Nonproprietary Names and Trademarks of Drugs Ampicillin sodium— Alpen-N, Amcill-S, Omnipen-N, Penbritin-S, Polycillin-N, Principen/N. Gentamicin sulfate—Garamycin. 1. Franciosi RA, Knostman JD, Zimmerman RA: Group B streptococcal neonatal and infant infections. J Pediatr 82:707-718, 1973. 2. Baker CJ, Barrett FF: Group B streptococcal infections in infants. JAMA 230:1158-1160, 1964. 3. Patterson MJ, Hafeez AEB: Group B streptococci in human disease. Bacteriol Rev 40:774\x=req-\ 792, 1976. 4. Howard JB, McCracken GH: The spectrum of group B streptococcal infections in infancy. Am J Dis Child 128:815-818, 1974. 5. Roe MH, Todd JK, Favara BE: Nonhemolytic group B streptococcal infections. J Pediatr 89:75-77, 1976. 6. Franks AL: Nonhemolytic group B streptococcal infections. J Pediatr 90:328, 1977. 7. Forster RK, Zachary IG, Cottingham AJ, et al: Further observations on the diagnosis, cause and treatment of endophthalmitis. Am J Ophthalmol 81:52-56, 1976. 8. Jensen AD, Naidoff MA: Bilateral meningococcal endophthalmitis. Arch Ophthalmol 90:396\x=req-\ 398, 1973. 9. Weintraub MI, Otto RN: Pneumococcal meningitis and endophthalmitis in a newborn. JAMA 219:1763-1764, 1972. 10. Agass MJB, Willoughby CP, Bron AJ, et al: Meningitis and endophthalmitis caused by streptococcus suis type II (group R). Br Med J 2:167\x=req-\ 168, 1977.

Subglottic Hemangioma: Approach

to

A New

Management

Tracheostomy, followed by irradiamore recently, systemic corticosteroids, has been the treatment of choice for airway obstruction caused by subglottic hemangioma.1-3 Tempotion or,

rary nasotracheal intubation for other causes of severe upper airway obstruction, such as epiglottitis and infectious croup has largely supplanted tracheostomy. The purpose of this report is to present a case of subglottic hemangioma producing severe airway obstruction that was successfully treated by the use of short-term nasotracheal intubation and systemic corticosteroids.

Report of a Case.\p=m-\A3-month-old girl was for admission for evaluation of inspiratory stridor of approximately six referred

weeks' duration. The child was noted to be in moderate respiratory distress, with inspiratory stridor and intercostal and subcostal retractions. A 5 \m=x\8-mm "strawberry" hemangioma that had enlarged progressively from birth was noted on the right side of the neck. The rest of the examination was normal. An arterial blood sample on admission showed Po2 of 109 mm Hg, Pco2 of 31 mm Hg, and a pH of 7.40

(room air). Within hours after admission, the child's stridor worsened considerably with the development of cyanosis and extreme irritability. At that time, the arterial Po, was 61 mm Hg, Pco, was 51 mm Hg, and the pH was 7.31 (0.3 FIO,). Emergency direct laryngoscopy and bronchoscopy were performed with the finding of a subglottic hemangioma on the posterioinferior wall of the trachea occupying two thirds of the airway. The deep-blue lesion was readily compressible and refilled rapidly. A nasotracheal tube was passed with complete relief of her symptoms. Intravenous dexamethasone was admin¬ istered in a dose of 0.4 mg/kg/day. On the third day after intubation, this was changed to prednisone, 2 mg/kg/day. Seven days after intubation, the nasotra¬ cheal tube was removed. Seventy-two hours after extubation, she was discharged home without stridor receiving prednisone, 2 mg/kg/day. The latter was to be contin¬ ued daily for one month and every other day for an additional month. Follow-up examination at six and 12 months after extubation showed no evi¬ dence of airway obstruction on examina¬ tion. The cutaneous hemangioma noted had not changed in size at the six-month examination, but measured 3x5 mm at the 12-month examination.

subglottic hemangiomas. By using intubation in conjunction with corticosteroids for systemic ef¬ fect, we were able to avoid a tracheos¬ tomy in our patient. There has been no stridor or other evidence of recurrence in the ensuing 12 months. The natural history of subglottic hemangioma is either to cause severe airway com¬

promise requiring tracheostomy or to produce recurrent episodes of stridor. In our patient, the absence of recur¬ rence strongly suggests that the natu¬ ral history of subglottic hemangioma has been altered by our therapeutic approach. The success in this patient empha¬ sizes the need for a collaborative study to determine whether treatment by

Comment—Subglottic hemangioma

is an unusual cause of upper airway obstruction in the infant. It almost invariably is first seen with stridor within the first three months of life and may progress to complete airway occlusion and death if untreated. The diagnosis is suggested when a cuta¬ neous hemangioma is present. Roent¬ genograms of the soft tissue of the neck are frequently helpful in outlin¬ ing lesions in the subglottic region and should be obtained when a heman¬ gioma is suspected. If these are compatible with the diagnosis, direct laryngoscopy and bronchoscopy should be performed by an experi¬ enced otolaryngologist accompanied with skilled anesthesia support. Published recommendations for therapy of airway obstruction caused by a subglottic hemangioma have always included tracheostomy.1·4 The use of short-term nasotracheal intuba¬ tion for this condition has obvious advantages over tracheostomy. In¬ creasing experience with intubation in other disorders has generally allayed anxiety regarding the possi¬ bility of long-term complications asso¬ ciated with the procedure.5 After the report of Cohen," the use of corticoste¬ roide for systemic effect has largely supplanted irradiation as the treat¬ ment of choice for reducing the size of

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intubation and corticosteroids for sys¬ temic effect has considerable advan¬ tages over the traditional approach of

tracheostomy.

DILLARD, MD Department of Pediatrics ROBERT G.

Bowman Gray School of Medicine 300 S Hawthorne Rd Winston-Salem, NC 27103 1. Ferguson CF, Flake CG: Subglottic hemangioma as a cause of respiratory obstruction in infants. Ann Otol Rhinol Laryngol 70:1095-1112, 1961. 2. Tefft M: The radiotherapeutic management of subglottic hemangioma in children. Radiology 86:207-214, 1966. 3. Cohen SR: Unusual lesions of larynx, trachea, and bronchial tree. Ann Otol Rhinol Laryngol 78:476-488, 1969. 4. Lee MH, Ramonathan S, Chalon J, et al: Subglottic hemangioma. Anesthesiology 45:459\x=req-\

462,1976.

5. Milko DO, Marshak G, Striker TW: Nasotracheal intubation in the treatment of acute epiglottitis. Pediatrics 53:674-677, 1974.

Fatal Aeromonas hydrophila Sepsis and Meningitis in a Child With Sickle Cell Anemia

Aeromonas hydrophila, a distinctly unusual organism for humans, usually causes a localized infection after contamination of the wound with water or animal products. In rare instances, systemic disease does occur in man, and 35 cases of septicemia have been documented.1-8 Most infections occurred in individuals undergoing chemotherapy for malignant neoplasms or in adults with cirrhosis. One adult with meningitis has been described, and he had a craniotomy after a head injury.3 In the pediatric age group (< 15 years old), there have been eight cases of A hydrophila septicemia reported, and all had malignant neoplasms.2.4.5.8.

As in adults, the usual A hydrophila infections were related to localized wound sepsis and trauma, and have not been commonly associated with septicemia. A child with sickle cell anemia who had a fulminating A hydrophila septicemia and meningitis is the subject of this report.

Report of a Case.\p=m-\A23-month-old black boy was brought to the emergency room of another hospital in peripheral vascular collapse. The diagnosis of sickle cell anemia had been established in the pediatrie hematology clinic of the Cook County Hospital, Chicago, when he was 6 months of age, when his hemoglobin electrophoresis showed hemoglobin S value of 68.4%, hemo¬ globin F value of 28.5%, and hemoglobin AL. value of 3.1%. The child had been in good health up until the evening prior to admis¬ sion when while eating dinner he was noted to be mildly febrile and irritable and so was given 150 mg of aspirin. The follow¬ ing morning he was lethargic and refused to eat. Shortly thereafter, profuse watery diarrhea developed that was unassociated with vomiting; he continued to take and retain fluids. Approximately three hours

after the onset of the diarrhea, he had a grand mal seizure and was rushed to the nearest emergency room. His temperature was 41 °C, respirations, 44/min, and heart rate, 144/min. He was unresponsive, pale, and was noted to have a maculopapular rash over the face, trunk, and thighs. The clinical impression was meningococcemia. The child was intubated, maintained on a ventilator, and given bicarbonate and intravenous penicillin G sodium. Shortly after arrival, he had a cardiac arrest and resuscitative efforts were unsuccessful. Postmortem cultures yielded a pure growth of A hydrophila from both blood and CSF. The organism was identified by standard biochemical tests, including the indole oxidase test." The spleen weighed 20 g (normal, 33 g) and on microscopic exami¬ nation the splenic sinusoids were packed with sickled erythrocytes. The adrenals showed focal hemorrhage. The brain showed focal areas of hemorrhagic necro¬ sis; the necrotic areas were infiltrated with polymorphonuclear leukocytes and macro¬ phages. The lungs and the gastrointestinal (GI) tract were essentially normal. The liver weighed 435 g, and showed a few foci of extramedulary hematopoiesis, focal in¬ filtration of some periportal areas with polymorphonuclear leukocytes, and sick-

ling.

Comment—Aeromonas has been isolated from tap water, rivers, swim¬ ming pools, and home-preserved foods. Human infections have fol¬ lowed an injury contaminated by fresh water or from fish who were infected.12-6 Most of the infections have been wound sepsis with localized skin and soft-tissue infection that

have

responded

to incision and drain¬

age. Aeromonas

hydrophila was first described by Sanarelli in 1891. The genus Aeromonas belong to the family Vibrionaceae. This Gram-negative or¬ ganism is motile due to polar flagella. On solid media, it is quite similar to the family Enterobacteriaceae. Aero¬ monas may be misclassified unless the indole oxidase test is routinely done, which is positive in Aeromonas and negative in the Enterobacteriaceae." We were able to locate 35 cases of A hydrophila septicemia; of these, 16 patients had leukemia or lymphoma, seven had cirrhosis, five had solid

tumors (most were receiving cancer chemotherapy), six had miscellaneous entities, including rheumatic fever, bleeding ulcer, quadriplegia, post¬ traumatic renal failure, and aplastic anemia, and one was a healthy male.18

We were unable to locate any reports of adults or children with sickle cell anemia infected with A hydrophila. There is a report of a 62-year-old woman with sickle cell anemia in whom a bacteremia with A shigelloides developed after a traumatic injury from a fish bone.1" The only case of A hydrophila meningitis was an adult who required craniotomy after trauma and meningitis devel¬

oped postoperatively. Our patient with both bacteremia and meningitis had no known contact '

exposure to any contaminated water source in the weeks preceding death. Aeromonas is known to inhabit the large bowel and may cause profuse or

watery diarrhea associated with a high fever, as seen in our patient. However, patients with the diarrheal

form usually do not have septicemia, and the organism is recovered from the stool only.7 Unfortunately, stool cultures were not available from this child; however, at autopsy the GI tract seemed normal. Diarrhea may be a nonspecific symptom in septic chil¬ dren. One may only speculate whether the maculopapular rash noted on admission would have progressed to the classical ecthyma gangrenosum seen with A hydrophila. Although the cultures were ob¬ tained postmortem, one would not have expected a pure growth of a single organism from both CSF and blood unless there had been antemor¬ tem infection. Antemortem infection was confirmed microscopically by the diffusely scattered areas of cortical necrosis infiltrated with polymorpho-

nuclear leukocytes and macrophages. It is generally accepted that chil¬ dren with sickle cell anemia are part of the spectrum of immunocompromised hosts, although the relative importance of the various factors remain disputed. The vast majority of infections in children with sickle cell anemia are caused by the pneumococcus, but it is important to remember that occasionally Gram-negative orga¬ nisms can cause a rapidly fatal septi¬ cemia." The clinician cannot solely

rely on penicillin as adequate therapy

for children with sickle cell anemia in septic shock. Penicillin and ampicillin are useless in Aeromonas infection and one needs to use an antibiotic that is effective against a broad range of

Gram-negative organisms.

RITA YADAVA, MB RUTH ANDREA SEELER, MD MITRA KALELKAR, MB JOYCE E. ROYAL, MD Division of Pediatric Hematology\p=m-\

Oncology

Cook County Hospital and Hektoen Institute for Medical Research Medical Examiner's Office of Cook

County Chicago, IL

60612

Metzger, PhD, director of the Division Microbiology, Hektoen Institute for Medical Research, Cook County Hospital, Chicago, iso¬ lated and identified the Aeromonas hydrophila organism. William

of

1. McCracken AW, Barkley R: Isolation of Aeromonas species from clinical sources. J Clin Pathol 25:970-975, 1972. 2. Washington JA: Aeromonas hydrophila in clinical bacteriological specimens. Ann Intern Med 76:611-614, 1972. 3. Quadri Hussain SM, Gordon LP, Wende RD, et al: Meningitis due to Aeromonas hydrophila. J Clin Microbiol 3:102-104, 1976. 4. Bulger RJ, Sherris JC: The clinical significance of Aeromonas hydrophila. Arch Intern Med 118:562-564, 1966. 5. Pearson TA, Mitchell CA, Hughes WT: Aeromonas hydrophila septicemia. Am J Dis Child 123:579-582, 1972. 6. Davis WA, Kane JG, Garagusi VF: Human Aeromonas infections: A review of the literature and a case report of endocarditis. Medicine, 57:267-277, 1978. 7. Scott EG, Russell CM, Noell KT, et al: Aeromonas hydrophila sepsis in a previously healthy man. JAMA 239:1742, 1978. 8. Ketover BP, Young LS, Armstrong D: Septicemia due to Aeromonas hydrophila: Clinical and immunological aspects. J Infect Dis 127:284-290, 1973. 9. Meeks MV: The genus Aeromonas: Methods of identification. Am J Med Technol 29:361-378, 1963. 10. Ellner PD, McCarthy LR: Aeromonas shigelloides bacteremia: A case report. Am J Clin Pathol 59:216-218, 1973. 11. Robinson MG, Halpern C: Infection, Escherichia coli and sickle cell anemia. JAMA 230:1145-1148, 1974.

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Fatal Aeromonas hydrophila sepsis and meningitis in a child with sickle cell anemia.

Nonproprietary Names and Trademarks of Drugs Ampicillin sodium— Alpen-N, Amcill-S, Omnipen-N, Penbritin-S, Polycillin-N, Principen/N. Gentamicin sulfa...
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