Fitzgerald Rj

Regional lymphadenitis following BCG vaccination

A cluster of cases of lymphadenitis occurred in Dublin following vaccination with a newly introduced Copenhagen 1331 strain of Bacille Calmette-Guerin (BCG) vaccine during 1989. All cases of BCG lymphadenitis presenting to paediatric surgical clinics over an 11-year period were reviewed to determine the optimum treatment for this problem. Seventeen patients are included, 16 of whom received vaccine in the newborn period; 1 received BCG at 8 months. Nine were treated by initial operation, 6 with antituberculous drugs, and 2 were observed without specific therapy. All but 1 of the medically treated patients and both patients who received observation only required operation for failure to resolve or progression of disease. The best results were obtained with excision and primary closure. We conclude that although sponteneous resolution occurs in a majority of all cases of BCG lymphadenitis in infants, in those patients with more severe disease who require surgical referral, a short trial of anti-microbial therapy is indicated. Patients who fail to improve or develop complications are then best treated by surgical excision of the involved nodes.

Spontaneous deep venous thrombosis in Duchenne muscular dystrophy

Deep venous thrombosis (DVT) is an uncommonly encountered condition in childhood and, as a consequence, the diagnosis may be overlooked. We describe the first two cases of DVT occurring in children with Duchenne muscular dystrophy. Both brothers were wheel-chair-bound for protracted periods. The first case occurred following spinal fusion for scoliosis. The second occurred spontaneously following immobilisation in hospital while undergoing investigation for a ureteric stone. Serological investigations to outrule an underlying thrombogenic cause showed no deficiency of protein C or antithrombin III nor the presence of lupus anticoagulant in either patient. The presence of flaccid lower extremities resulting in prolonged immobilisation combined with an ineffective muscle pump for venous return may have predisposed the patients in our series. The issue of prophylaxis should now be actively considered in such patients in high-risk circumstances.

Delayed presentation of a contralateral, posterolateral congenital diaphragmatic hernia

Twenty cases of bilateral posterolateral congenital diaphragmatic hernia have been reported to date. Four of these patients have survived. We present a case in which an infant was readmitted, aged 8 weeks, following an initial primary repair and underwent successful surgical correction of a contralateral diaphragmatic defect. Ultrasound examination of the contralateral hemidiaphragm is suggested as a useful modality during initial assessment. In doubtful cases, where ultrasound has given equivocal information, peroperative examination of the contralateral hemidiaphragm is recommended. Failure to appreciate the existence of this rare condition may lead to inappropriate clinical management.

Absence of suprarenal segment of inferior vena cava with cavernous transformation

A 13-year-old boy with congenital absence of the inferior vena above the renal hilum and azygos continuation is presented. Ultrasound and radiological features of focal dilatation of one of the venous collaterals suggested an intra-abdominal mass, causing a diagnostic dilemma. An inferior vena cavogram is the definitive investigation to diagnose this anomaly. Awareness of the condition is important, as injury to the lesion can cause severe haemorrhage and accidental ligation of the azygos vein may be fatal.

The second therapeutic enema in intussusception

The original article recently published by Glover et al. [1] suggests that a second therapeutic gas enema may be successful in reducing intussusception. In a paper read to the British Association of Paediatric Surgeons in Vienna in 1985 [2] and subsequently published [3], we showed that a second barium enema can indeed be successful. In 9 out of 13 attempted cases the second enema either showed or effected reduction. The criteria for attempting the second enema were that: (1) the reduction on the first attempt had been as far as the ileocaecal valve; (2) the child was well; (3) careful monitoring of the patient was maintained; and (4) if the second enema failed the patient was operated upon immediately. In none of the 4 unsuccessful cases was resection necessary. Since that time we too have converted to gas enema and have used the second enema to good effect. We shall be publishing these results.

Heterotopic perineal intestinal mucosa —a variant of the exstrophy-epispadias complex

We report two cases of sequestration of a segment of intestinal mucosa in the perineal area. In one patient this was associated with a mildly ectopic anus. No abnormalities were identified in the bladder, urethra, vagina, or rectum. The lesions were treated by excision following complete anatomical mapping.