. Babson, and 1. W. Reynolds for their critical review of this manuscript. Jayant P. Shenai, M.D.. D.C.H., M.B.B.S. Research Fellow ill Neonatology University of Oregon Health Sciences Center 3181 S. W. Sam Jackson Park Ref. Portland, OR 97201 REFERENCE
1. Hepner R, and Lubchenco LO: A method for continuous urine and stool collection in young infants, Pediatrics 26:828, 1960.
RESULTS AND DISCUSSION The method described has been successfully used over a nine-month period of time in 96-hour nutritional balance studies
Information for authors Most of the provisions of the Copyright Act of 1976 became effective on January 1, 1978. Therefore. all manuscripts must be accompanied by the following statement. signed by each author: "The undersigned authorts) transfers all copyright ownership of the manuscript entitled (title of article) to The C. V. Mosby Company in the event the work is published. The authorts) warrants that the article is original. is not under consideration by another journal. and has not been previously published." Authors will he consulted. when possible. regarding republication of their material.
