Letters to the Editor Bradycardia in Children With Crimean-Congo Hemorrhagic Fever To the Editors: e evaluated 54 children with CrimeanCongo hemorrhagic fever (CCHF) disease in the Central Blacksea Region and the study was published in the August 2014 issue of the Pediatric Infectious Disease Journal.1 This is one of the largest series in this topic. In the article, bradycardia was reported in 18 patients and it was suggested that bradycardia was related to ribavirin therapy in children with CCHF. Here, I want to discuss another approach to bradycardia in CCHF patients. CCHF is a tickborne viral disease with a mortality rate of 15–70%. Early and extensive supportive treatment is the mainstay of treatment. Although there are some debates on the clinical benefit of ribavirin, it is still the only antiviral agent recommended by the World Health Organization for CCHF patients.2 In the study, we gave ribavirin treatment especially to the severely affected patients such as the patients with marked fatigue and/or who had leukopenia, thrombocytopenia and bleeding manifestations. We know that bradycardia is one of the early signs of CCHF patients.2 It has also been reported as the manifestation of the disease in other viral hemorrhagic fever diseases such as dengue hemorrhagic fever and hemorrhagic fever with renal syndrome.3,4 In our study, all the patients with bradycardia were receiving ribavirin treatment. Ribavirin was stopped in 4 (22.2%) patients with bradycardia. However, regarding the patients’s severe CCHF disease, ribavirin treatment was not stopped in the remaining 14 (77.8%) patients and they were followed closely. Bradycardia in these patients did not get worse on the followup and all of the patients with bradycardia recovered completely. Recently, Oflaz et al5 reported reversible bradycardia in 7 of 52 children with CCHF and bradycardia was present in 3 of these 7 patients at admission before ribavirin treatment. In addition, they observed bradycardia more frequently in patients whose clinical courses were more severe. I believe it is very difficult to say that bradycardia in CCHF patients is related to ribavirin treatment. The disease itself can be the cause of the bradycardia. Further studies will help to clarify this topic.
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The author has no funding or conflict of interest to disclose. Copyright © 2015 by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0891-3668/15/3402-0225 DOI: 10.1097/INF.0000000000000524
Gülnar Şensoy, MD
Department of Pediatric Infectious Diseases Faculty of Medicine Ondokuz Mayis University Samsun, Turkey REFERENCES 1. Belet N, Top A, Terzi O, Arslan HN, Baysal K, Sensoy G. Evaluation of children with CrimeanCongo hemorrhagic fever in the Central Blacksea Region. Pediatr Infect Dis J. 2014; 33:e194–e197. 2. Mardani M, Rahnavardi M, Sharifi-Mood B. Current treatment of Crimean-Congo hemorrhagic fever in children. Expert Rev Anti Infect Ther. 2010;8:911–918. 3. Mahmod M, Darul ND, Mokhtar I, Nor NM, Anshar FM, Maskon O. Atrial fibrillation as a complication of dengue hemorrhagic fever: non-self-limiting manifestation. Int J Infect Dis. 2009; 13: e316–318. 4. Rusnak JM, Byrne WR, Chung KN, et al. Experience with intravenous ribavirin in the treatment of hemorrhagic fever with renal syndrome in Korea. Antiviral Res. 2009;81:68–76. 5. Oflaz MB, Kucukdurmaz Z, Guven AS, et al. Bradycardia seen in children with CrimeanCongo hemorrhagic fever. Vector Borne Zoonotic Dis. 2013;13:807–811.
Herpes Zoster Multiplex and Bilateral in an Immunocompetent Child To the Editors:
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healthy 7-year-old Caucasian male child with a history of chickenpox caused by varicella zoster virus (VZV) 2 years earlier was referred to our outpatient department of Dermatology because of a painful vesicopapular eruption in the torso evolving for the previous 3 days. Erythematous papules and vesicles surrounded by erythema were observed clustered on the right shoulder (C4 dermatome), left scapula (T3-4 dermatomes) and left lumbar region (L2 dermatome), which had been preceded by local pain 2 days before (see Fig., Supplemental Digital Content 1, http://links.lww.com/INF/B1000). There were no other cutaneous or systemic abnormalities, such as fever, lymphadenopathies or headache. Blood tests were unremarkable, namely complete blood count with The authors have no funding or conflict of interests to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.pidj.com). Copyright © 2015 by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0891-3668/15/3402-0225 DOI: 10.1097/INF.0000000000000528
The Pediatric Infectious Disease Journal • Volume 34, Number 2, February 2015
white blood cell differential, biochemistry panel including lactate dehydrogenase, HIV, HCV and HBV antibody tests, immunoglobulin values and immunophenotyping studies of peripheral blood. The presumed diagnosis of herpes zoster (HZ) multiplex bilateralis was confirmed by polymerase chain reaction of the vesicle content. Oral acyclovir (800 mg, 5 times per day) was started and maintained for 7 days, with resolution of skin lesions and symptoms in 10 days. No recurrent zosteriform lesions were noticed during a follow-up period of 6 months. Herpes zoster multiplex bilateralis is caused by the concurrent VZV reactivation in more than 2 noncontiguous dermatomes in both sides of the body, which had hitherto remained latent in sensory dorsal root ganglia after the episode of chickenpox.1 Childhood zoster is more likely if primary infection occurred within the first year of age including in utero. Multiple dermatome involvement in the lack of immune deficiency is rare or otherwise unreported in children.2 Most of the reported cases involving noncontiguous dermatomes have been limited to 2 dermatomes and are referred as HZ duplex.1,3 This rare clinical entity is almost exclusively associated with age-related decline in cellular immunity, primary or acquired immunodeficiencies and with the use of immunosuppressive drugs.1 According to recent studies,4,5 the simultaneous reactivation of VZV in multiple noncontiguous dermatomes usually requires an immunocompromised milieu, leading to the recommendation that these patients should undergo a complete status immune evaluation.5 It seems not to portend a poor prognosis.3 We present a rare case of HZ involving 3 noncontiguous dermatomes in both halves of the body, in the absence of an immunodeficiency background. To our knowledge, most of case reports of HZ duplex/multiplex bilateralis were related to older age and/or immunocompromised patients,1,3 and in the few cases reported in children, only 4 of them were confirmed to be immunocompetent.3,5
Ana Pedrosa, MD Maria João Cruz, MD Alberto Mota, MD, PhD
Department of Dermatology and Venereology Centro Hospitalar São João EPE Porto, Portugal Faculty of Medicine University of Porto
Teresa Baudrier, MD Filomena Azevedo, MD
Department of Dermatology and Venereology Centro Hospitalar São João EPE Porto, Portugal www.pidj.com | 225
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REFERENCES 1. Vu AQ, Radonich MA, Heald PW. Herpes zoster in seven disparate dermatomes (zoster multiplex): report of a case and review of the literature. J Am Acad Dermatol. 1999;40(5 pt 2):868–869. 2. Feder HM Jr, Hoss DM. Herpes zoster in otherwise healthy children. Pediatr Infect Dis J. 2004;23:451–457. 3. Castronovo C, Nikkels AF. Chronic herpes zoster duplex bilateralis. Acta Derm Venereol. 2012;92:148–151. 4. Agrawal S, Aara N, Bumb R. Herpes zoster duplex bilateralis symmetricus in an immunocompetent subject. Int J Dermatol. 2014;53:e281–e282. 5. Yan C, Laguna BA, Marlowe LE, et al. Herpes zoster duplex bilateralis in an immunocompetent adolescent boy: a case report and literature review. Pediatr Dermatol. 2014;31:341–344.
Atypical Cystic Echinococcosis in a Young Child To The Editors:
A
n almost 4-year-old Argentinian girl had abdominal pain and daily fevers of 38.5°C for 5 days. She appeared to be in good general condition except for petechial lesions on the anterior trunk. She also had a painful and tense abdomen on light palpation. Abdominal ultrasonography revealed a large intraperitoneal cystic lesion measuring 11.56 cm × 10.5 cm × 4.18 cm with thin walls and liquid in the cavity (See Figure, Supplemental Digital Content 1, http:// links.lww.com/INF/B990). Laboratory tests showed slight eosinophilia. Preoperative diagnosis was a congenital cystic mass of the mesenterium. Laparotomy showed liquid in the cavity and a flaccid cyst of very thin walls surrounded by the small intestine, the stomach and the omentum. During removal, it was damaged and it resembled a hydatid membrane. The abdominal cavity was washed with physiologic solution and hypertonic saline solution-soaked pads were This work was supported by the PIP 0029 (Consejo Nacional de Investigaciones Científicas y Técnicas [CONICET], Argentina) and Universidad Nacional de Mar del Plata grants EXA 576/12 and EXA 634/13. The authors have no funding or conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.pidj.com). Copyright © 2015 by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0891-3668/15/3402-0226 DOI: 10.1097/INF.0000000000000525
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The Pediatric Infectious Disease Journal • Volume 34, Number 2, February 2015
used. The patient had an uneventful recovery and received albendazole treatment (15 mg/kg/day). She was discharged after the third postoperative day when abdominal ultrasonography and chest radiography were normal. Outpatient follow-up included abdominal ultrasonography bimonthly and albendazole treatment. Histopathological examination confirmed hydatid cyst showing laminated and germinal layers with abundant eosinophils, multinucleated giant cells and scoleces (See Figure, Supplemental Digital Content 2, http://links.lww.com/ INF/B991, which shows a histophatological section of hydatic cyst. Laminal layer, germinal layer and vesicle with 2 scoleces are seen. HE stain). Intraperitoneal hydatid cysts usually develop secondary to spontaneous or iatrogenic rupture of hepatic, splenic or mesenteric cysts. Rarely, an isolated primary cyst can develop in the peritoneum without evidence of cysts in other intra-abdominal organs.1 The growth rate of a hydatid cyst has been variably reported at 1–16 cm per year in abdomen.2 Abdominal cystic echinococcosis had been infrequently reported and only in adults.3 If the girl ingested the oncosphere in the first semester of life, an estimated minimum growth rate of the cyst was 2.5–3 cm per year. Canine coproparasitological research in the environment where the family was living showed a dog with Taenia spp. These findings confirm the persistence of the habit of feeding dogs with raw offal and the existence of hosts involved in the parasite life cycle, which represent risk factors to develop cystic echinococcosis or other parasitic diseases.
Carla Mariela Lavallen, BSc
Laboratorio de Zoonosis Parasitarias Facultad de Ciencias Exactas y Naturales Universidad Nacional de Mar del Plata CONICET (Consejo Nacional de Investigaciones Científicas y Técnicas)
Mauricio Pons, MD Enrique Mercuri, MD Viviana Ortolani, MD
HIEMI (Hospital Interzonal Especializado Materno Infantil “Victorio Tetamanti”)
Nathalia Scioscia, DVM
Laboratorio de Zoonosis Parasitarias Facultad de Ciencias Exactas y Naturales Universidad Nacional de Mar del Plata CONICET (Consejo Nacional de Investigaciones Científicas y Técnicas)
Patricia Hollmann, DVM
Centro Municipal de Zoonosis, Secretaría de Salud, Partido de General Pueyrredon
Guillermo María Denegri, PhD Marcela Cecilia Dopchiz, PhD
Laboratorio de Zoonosis Parasitarias Facultad de Ciencias Exactas y Naturales Universidad Nacional de Mar del Plata CONICET (Consejo Nacional de Investigaciones Científicas y Técnicas) Buenos Aires, Argentina REFERENCES 1. Gorad K, Rayate N, Oswal K, et al. Laparoscopic removal of pelvic hydatid cysts in young female: a case report. Minim Invasive Surg. 2011;2011:1–3. 2. Roming T, Zeyhle E, Macpherson CNL, Rees PH, Were JBO. Cyst growth and spontaneous cure in hydatid disease. Lancet. 1986;1:861. 3. Dopchiz MC, Elissondo MC, Andresiuk MV, et al. Pediatric hydatidosis in the south-east of the Buenos Aires province, Argentina. Rev Argent Microbiol. 2009;41:105–111.
Intestinal Parasites Among Children With Diarrhea Younger Than 5 Years of Age in Rural Ethiopia To the Editors:
W
e performed a retrospective crosssectional study in a rural hospital in southern Ethiopia to document parasitic infection in children younger than 5 with acute diarrhea (defined as ≥ 3 loose stools within 24 hours for
W
The author has no funding or conflict of interest to disclose. Copyright © 2015 by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0891-3668/15/3402-0225 DOI: 10.1097/INF.0000000000000524
Gülnar Şensoy, MD
Department of Pediatric Infectious Diseases Faculty of Medicine Ondokuz Mayis University Samsun, Turkey REFERENCES 1. Belet N, Top A, Terzi O, Arslan HN, Baysal K, Sensoy G. Evaluation of children with CrimeanCongo hemorrhagic fever in the Central Blacksea Region. Pediatr Infect Dis J. 2014; 33:e194–e197. 2. Mardani M, Rahnavardi M, Sharifi-Mood B. Current treatment of Crimean-Congo hemorrhagic fever in children. Expert Rev Anti Infect Ther. 2010;8:911–918. 3. Mahmod M, Darul ND, Mokhtar I, Nor NM, Anshar FM, Maskon O. Atrial fibrillation as a complication of dengue hemorrhagic fever: non-self-limiting manifestation. Int J Infect Dis. 2009; 13: e316–318. 4. Rusnak JM, Byrne WR, Chung KN, et al. Experience with intravenous ribavirin in the treatment of hemorrhagic fever with renal syndrome in Korea. Antiviral Res. 2009;81:68–76. 5. Oflaz MB, Kucukdurmaz Z, Guven AS, et al. Bradycardia seen in children with CrimeanCongo hemorrhagic fever. Vector Borne Zoonotic Dis. 2013;13:807–811.
Herpes Zoster Multiplex and Bilateral in an Immunocompetent Child To the Editors:
A
healthy 7-year-old Caucasian male child with a history of chickenpox caused by varicella zoster virus (VZV) 2 years earlier was referred to our outpatient department of Dermatology because of a painful vesicopapular eruption in the torso evolving for the previous 3 days. Erythematous papules and vesicles surrounded by erythema were observed clustered on the right shoulder (C4 dermatome), left scapula (T3-4 dermatomes) and left lumbar region (L2 dermatome), which had been preceded by local pain 2 days before (see Fig., Supplemental Digital Content 1, http://links.lww.com/INF/B1000). There were no other cutaneous or systemic abnormalities, such as fever, lymphadenopathies or headache. Blood tests were unremarkable, namely complete blood count with The authors have no funding or conflict of interests to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.pidj.com). Copyright © 2015 by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0891-3668/15/3402-0225 DOI: 10.1097/INF.0000000000000528
The Pediatric Infectious Disease Journal • Volume 34, Number 2, February 2015
white blood cell differential, biochemistry panel including lactate dehydrogenase, HIV, HCV and HBV antibody tests, immunoglobulin values and immunophenotyping studies of peripheral blood. The presumed diagnosis of herpes zoster (HZ) multiplex bilateralis was confirmed by polymerase chain reaction of the vesicle content. Oral acyclovir (800 mg, 5 times per day) was started and maintained for 7 days, with resolution of skin lesions and symptoms in 10 days. No recurrent zosteriform lesions were noticed during a follow-up period of 6 months. Herpes zoster multiplex bilateralis is caused by the concurrent VZV reactivation in more than 2 noncontiguous dermatomes in both sides of the body, which had hitherto remained latent in sensory dorsal root ganglia after the episode of chickenpox.1 Childhood zoster is more likely if primary infection occurred within the first year of age including in utero. Multiple dermatome involvement in the lack of immune deficiency is rare or otherwise unreported in children.2 Most of the reported cases involving noncontiguous dermatomes have been limited to 2 dermatomes and are referred as HZ duplex.1,3 This rare clinical entity is almost exclusively associated with age-related decline in cellular immunity, primary or acquired immunodeficiencies and with the use of immunosuppressive drugs.1 According to recent studies,4,5 the simultaneous reactivation of VZV in multiple noncontiguous dermatomes usually requires an immunocompromised milieu, leading to the recommendation that these patients should undergo a complete status immune evaluation.5 It seems not to portend a poor prognosis.3 We present a rare case of HZ involving 3 noncontiguous dermatomes in both halves of the body, in the absence of an immunodeficiency background. To our knowledge, most of case reports of HZ duplex/multiplex bilateralis were related to older age and/or immunocompromised patients,1,3 and in the few cases reported in children, only 4 of them were confirmed to be immunocompetent.3,5
Ana Pedrosa, MD Maria João Cruz, MD Alberto Mota, MD, PhD
Department of Dermatology and Venereology Centro Hospitalar São João EPE Porto, Portugal Faculty of Medicine University of Porto
Teresa Baudrier, MD Filomena Azevedo, MD
Department of Dermatology and Venereology Centro Hospitalar São João EPE Porto, Portugal www.pidj.com | 225
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REFERENCES 1. Vu AQ, Radonich MA, Heald PW. Herpes zoster in seven disparate dermatomes (zoster multiplex): report of a case and review of the literature. J Am Acad Dermatol. 1999;40(5 pt 2):868–869. 2. Feder HM Jr, Hoss DM. Herpes zoster in otherwise healthy children. Pediatr Infect Dis J. 2004;23:451–457. 3. Castronovo C, Nikkels AF. Chronic herpes zoster duplex bilateralis. Acta Derm Venereol. 2012;92:148–151. 4. Agrawal S, Aara N, Bumb R. Herpes zoster duplex bilateralis symmetricus in an immunocompetent subject. Int J Dermatol. 2014;53:e281–e282. 5. Yan C, Laguna BA, Marlowe LE, et al. Herpes zoster duplex bilateralis in an immunocompetent adolescent boy: a case report and literature review. Pediatr Dermatol. 2014;31:341–344.
Atypical Cystic Echinococcosis in a Young Child To The Editors:
A
n almost 4-year-old Argentinian girl had abdominal pain and daily fevers of 38.5°C for 5 days. She appeared to be in good general condition except for petechial lesions on the anterior trunk. She also had a painful and tense abdomen on light palpation. Abdominal ultrasonography revealed a large intraperitoneal cystic lesion measuring 11.56 cm × 10.5 cm × 4.18 cm with thin walls and liquid in the cavity (See Figure, Supplemental Digital Content 1, http:// links.lww.com/INF/B990). Laboratory tests showed slight eosinophilia. Preoperative diagnosis was a congenital cystic mass of the mesenterium. Laparotomy showed liquid in the cavity and a flaccid cyst of very thin walls surrounded by the small intestine, the stomach and the omentum. During removal, it was damaged and it resembled a hydatid membrane. The abdominal cavity was washed with physiologic solution and hypertonic saline solution-soaked pads were This work was supported by the PIP 0029 (Consejo Nacional de Investigaciones Científicas y Técnicas [CONICET], Argentina) and Universidad Nacional de Mar del Plata grants EXA 576/12 and EXA 634/13. The authors have no funding or conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (www.pidj.com). Copyright © 2015 by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0891-3668/15/3402-0226 DOI: 10.1097/INF.0000000000000525
226 | www.pidj.com
The Pediatric Infectious Disease Journal • Volume 34, Number 2, February 2015
used. The patient had an uneventful recovery and received albendazole treatment (15 mg/kg/day). She was discharged after the third postoperative day when abdominal ultrasonography and chest radiography were normal. Outpatient follow-up included abdominal ultrasonography bimonthly and albendazole treatment. Histopathological examination confirmed hydatid cyst showing laminated and germinal layers with abundant eosinophils, multinucleated giant cells and scoleces (See Figure, Supplemental Digital Content 2, http://links.lww.com/ INF/B991, which shows a histophatological section of hydatic cyst. Laminal layer, germinal layer and vesicle with 2 scoleces are seen. HE stain). Intraperitoneal hydatid cysts usually develop secondary to spontaneous or iatrogenic rupture of hepatic, splenic or mesenteric cysts. Rarely, an isolated primary cyst can develop in the peritoneum without evidence of cysts in other intra-abdominal organs.1 The growth rate of a hydatid cyst has been variably reported at 1–16 cm per year in abdomen.2 Abdominal cystic echinococcosis had been infrequently reported and only in adults.3 If the girl ingested the oncosphere in the first semester of life, an estimated minimum growth rate of the cyst was 2.5–3 cm per year. Canine coproparasitological research in the environment where the family was living showed a dog with Taenia spp. These findings confirm the persistence of the habit of feeding dogs with raw offal and the existence of hosts involved in the parasite life cycle, which represent risk factors to develop cystic echinococcosis or other parasitic diseases.
Carla Mariela Lavallen, BSc
Laboratorio de Zoonosis Parasitarias Facultad de Ciencias Exactas y Naturales Universidad Nacional de Mar del Plata CONICET (Consejo Nacional de Investigaciones Científicas y Técnicas)
Mauricio Pons, MD Enrique Mercuri, MD Viviana Ortolani, MD
HIEMI (Hospital Interzonal Especializado Materno Infantil “Victorio Tetamanti”)
Nathalia Scioscia, DVM
Laboratorio de Zoonosis Parasitarias Facultad de Ciencias Exactas y Naturales Universidad Nacional de Mar del Plata CONICET (Consejo Nacional de Investigaciones Científicas y Técnicas)
Patricia Hollmann, DVM
Centro Municipal de Zoonosis, Secretaría de Salud, Partido de General Pueyrredon
Guillermo María Denegri, PhD Marcela Cecilia Dopchiz, PhD
Laboratorio de Zoonosis Parasitarias Facultad de Ciencias Exactas y Naturales Universidad Nacional de Mar del Plata CONICET (Consejo Nacional de Investigaciones Científicas y Técnicas) Buenos Aires, Argentina REFERENCES 1. Gorad K, Rayate N, Oswal K, et al. Laparoscopic removal of pelvic hydatid cysts in young female: a case report. Minim Invasive Surg. 2011;2011:1–3. 2. Roming T, Zeyhle E, Macpherson CNL, Rees PH, Were JBO. Cyst growth and spontaneous cure in hydatid disease. Lancet. 1986;1:861. 3. Dopchiz MC, Elissondo MC, Andresiuk MV, et al. Pediatric hydatidosis in the south-east of the Buenos Aires province, Argentina. Rev Argent Microbiol. 2009;41:105–111.
Intestinal Parasites Among Children With Diarrhea Younger Than 5 Years of Age in Rural Ethiopia To the Editors:
W
e performed a retrospective crosssectional study in a rural hospital in southern Ethiopia to document parasitic infection in children younger than 5 with acute diarrhea (defined as ≥ 3 loose stools within 24 hours for
