868 red lips. She had not suffered from any illness prior to this. On 5 February, she started having fever and a maculopapular rash appeared 3 days later. A paediatrician made the diagnosis of exanthema subitum. Because the fever continued, she was admitted to a local hospital on 12 February. Her rash had spread from the extremities to the trunk. W B C count was 19600/~tl with 67% neutrophils. E S R was 94 mm/h and C-reactive protein was positive. Sepsis was put forward as a possible diagnosis. Therefore aminobenzyl-penicillin and cephem were given intravenously. No improvement was obtained after 6 days of antibiotic therapy. On admission to our hospital, she had been ill for altogether 13 days. Body temperature was 39.5~ A maculopapular rash was observed on her face, neck and trunk. Her lips were red and fissured, her pharynx injected and pea-sized cervical lymph nodes were found. W B C count was 12200/pl with 29% neutrophils, 52% lymphocytes and 7% monoeytes. Positive C-reactive protein, elevated E S R and slight elevation of liver transaminase levels were observed. Echocardiography showed dilatation of the right coronary artery. Gammaglobulins were given intravenously at a dose of 270 mg/kg together with 30 mg/kg of N-acetyl salicylic acid for 5 consecutive days. The fever abated within 2 days. O n February 19, skin desquamation from finger and toetips became evident. Two days later, a relative lymphocytosis of 83% was noted and again 2 days later there was a definite thrombocytosis of 880000/~tl. The bacterial cultures from blood, cerebrospinal fluid, urine and pharynx were all negative. This patient therefore met the diagnostic criteria for Kawasaki disease of the Japanese MLCS Research Committee. After 1 weeks's cultivation, HHV-6 was isolated from the peripheral mononuclear cells of the first blood sample obtained on admission. Isolation and identification of HHV-6 were done by modified methods described previously [7]. Serum antibody titer against HHV-6 was negative on admission. Seroconversion was observed in the convalescent sera but this was due to the infusion of gammaglobulins which contained a high titer of HHV-6 antibody. The incubation period of HHV-6 is estimated to be 7-17 days in the case of exanthema subitum [2]. This patient might have been infected with HHV-6 about the same time as Kawasaki disease developed. We were indeed unable to isolate HHV-6 from five other patients with Kawasaki disease. We therefore feel that the isolation of HHV-6 from the present infant with Kawasaki disease is coincidental as it was in the two patients with Kawasaki disease in whom measles virus [5] and parainfluenza virus [4] respectively were isolated.

References 1. Asano Y, Yoshikawa T, Suga S, Yazaki T, Kondo K, Yamanish K (1990) Fetal fulminant hepatitis in an infant with human herpesvirus-6 infection. Lancet 335 : 862-863 2. Phillips CF (1992) Exanthema subitum. In: Behrman RE (ed) Nelson textbook of pediatrics, 14th edn. WB Saunders, Philadelphia, pp 796-797 3. Huang LM, Lee CHY, Lin KH, Chuu WM, Lee PI, Chen RL, Chen JM, Lin DT (1990) Human herpesvirus-6 associated with fatal haemophagocytic syndrome. Lancet 336: 61 4. Keim DE, Keller EW, Hirsch MS (1977) Mucocutaneous Lymph-Node Syndrome and parainfluenza 2 virus infection. Lancet II : 303 5. Whitby D, Hoad JG, Tizard EJ, Dillon MJ, Weber JN, Weiss RA, Schulz TF (1991) Isolation of measles virus from a child with Kawasaki disease. Lancet 338 : 1215 6. Yamanishi K, Okuno T, Shiraki K, Takahashi M, Kondo T, Asano Y (1988) Identification of human herpesvirus-6 as a causal agent for exanthema subitum. Lancet I: 1065-1067 7. Yoshiyama H, Suzuki E, Yoshida T, Kaji T, Yamamota N (1990) Role of human herpesvirus-6 infection in infants with exanthema subitum. Pediatr Infect Dis 9:71-74

Prevention of necrotizing enterocolitis A. Valls-i-Soler, J. L6pez Heredia, L. Romfin Echevarria, E.Hernfiez Ortega, and E. Gastiasoro Cuesta Neonatal Intensive Care Unit Department of Paediatrics Hospital Infantil de Cruces and Basque University School of Medicine Bilbao, Spain Received February 12, 1991 / Accepted after revision December 10, 1991

Sir: Fast et al. [3] reported in this journal the failure of an oral immunoglobulin preparation to prevent necrotising enterocolitis (NEC). We wish to report two cases of N E C occurring in preterm infants fed a formula supplemented with an IgA (73%)IgG preparation (Igabulin, I m m u n o A G , Vienna, Austria). This prophylactic measure, based on the proven preventive value of breast milk, was reported to be effective in a randomized clinical trial performed in 179 n e w b o r n infants [2]. For the past 2 years our incidence of N E C among formula fed very low birth weight infants was 8.3% (9/108 infants). In January 1991 we started oral IgA-IgG feedings in all infants of less than 1500 g for whom maternal breast milk was not available. In the first 10 days of the study four very low birth weight infants were admitted, two (a 835 g infant with respiratory distress syndrome and a 1300 g infant with congenital malformations) died before feedings could be started. A n o t h e r two infants (gestational ages of 28 and 27 weeks and birthweights of 1150 g and 770 g, respectively) were given 200 mg of IgA-IgG three times a day along with a lactose-free protein hydrolysate starting on days 4 and 8, respectively. Both babies had respiratory distress syndrome and were on mechanical ventilation prior to formula feeding. After 6 and 11 days, respectively of IgA-IgG feeding both developed clinical and X-ray evidence of NEC, classified as stages II and III according to the criteria of Bell et al. [1]. The first infant was treated medically and the other needed surgery for an intestinal perforation. Both babies survived. The reasons for the failure of the I g A - I g G feeding to prevent the development of N E C in these two infants remains obscure. Since N E C is a multifactorial disease, it is possible that it may be preventable in one unit and not in others depending upon local predisposing factors.

References 1, Bell M, Ternberg J, Feigin RD, Keating JP, Marshall R, Barton L, Brotherton T (1978) Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging. Ann Surg 187 : 1-7 2, Eibl MM, Wolf HM, Ft~rnkranz H, Rosenkranz A (1988) Prevention of necrotizing enterocolitis in low-birth-weight infants by IgA-IgG feeding. N Engl J Med 319 : 1-7 3. Fast CH, Rosegger FC (1991) Necrotizing enterocolitis: prophylaxis with oral antibiotics and lyophyilized enterobacteria, vs. oral IG. A randomized trial. Eur J Pediatr 150 : 605

I Abbreviarion:NEC = necrotising enterocolitis