Hiroshi Sakakibara

Pediatric hypervirulent Klebsiella pneumoniae septic arthritis

Cases of infection with hypervirulent Klebsiella pneumoniae are gradually increasing in number, and cause life‐threatening community‐acquired infection even in immunocompetent patients. A 14‐year‐old boy developed septic hip arthritis due to hypervirulent K. pneumoniae (sequence type 23, serotype K1, magA positive). The patient initially seemed to have been successfully treated with antibiotics and surgical intervention, but septic arthritis developed into osteomyelitis of the femoral head and myositis, which required long‐term antibiotic therapy and additional surgical intervention. This is the first pediatric case of hypervirulent K. pneumoniae septic hip arthritis. Treatment plans should mainly consist of antibiotic therapy and surgical intervention. Clinicians, even pediatricians, in developed countries should be aware of the increasing incidence of hypervirulent Klebsiella pneumoniae infection.

Epidemiology of Pediatric Convulsive Status Epilepticus With Fever in the Emergency Department A Cohort Study of 381 Consecutive Cases

Pediatric convulsive status epilepticus with fever is common in the emergency setting but leads to severe neurological sequelae in some patients. To explore the epidemiology of convulsive status epilepticus with fever, a retrospective cohort covering all convulsive status epilepticus cases with fever seen in the emergency department of a tertiary care children’s hospital were consecutively collected. Of the 381 consecutive cases gathered, 81.6% were due to prolonged febrile seizure, 6.6% to encephalopathy/encephalitis, 0.8% to meningitis, and 7.6% to epilepsy. In addition, seizures were significantly longer in encephalopathy/encephalitis cases than in prolonged febrile seizure cases (log rank test, P < .001). These results provide for the first time the pretest probability of final diagnoses in children with convulsive status epilepticus with fever in the emergency setting, and will help optimize the management of pediatric patients presenting to the emergency department with convulsive status epilepticus with fever.

Anaphylactic shock after the ingestion of jellyfish without a history of jellyfish contact or sting

We read with interest the article entitled “Anaphylaxis caused by ingestion of jellyfish” by Imamura et al. in this journal [1]. They stated that their case subject was sensitized through the skin by jellyfish stings and that subsequent jellyfish intake induced anaphylaxis. However, we experienced a case of anaphylaxis after jellyfish ingestion without any history of jellyfish contact or sting.A 14-year-old boy developed a cough, urticaria and dyspnea 30 minutes after he ate a breakfast that [...]

Tachycardia may prognosticate life- or organ-threatening diseases in children with abdominal pain

Background Abdominal pain is common in children, but expeditious diagnosis of life‐ or organ‐threatening diseases can be challenging. An evidence‐based definition of tachycardia in children was established recently, but its diagnostic utility has not yet been studied. Objective To test the hypothesis that abdominal pain with tachycardia may pose a higher likelihood of life‐ or organ‐threatening diseases in children. Methods A nested case‐control study was conducted in a pediatric emergency department in 2013. Tachycardia was defined as a resting heart rate of more than 3 standard deviations above the average for that age. Life‐ or organ‐threatening diseases were defined as “disorders that might result in permanent morbidity or mortality without appropriate intervention.” A triage team recorded vital signs before emergency physicians attended patients. Patients with tachycardia (cases) and without tachycardia (controls) were systematically matched for age, sex, and month of visit. The groups were compared for the presence of life‐ or organ‐threatening diseases. Results There were 1683 visits for abdominal pain, 1512 of which had vital signs measured at rest. Eighty‐three patients experienced tachycardia, while 1429 did not. Fifty‐eight cases and 58 controls were matched. Life‐ or organ‐threatening diseases were more common in the case group (19%) than the control group (5%, p = 0.043). The relative risk of tachycardia to the presence of the diseases was 3.7 (95% confidence interval 1.2–12.0). Conclusion Tachycardia significantly increased the likelihood of life‐ or organ‐threatening diseases. Tachycardia in children with abdominal pain should alert emergency physicians to the possibility of serious illness.

Neonatal Staphylococcus lugdunensis urinary tract infection

Staphylococcus lugdunensis is a known pathogen of infective endocarditis, but not of urinary tract infection. We report a previously healthy neonate without congenital anomalies of the kidney and urinary tract who developed urinary tract infection due to Staphylococcus lugdunensis, illustrating that Staphylococcus lugdunensis can cause urinary tract infection even in those with no urinary tract complications.

Unilateral lung hyperinflation caused by bridging bronchus on chest radiography in an infant

A 5-month-old boy presented to the emergency department with cough and dyspnea. Although his parents had noted that his breathing was occasionally noisy from the neonatal period, he was not examined medically. He had no significant past medical history or allergies. The family history was unremarkable. Written informed consent was obtained from the patient’s parents for the publication of this report. The respiratory rate was 57 breaths/min, and oxygen saturation was 88% in room air. Physical examination indicated wheeze and inspiratory stridor, nasal flaring, and suprasternal retraction. The laboratory data were as follows: white blood cell count, 9,650/lL; C-reactive protein, 0.18 mg/dL; and carbon dioxide partial pressure, 62.2 mmHg on venous blood analysis. Rapid antigen-based testing for respiratory syncytial virus was negative. Inhaled bronchodilators were ineffective. Chest radiography indicated hyperinflation of the right lung with a leftward shift of the mediastinum (Fig. 1a). The patient was admitted to the pediatric intensive care unit and intubated due to the progression of respiratory failure. Chest radiography performed after intubation showed improvement in aeration of the right middle and lower lobes, indicating that the level of the tracheal bifurcation was higher, and that of the right lower pulmonary artery and vein lower, than normal (Fig. 1b). This suggested a bronchial branching malformation, and hence chest contrast-enhanced computed tomography (CT) was performed. The CT showed abnormal bronchi with the right upper lobe bronchus arising from the trachea at the level of the fourth thoracic vertebra and the intermediate bronchus arising from the left main bronchus at the level of the sixth thoracic vertebra. The latter crossed the midline (Fig. 1c). CT also showed the left pulmonary artery arising from the right pulmonary artery and compressing the left bronchus (Fig. 1d). On further investigation, bronchoscopy indicated stenosis of the right upper lobe bronchus. A diagnosis of bridging bronchus with left pulmonary artery sling and stenosis of the right upper lobe bronchus was therefore confirmed. Slide tracheoplasty and surgical repair of the pulmonary artery sling were performed on hospital day 25. The patient was discharged on hospital day 93. Unilateral hyperlucent lung can be divided into five types on etiology: abnormalities of the chest wall (e.g. Poland syndrome); lung parenchyma (e.g. bronchial atresia and Swyer–James syndrome); pulmonary vessels (e.g. pulmonary artery sling); central airways (e.g. foreign body aspiration and endobronchial tumor); and mediastinum (e.g. bronchopulmonary foregut malformation). Of these, bridging bronchus is a rare congenital malformation categorized as a lung parenchymal abnormality, and is defined as an anomalous bronchial branching pattern characterized by a large bronchial branch arising from the left main stem bronchus, bridging the mediastinum from the ipsilateral to contralateral lung, and reaching the right lower and middle lobes. In addition, it is often complicated by tracheal stenosis, bronchomalacia, and cardiovascular anomalies such as pulmonary artery sling. Tracheal stenosis can cause respiratory distress, wheezing, coughing, stridor, or life-threatening airway obstruction. This patient presented with wheeze and inspiratory stridor. He also had a left pulmonary artery sling and tracheal stenosis of the right upper lobe bronchus. We believe that hyperinflation of the right upper lobe seen on chest radiography was caused by the stenosis of the right upper lobe bronchus. The bridging bronchus can be misdiagnosed as bronchiolitis and asthma given that these diseases cause wheezing in young infants. We therefore believe that chest radiography is crucial in identification of the cause of the first episode of wheezing in young infants. If chest radiography is abnormal, contrast-enhanced CT is strongly recommended, because it can help detect bridging bronchus early.

Anemia Due to ABO Incompatibility in a Neonate

To the Editor:Anemia due to ABO-incompatibility hemolytic disease (ABO HD) is less common and hemoglobin concentrations in ABO HD patients are not commonly monitored. We report herein a case of severe, late anemia due to ABOHD requiring a transfusion. A girl presented with pallor at age 22 d. Her parents were both Nepalese. The couple’s first child was stillborn; the second child had jaundice due to ABO incompatibility and needed exchange blood transfusion. The laboratory test results are shown in Table 1. Her blood type was B Rh(D), and her mother’s blood type was O Rh(D). The direct Coombs test was positive at age 5 d but was negative at age 26 d. The indirect Coombs tests for the anti-A and anti-B antibody were both positive. The indirect Coombs test for the anti-B antibody produced a weaker reaction than for the antiA antibody, and no other irregular antibodies were found. Four days after her visit, her hemoglobin level was 5.0 g/dl, and a transfusion was required. At age 41 d, the reaction to anti-B antibody in the indirect Coombs test became weaker, and no progression of the anemia was observed. At that time, the maternal IgG anti-A and anti-B titers were 1024 and 4096, respectively. A previous study demonstrated an association between the maternal antibody level and the risk of ABO HD, especially when the antibody titer ≥512 [1]. The anti-A and anti-B antibody titers are known to be different among different ethnic groups [2, 3]. Infants with ABO HD whose hemoglobin concentration at discharge of >15 g/dl are thought not to need frequent hemoglobin measurements [4]. In this report, the patient’s mother might have been sensitized to the B antigen of the first child, in addition to any ethnic factors. The patient herself might also have had a high anti-B antibody titer causing a positive direct Coombs test immediately after birth. The high antibody titer might have caused persistence of the hemolysis and thus, treatment was required. Physicians should consider the possibility that anemia may later develop in patients whomay have highABO antibody titer.