Bernard Boxerbaum

Long-Term Prognosis of Rheumatic Fever Patients Receiving Regular Intramuscular Benzathine Penicillin

The prognosis for 115 rheumatic fever patients subsequently receiving regular intramuscular penicillin prophylaxis for at least 5 years was studied. Average follow-up was 9.3 years, and 57 patients were followed for 10 years or longer. Of the 79 patients with acute mitral regurgitation, 70% lost their murmur from 4 days to 8.5 years after it was first heard. This is in contrast to those with acute aortic regurgitation which persisted in 73%. No patient developed mitral or aortic stenosis: this suggests that regular prophylaxis may prevent the development of stenosis. Congestive failure, cardiomegaly, and arrhythmia correlated closely with persistence of murmurs, but increased P-R interval, acute QRS or T-voltage variation or both, and ST-T abnormalities did not.

Infective endocarditis in infants and children during the past 10 years: A decade of change

Abstract Infective endocarditis (IE) is closely associated with congenital heart diseases. 1–9 In major series done over several decades up to the early 1970s 2,6 and in a recent review 8 both the changing pattern of etiologic agents and the increasing incidence of IE overal has been stressed. In the last decade, the practice of pediatric cardiology has changed greatly. New diagnostic methods such as M-mode and two-dimensional echocardiography (2DE) have been developed. The rate of survival, particularly that of infants and of children with complex heart diseases, has greatly increased, coincident with improved surgery and intensive care of severely ill infants and children. Advances have also occurred in the antibiotic armamentarium. With these multiple recent developments it was questioned whether a change might have also taken place in the pattern of IE. Few reviews, however, dealing with the pattern of pediatric IE over the last decade are available. 8–10 This report is a review of our experience in diagnosis and treatment of pediatric IE during the last decade (1972 to 1982).

Isolation of rapidly growing mycobacteria in patients with cystic fibrosis

as a consequence of the traction placed on the caudal nerve roots has been referred to as the tethered cord syndrome. 1 Typically, individuals with untreated lesions present with orthopedic deformities of the lower extremities or with urologic problems such as retention, incontinence, or infection. The insidious fashion in which the complications of the tethered cord syndrome develop means that some children may suffer irreversible damage to the nerve roots before symptoms are mani fes t? ~ Early diagnosis is therefore imperative. In the four patients with dysraphism, the neurologic examinations were normal and the radiographs were considered normal preoperatively. This implies that evaluation must extend beyond these studies. Addit ional information may be obtained through the use of air or positive contrast myelography or computerized tomograplay of the spine5 ~ The relative risk of these procedures vis-fi-vis radiation exposure and technical difficulty should be weighed against direct surgical exploration, in which both diagnostic and therapeutic benefit may be obtained. Although careful and repeated neurologic follow-up is an acceptable alternative, it is our opinion that surgical exploration of the structures underlying the cutaneous defect may well be the most conservative approach to aplasia cutis congenita of the lumbosacral area.

Systemic Malassezia furfur infections in patients receiving intralipid therapy

Systemic infection with Malassezia furfur was first reported in 1981 as a specific complication of Intralipid therapy in a neonate. Six additional patients, including three older than 16 years of age, were identified subsequently. All had received prolonged Intralipid infusion through central venous catheters. Pulmonary infection was documented in tissue in three cases, the clinical presentation was characterized by pulmonary infiltrates, fever, and, in the infants, thrombocytopenia. Two subgroups of patients appear to be at the greatest risk for Malassezia infection: neonates with cardiopulmonary disease and adults with severe gastrointestinal disease and immunosuppression. The documentation of pulmonary arterial lipid deposits in vessels that had been infiltrated by Malassezia organisms and the observation of organisms in small pulmonary thromboemboli suggest that these lipophilic and lipid-dependent organisms are introduced into the bloodstream from venous catheters and require high lipid concentrations to proliferate in tissue.

Inhibitory effect of cystic fibrosis serum on pseudomonas phagocytosis by rabbit and human alveolar macrophages.

Summary: This report presents experimental observations indicating the presence of an inhibitory activity in cystic fibrosis (CF) serum which impairs phagocytosis of Pseudomonas aeruginosa by rabbit as well as human alveolar macrophages. Of the 49 patient serum samples studied, 40 consistently showed ≥ 60% inhibition, 3 showed no inhibition and 6 were in the range of 20–60% inhibition of Pseudomonas phagocytosis. In parallel studies, the phagocytosis of S. aureus and S. marcescens was found not to be inhibited by CF serum. Mixing of CF serum with normal serum could not overcome the inhibitory effect, indicating the presence of an inhibitory factor rather than the lack of a necessary component. The inhibitory activity is not lost upon exposure of serum to glass, upon freezing the serum once, or upon heating at 56 C for 30 minutes.Speculation: The serum of cystic fibrosis patients selectively inhibits alveolar macrophage function in vitro; the expression of this inhibitory activity in vivo may compromise effective host control of infection. Investigation of the origin, nature and pathophysiologic role of the activity may suggest new approaches to the control of Pseudomonas pulmonary infection.Pultionary infection is a major factor in the morbidity and mortality associated with cystic fibrosis (CF) (6). Pseudomonas, a uhrquitous organism in the environment, is cystic fibrosis (CF) (6). Pseudomonas, a uhrquitous organism in the environment, is usually not pathogenic for healthy individuals. However, individuals with the chronic lung disease of CF are particularly susceptible to opportunistic Pseudomonas aeruginosa infections. The frequency of this organism in CF pulmonary infections is inadequately explained. It is well known that most CF patients have elevated levels of Pseudomonas antibodies in their sera and pulmonary secretions (l2,14). While recently there has been an indication that a lymphocyte unresponsiveness to Pseudomonas may be acquired as the infection progresses (18,19), no other immunologic abnormality has been consistendy observed (5.10). Extrapulmonary infection is extremely rare and sepsis is almost never, seen after the first months of life (22). This unusual susceptibility to Pseudomonas despite apparently normal systemic humoral and cellular immunity. suggests that local pulmonary host defense mechanisms are defective in CF. Several recent studies have indicated that lung defenses can, to a certain extent, function independently of systemic humoral and cell mediated immune systems (9,15,20,21).Lung defenses include mucociliary transport as well as phagocytic cells, lymphocytes, and immunoglobulin secretion. Since mucociliary transport in some CF patients is compromised (5). clearing of the bacteria becomes more dependent on the efficient action of the phagocytic cells. Previous studies in our laboratory (2) and by Biggar, et al. (I) have shown that CF serum impairs phagocytosis of Pseudomonas by rabbit alveolar macrophages. This report presents experimental observations indicating the presence of an inhibitory activity in CF serum which impairs phagocytosis of Pseudomonas by human as well as rabbit alveolar macrophages.

Frequency and significance of isolation of Ureaplasma urealyticum and Mycoplasma hominis from cerebrospinal fluid and tracheal aspirate specimens from low birth weight infants

To investigate the pathogenicity of Ureaplasma urealyticum and Mycoplasma hominis in preterm infants, we conducted a study to determine (1) frequency of isolation from cerebrospinal fluid and tracheal aspirate specimens and (2) clinical outcomes and effect of erythromycin treatment in ureaplasma-colonized infants. From the cerebrospinal fluid of 920 infants, U. urealyticum was isolated from 2 (0.2%) and M. hominis from none. From tracheal aspirate specimens from 224 infants, U. urealyticum was recovered from 37 (17%) and M. hominis from 4 (2%). Demographic characteristics and clinical outcomes were compared in very low birth weight infants (< 1500 gm) who were culture-positive or -negative for U. urealyticum. Although infants with positive results were less mature than their cohorts with negative results, there were no substantive differences in clinical outcomes between the two groups. Initiation of erythromycin treatment of infants with positive ureaplasma culture results at a mean age of 16.4 days did not appear to alter the clinical outcome. We conclude that in preterm infants (1) infection of the cerebrospinal fluid by U. urealyticum is infrequent, (2) ureaplasma organisms are frequently present in tracheal aspirate specimens but do not appear to be related to the presence or the subsequent development of respiratory disease, and (3) initiation of erythromycin treatment at 1 to 3 weeks of age does not alter the clinical course.

Identification and quantification of ureaplasmas colonizing the respiratory tract and assessment of their role in the development of chronic lung disease in preterm infants

Background. The role of Ureaplasma urealyticum in the development of chronic lung disease (CLD) in preterm infants continues to be disputed. Recently U. urealyticum has been found to consist of two species, U. urealyticum and Ureaplasma parvum, a finding that has not been considered in previous studies of CLD. This study examined the possible relationships between development of CLD and respiratory colonization by these newly redefined species, their concentrations in lower respiratory secretions and the effect of pulmonary surfactant treatment on these relationships in preterm infants with birth weights <1500 g. Methods. Endotracheal aspirates (ETA) were collected from intubated infants when airway suctioning was medically required. ETA were stored at −80°C until quantitative cultures for ureaplasmas and Mycoplasma hominis were performed. Culture results were correlated with development of CLD. Results. Of 475 infants (birth weights <1500 g) admitted during the 2-year study period, 272 were excluded because they were not intubated or were extubated before ETA could be obtained. An additional 28 infants died, were discharged or were transferred before they could be assessed for CLD. From the remaining 175 infants ureaplasmas were isolated from 66 (38%). No statistically significant associations were identified between development of CLD and the Ureaplasma species isolated, or concentration of ureaplasmas in lower respiratory secretions. These findings were not altered by treatment with pulmonary surfactant (Survanta). Conclusion. Lower respiratory colonization by ureaplasmas does not appear to be a contributory cause of CLD in preterm infants.

Ultrastructure and function of alveolar macrophages from cystic fibrosis patients

Summary: Alveolar macrophages were isolated from three cystic fibrosis patients, and the structure and function of these cells were compared to that of normal alveolar macrophages. The cystic fibrosis (CF) and normal alveolar macrophages were able to phagocytize Pseudomonas in the presence of normal serum, but cells from both sources had decreased phagocytosis of Pseudomonas in the presence of CF seram. Phagocytosis of Staphylococcus was not inhibited. Ultrastructural studies showed CF macrophages to be morphologically normal, however, in contrast to CF polymorphonuclear cells, they had not been heavily engaged in phagocytosis. The similarities between CF and normal macrophages suggest that the chronic pulmonary infection of CF may be due to an extrinsic factor in an altered lung environment rather than to any intrinsic cellular defect of the alveolar macrophage.Speculation: Functional and morphologic observations indicate that cystic fibrosis alveolar macrophages are not providing an adequate phagocytic defense against Pseudomonas. This defective phagocytosis does not appear to arise from an intrinsic problem with the macrophages, but rather appears to be due to extrinsic factors, i.e.. an altered lung environment together with a substance(s) present in cystic fibrosis serum which selectively inhibit Pseudomonas phagocytosis.

Asymptomatic Bacteremia in the Newborn Infant.

Routine blood cultures were drawn from 131 asymptomatic 3-day-old infants, yielding 21 positive cultures. Of these, 18 were not clinically significant, 1 patient had probable septicemia, and 2 had prolonged bacteremia. A third case of prolonged bacteremia was discovered at 8 days of age. The 3 patients with prolonged bacteremia and the one with septicemia are presented in detail. The occurrence of bacteremia in asymptomatic infants emphasizes the need for carefully evaluating every positive blood culture obtained from a newborn infant.

Bacteriostatic qualities of human milk

A practical concern of the working mother is the bacteriostatic quality of human milk over time without benefit of refrigeration. Therefore, quantitative cultures of human milk stored at room temperature were performed at 0, 2, 4, 6, and 24 hours after expression. Milk from 10 mothers less than six days postpartum (colostrum) and from 10 mothers 7 to 42 weeks postpartum (mature milk) was studied. The number of colony-forming units per milliliter of milk cultured at 0 time did not significantly increase in mature milk after 6 hours nor in colostrum after 24 hours of storage at room temperature. Thus, mothers who express milk for their own infants while at work may assume that the bacterial contamination of their milk will not increase significantly for up to but no longer than 6 hours after expression, even if they have no access to refrigeration.