CLINICAL NOTES
Articles in this section are limited tO 400 words or less, 1 illustration or 1 short table, and up to 4 references. These articles are subject to the same critical peer review and editing as articles appearing in other sections of "J~cIE JOURNAL.
Group B streptococcal endocarditis detected by echocardiography Bacterial endocarditis due to the group B streptococcus is recognized in adults. Despite the frequent occurrence of group B streptococcal infection in infancy, bacterial endocarditis due to this organism has not been identified in the pediatric age group. The following report describes such an instance; echocardiography contributed to the antemortem diagnosis. CASE REPORT A 4-week-old girl presented with respiratory distress and congestive heart failure. The gestational and perinatal events were unremarkable except that both the mother and infant had low-grade fever for one day following delivery. In each the temperature returned to normal without treatment and both were discharged on the third postpartum day. The infant seemed well until three weeks of age when the parents noticed that she would not move her left arm. Roentgenograms of the chest and arm were reported to be normal and no treatment was recommended. Several days later the mother noticed that the infant tired easily with feedings and seemed short of breath. These symptoms progressed over the next three days and she was admitted to the hospital. Examination showed a hypotonic 4,200-gin infant in severe respiratory distress with tachypnea (68 respirations/minute) and tachycardia (170 beats/minute). The axillary temperature was 36.6~ The blood pressure was not audible. The skin was cool, pale, and mottled. Rales were present over both lung fields. These findings along with a prominent right ventricular impulse, a Grade 2/6 systolic murmur along the left sternal border, a prominent gallop heard over the midprecordium, hepatomegaly, splenomegaly, and weak pulses indicated congestive heart failure. The extremities and joints appeared normal. Laboratory data included a hematocrit of 34% and a white blood cell count of 20,000 cells/mm 3 with a shift to the left. The platelet count was 10,000/mm? Roentgen examination of the chest showed cardiomegaly and prominent pulmonary vascular markings. The joint space of the left shoulder was widened, and there was fuzziness of the proximal humeral metaphysis suggesting septic arthritis. An electrocardiogram showed right ventricular hypertrophy. An echocardiogram was obtained using standard techniques
0022-3476/78/0292-0335500.20/0
9 1978 T h e C.V. M o s b y Co.
(Fig. 1). Repeated scans from the mitral region to the aorta showed a persistent echo-dense mass behind the anterior leaflet of the mitral valve; this density also appeared in the left atrium. The right ventricle and left atrium were dilated and the ventricular septum moved paradoxically. Because septicemia with suppurative arthritis and possible bacterial endocarditis involving the mitral valve were suspected, digoxin, gentamicin, and ampicillin were started. Cultures of blood and joint fluid grew a group B beta-hemolytic streptococcus, type Bin. The antibiotics were replaced by penicillin. After an initial stable period of several days, the infant's condition suddenly deteriorated. Cardiac catheterization demonstrated an atrial septal defect with left-to-right shunting and mitral insufficiency. Later the same day the infant died. The major postmortem findings were limited to the heart and left humerus. There was an atrial septal defect with partial anomalous pulmonary venous drainage. A friable yellow vegetation 0.7 cm in greatest diameter was firmly seated on the atrial surface of the anterior mitral leaflet. Similar but smaller vegetations were present on the posterior mitral leaflet and extended onto the posterior wall of the left atrium. The underlying valve was normal. Microscopic examination of the mitral vegetation showed a mass o f fibrin and platelets containing enmeshed neutrophils and covered on its mural surface by colonies of grampositive cocci. At the base of the vegetation there was a dense layer of degenerating neutrophils overlying an exuberant growth of granulation tissue. The left shoulder joint contained 5 ml of purulent fluid. The humerus appeared grossly normal but microscopically showed subacute osteomyelitis. DISCUSSION Howard and McCracken 1 reviewed the spectrum of group B streptococcal infection in infancy. They collected 200 cases from the literature and added 71 cases of their own. No case of bacterial endocarditis was noted. Bacterial endocarditis is infrequent in infancyY It is most often not associated with underlying heart disease, but in the septic infant the presence of congenital heart disease increases the incidence of endocarditis by a factor of ten? In this patient it is probable that turbulence related to increased left atrial flow contributed to localization of bacteria on the mitral valve and adjacent atrial wall. Echocardiography is now commonly used to diagnose bacterial endocarditis in adults? Vegetations as small as 2 m m in diameter
The Journal o f P E D I A T R I C S VoL 92, No. 2, pp. 335-339
335
336
Clinical notes
The Journal of Pediatrics February 1978
R~
Mc IS$
Fig. 1. Echocardiogram showing a scan from the left ventricle to the aorta (A O). A line drawing is included on each end of the scan for labeling important structures. A persistent echo-dense mass representing a large vegetation is present behind the anterior leaflet o f the mitral valve (MV). The mass prolapses into the left atrium (LA) during systole. Other findings include a dilated right ventricle (R V) with abnormal motion of the ventricular septum (S). Also shown are the right ventricular outflow tract (R VOT) and free wall (R V~W). The electrocardiogram (ECG) is displayed at the top of the tracing.
can be identified by ultrasound. The typical appearance is an irregular mass of echoes superimposed on the normally delicate valve tracing. These changes are nonspecific and may also be found in valves thickened by nonthrombotic disease. Although echocardiography appears to be a useful indicator of endocarditis, only a few pediatric patients have been described in which this technique was used to make the diagnosis. To our knowledge, our patient and another recently published example 5 are the only reported young infants in whom echocardiography has been successfully used to detect bacterial endocarditis. These cases emphasize the potential value o f ultrasound in the evaluation of infants with suspected endocarditis.
Arthur G. Weinberg, M.D. Associate Professor of Pathology and Pediatrics W. Pennock Laird, M.D. Assistant Professor of Pediatrics Departments of Pathology and Pediatrics Children's Medical Center 1935 Amelia St. Dallas, TX 75235 REFERENCES 1. Howard JB, and McCracken GH Jr: The spectrum of group B streptococcal infections in infancy, Am J Dis Child 128:815, 1974. 2. Macaulay D: Acute endocarditis in infancy and early childhood, Am J Dis Child 88:715, 1954. 3. Johnson DH, Rosenthal A, and Nadas AS: Bacterial endocarditis in children under 2 years of age, Am J Dis Child 129:183, 1975. 4. Dillon JC, Feigenbaum H, Koncke LL, et al: Echocardiographic manifestations o f valvular vegetations, Am Heart J 86:698, 1973. 5. Bender RL, Jaffe RB, McCarthy D, and Ruttenberg HD: Echocardiographic diagnosis of bacterial endocarditis of the mitral valve in a neonate, Am J Dis Child 131:746, 1977.
Fluctuation of circulating colony-forming cells with transfusion in a patient with fl.thalassemia major The vitro culture of hematopoietic cells has been found to be useful not only in understanding the physiology of hematopoiesis, but also in the estimation of prognosis in some hematologic diseases. The agar culture system can support the clonal growth of committed granulocyte-monocyte progenitor ceils. Colonyforming units in culture (CFU-C) exist not only in bone marrow but also in the peripheral blood in a much smaller concentration. 1, ~ We have observed fluctuation of circulating CFU-C in peripheral blood associated with transfusion in a patient with B-thalassemia major. METHOD The double-layer agar culture technique o f Kurnick and Robinson ~ was used with slight modification. Alpha-medium (K-C Biological, Lenexa, Kan.) was used instead of McCoy 5A medium, and 10% fetal calf serum plus 5% horse serum was substituted for the 15% fetal calf serum supplementation. Peripheral white blood cells from one of the authors were used for preparation of normal feeder layers. Nucleated cells of peripheral blood were washed once and plated a s a 1 ml suspension at a concentration o f 2 x 1@ and 1 x 106 nucleated cells/ml. Colony numbers were scored with an inverted microscope at 40• magnification after 12 to t4 days incubation in a humidified incubator at 37.5~ With a constant flow of 7.5% carbon dioxide in air. Colonies were defined as those cell aggregates containing more than 40 cells. A six-year-old girl o f Italian descent with fl-thalassemia major
0022-3476/78/0292-0336500.20/0
9 1978 T h e C.V. M o s b y Co.
Articles in this section are limited tO 400 words or less, 1 illustration or 1 short table, and up to 4 references. These articles are subject to the same critical peer review and editing as articles appearing in other sections of "J~cIE JOURNAL.
Group B streptococcal endocarditis detected by echocardiography Bacterial endocarditis due to the group B streptococcus is recognized in adults. Despite the frequent occurrence of group B streptococcal infection in infancy, bacterial endocarditis due to this organism has not been identified in the pediatric age group. The following report describes such an instance; echocardiography contributed to the antemortem diagnosis. CASE REPORT A 4-week-old girl presented with respiratory distress and congestive heart failure. The gestational and perinatal events were unremarkable except that both the mother and infant had low-grade fever for one day following delivery. In each the temperature returned to normal without treatment and both were discharged on the third postpartum day. The infant seemed well until three weeks of age when the parents noticed that she would not move her left arm. Roentgenograms of the chest and arm were reported to be normal and no treatment was recommended. Several days later the mother noticed that the infant tired easily with feedings and seemed short of breath. These symptoms progressed over the next three days and she was admitted to the hospital. Examination showed a hypotonic 4,200-gin infant in severe respiratory distress with tachypnea (68 respirations/minute) and tachycardia (170 beats/minute). The axillary temperature was 36.6~ The blood pressure was not audible. The skin was cool, pale, and mottled. Rales were present over both lung fields. These findings along with a prominent right ventricular impulse, a Grade 2/6 systolic murmur along the left sternal border, a prominent gallop heard over the midprecordium, hepatomegaly, splenomegaly, and weak pulses indicated congestive heart failure. The extremities and joints appeared normal. Laboratory data included a hematocrit of 34% and a white blood cell count of 20,000 cells/mm 3 with a shift to the left. The platelet count was 10,000/mm? Roentgen examination of the chest showed cardiomegaly and prominent pulmonary vascular markings. The joint space of the left shoulder was widened, and there was fuzziness of the proximal humeral metaphysis suggesting septic arthritis. An electrocardiogram showed right ventricular hypertrophy. An echocardiogram was obtained using standard techniques
0022-3476/78/0292-0335500.20/0
9 1978 T h e C.V. M o s b y Co.
(Fig. 1). Repeated scans from the mitral region to the aorta showed a persistent echo-dense mass behind the anterior leaflet of the mitral valve; this density also appeared in the left atrium. The right ventricle and left atrium were dilated and the ventricular septum moved paradoxically. Because septicemia with suppurative arthritis and possible bacterial endocarditis involving the mitral valve were suspected, digoxin, gentamicin, and ampicillin were started. Cultures of blood and joint fluid grew a group B beta-hemolytic streptococcus, type Bin. The antibiotics were replaced by penicillin. After an initial stable period of several days, the infant's condition suddenly deteriorated. Cardiac catheterization demonstrated an atrial septal defect with left-to-right shunting and mitral insufficiency. Later the same day the infant died. The major postmortem findings were limited to the heart and left humerus. There was an atrial septal defect with partial anomalous pulmonary venous drainage. A friable yellow vegetation 0.7 cm in greatest diameter was firmly seated on the atrial surface of the anterior mitral leaflet. Similar but smaller vegetations were present on the posterior mitral leaflet and extended onto the posterior wall of the left atrium. The underlying valve was normal. Microscopic examination of the mitral vegetation showed a mass o f fibrin and platelets containing enmeshed neutrophils and covered on its mural surface by colonies of grampositive cocci. At the base of the vegetation there was a dense layer of degenerating neutrophils overlying an exuberant growth of granulation tissue. The left shoulder joint contained 5 ml of purulent fluid. The humerus appeared grossly normal but microscopically showed subacute osteomyelitis. DISCUSSION Howard and McCracken 1 reviewed the spectrum of group B streptococcal infection in infancy. They collected 200 cases from the literature and added 71 cases of their own. No case of bacterial endocarditis was noted. Bacterial endocarditis is infrequent in infancyY It is most often not associated with underlying heart disease, but in the septic infant the presence of congenital heart disease increases the incidence of endocarditis by a factor of ten? In this patient it is probable that turbulence related to increased left atrial flow contributed to localization of bacteria on the mitral valve and adjacent atrial wall. Echocardiography is now commonly used to diagnose bacterial endocarditis in adults? Vegetations as small as 2 m m in diameter
The Journal o f P E D I A T R I C S VoL 92, No. 2, pp. 335-339
335
336
Clinical notes
The Journal of Pediatrics February 1978
R~
Mc IS$
Fig. 1. Echocardiogram showing a scan from the left ventricle to the aorta (A O). A line drawing is included on each end of the scan for labeling important structures. A persistent echo-dense mass representing a large vegetation is present behind the anterior leaflet o f the mitral valve (MV). The mass prolapses into the left atrium (LA) during systole. Other findings include a dilated right ventricle (R V) with abnormal motion of the ventricular septum (S). Also shown are the right ventricular outflow tract (R VOT) and free wall (R V~W). The electrocardiogram (ECG) is displayed at the top of the tracing.
can be identified by ultrasound. The typical appearance is an irregular mass of echoes superimposed on the normally delicate valve tracing. These changes are nonspecific and may also be found in valves thickened by nonthrombotic disease. Although echocardiography appears to be a useful indicator of endocarditis, only a few pediatric patients have been described in which this technique was used to make the diagnosis. To our knowledge, our patient and another recently published example 5 are the only reported young infants in whom echocardiography has been successfully used to detect bacterial endocarditis. These cases emphasize the potential value o f ultrasound in the evaluation of infants with suspected endocarditis.
Arthur G. Weinberg, M.D. Associate Professor of Pathology and Pediatrics W. Pennock Laird, M.D. Assistant Professor of Pediatrics Departments of Pathology and Pediatrics Children's Medical Center 1935 Amelia St. Dallas, TX 75235 REFERENCES 1. Howard JB, and McCracken GH Jr: The spectrum of group B streptococcal infections in infancy, Am J Dis Child 128:815, 1974. 2. Macaulay D: Acute endocarditis in infancy and early childhood, Am J Dis Child 88:715, 1954. 3. Johnson DH, Rosenthal A, and Nadas AS: Bacterial endocarditis in children under 2 years of age, Am J Dis Child 129:183, 1975. 4. Dillon JC, Feigenbaum H, Koncke LL, et al: Echocardiographic manifestations o f valvular vegetations, Am Heart J 86:698, 1973. 5. Bender RL, Jaffe RB, McCarthy D, and Ruttenberg HD: Echocardiographic diagnosis of bacterial endocarditis of the mitral valve in a neonate, Am J Dis Child 131:746, 1977.
Fluctuation of circulating colony-forming cells with transfusion in a patient with fl.thalassemia major The vitro culture of hematopoietic cells has been found to be useful not only in understanding the physiology of hematopoiesis, but also in the estimation of prognosis in some hematologic diseases. The agar culture system can support the clonal growth of committed granulocyte-monocyte progenitor ceils. Colonyforming units in culture (CFU-C) exist not only in bone marrow but also in the peripheral blood in a much smaller concentration. 1, ~ We have observed fluctuation of circulating CFU-C in peripheral blood associated with transfusion in a patient with B-thalassemia major. METHOD The double-layer agar culture technique o f Kurnick and Robinson ~ was used with slight modification. Alpha-medium (K-C Biological, Lenexa, Kan.) was used instead of McCoy 5A medium, and 10% fetal calf serum plus 5% horse serum was substituted for the 15% fetal calf serum supplementation. Peripheral white blood cells from one of the authors were used for preparation of normal feeder layers. Nucleated cells of peripheral blood were washed once and plated a s a 1 ml suspension at a concentration o f 2 x 1@ and 1 x 106 nucleated cells/ml. Colony numbers were scored with an inverted microscope at 40• magnification after 12 to t4 days incubation in a humidified incubator at 37.5~ With a constant flow of 7.5% carbon dioxide in air. Colonies were defined as those cell aggregates containing more than 40 cells. A six-year-old girl o f Italian descent with fl-thalassemia major
0022-3476/78/0292-0336500.20/0
9 1978 T h e C.V. M o s b y Co.
