J. Owen Hendley

Spread of Streptococcus pneumoniae in Families. II. Relation of Transfer of S. pneumoniae to Incidence of Colds and Serum Antibody

Factors that affect the spread of Streptococcus pneumoniae and the antibody responses associated with colonization were studied in 64 families for periods of eight to 52 weeks. Surveillance included daily recording of respiratory symptoms and bimonthly pharyngeal cultures for identification of the pneumococcal carrier state. Rhinovirus cultures were included for a portion of the study period. Intrafamilial carriage of a single type of S. pneumoniae and simultaneous spread to more than one family member were commonmspread often occurred in association with an upper respiratory tract infection; simultaneous transmission of S. pneumoniae and a rhinovirus was documented. Preexisting, type-specific serum antibody did not prevent acquisition of homotypic S. pneumoniae but did appear to shorten the duration of pharyngeal carriage. Sera of all 11 adults had greater than 150 ng of antibody nitrogen/ml of homotypic serum antibody (measured by a radioimmunoassay) before colonization. In contrast, only one of 13 preschool children had homotypic antibody concentrations of this magnitude before colonization. A threefold or greater rise in the concentration of homotypic antibody occurred in 13 of 24 children (54%) after acquisition of S. pneumoniae; the increase in antibody concentration was associated with illness in six of the children. On the other hand, acquisition of S. pneumoniae in adults was not associated with an increase in concentration of homotypic serum antibody.

Etiology of acute conjunctivitis in children

To determine the etiology of acute conjunctivitis in children seen in pediatric practice, 99 patients with conjunctivitis and 102 age-and season-matched controls were cultured for aerobic bacteria including Haemophilus influenzae, and for viruses, Chlamydia trachomatis, and mycoplasmas. Agents statistically associated with conjunctivitis included H. influenzae (42% vs 0%), Streptococcus pneumoniae (12% vs 3%), and adenoviruses (20% vs 0%). One of these three etiologic agents was isolated from 71 (72%) of the patients. Simultaneous infection with two pathogens was uncommon. Staphylococcus aureus was equally prevalent in diseased and control eyes; one strain of C. trachomatis was isolated from a control eye. Although there were variations in the clinical features of viral and bacterial conjunctivitis, differentiation in an individual patient was difficult. An adenovirus was isolated from 11 (65%) of 17 patients who had pharyngitis in addition to conjunctivitis. H. influenzae was isolated from 14 (74%) of 19 children who had both otitis and conjunctivitis. Adenovirus conjunctivitis was common in the fall and H. influenzae in winter.

Histopathologic Examination and Enumeration of Polymorphonuclear Leukocytes in the Nasal Mucosa during Experimental Rhinovirus Colds

The histology of the nasal mucosa was examined by serial scrape and punch biopsies in 20 rhinovirus infected volunteers and 10 sham inoculated controls. No morphologic changes could be detected in the epithelial or subepithelial portions in the mucosa of specimens from infected volunteers. There was a significant increase in the number of polymorphonuclear leukocytes (PMNs) in the nasal epithelium of the infected subjects early in the course of the cold compared to their pre-infection baseline. However, trauma to the nasal mucosa from repeated sampling led to an outpouring of PMNs into nasal mucus, making evaluation of the results difficult. The number of mast cells seen in the mucosal specimens of the infected subjects did not differ from that seen in controls.

Nose Blowing Propels Nasal Fluid into the Paranasal Sinuses

Intranasal pressures were measured in adults during nose blowing, sneezing, and coughing and were used for fluid dynamic modeling. Sinus CT scans were performed after instillation of radiopaque contrast medium into the nasopharynx followed by nose blowing, sneezing, and coughing. The mean (+/-SD) maximal intranasal pressure was 66 (+/-14) mm Hg during 35 nose blows, 4.6 (+/-3.8) mm Hg during 13 sneezes, and 6.6 (+/-3.8) mm Hg during 18 coughing bouts. A single nose blow can propel up to 1 mL of viscous fluid in the middle meatus into the maxillary sinus. Sneezing and coughing do not generate sufficient pressure to propel viscous fluid into the sinus. Contrast medium from the nasopharynx appeared in >/=1 sinuses in 4 of 4 subjects after a nose blow but not after sneezing or coughing.

Oral prednisone therapy in experimental rhinovirus infections.

This study was designed to test the effects of oral steroid therapy on the kinin levels and symptoms of experimental rhinoviral colds. Forty-seven men were randomized to receive prednisone (20 mg) or placebo. Therapy was administered three times a day for 5 days, after one dose was given 11 hours before inoculation with rhinovirus. Viral titers, symptom scores, and kinin and albumin concentrations in nasal washes were monitored. The mean kinin levels were lower in the steroid group (287 vs 449 pg/ml, p = 0.005) with significant differences in kinin levels on days 3 and 4 (p < 0.01). No significant difference in total symptom scores was seen between the two groups. Except for increased sneezing (p < 0.01) and mucus weights (p < 0.05) on day 1 in patients treated with prednisone, there were no significant differences in individual symptom scores. Headache tended to be less prominent in steroid recipients. Mean viral titers were higher in the steroid group (1.13 vs 0.79, p = 0.03) with significant differences in the daily viral titers on days 3 (p < 0.05) and 4 (p < 0.01). Steroids reduced kinin levels in rhinoviral infections, but that reduction was not associated with a significant reduction in symptoms. This study also provides evidence for the enhancement of viral growth in steroid recipients.

Efficacy of topical antibiotic therapy in acute conjunctivitis in children

We studied 102 children aged 1 month to 18 years in a randomized, double-blind trial designed to determine both the natural history of bacterial conjunctivitis and whether topical antibiotic therapy is beneficial. Affected eyes were treated four times a day for 7 days with drug (polymyxin-bacitracin ophthalmic ointment) or placebo. Eighty-four patients had proved bacterial conjunctivitis (Haemophilus influenzae 61, Streptococcus pneumoniae 22, both one); 66 of these received only topical therapy. By 3 to 5 days, 21 of 34 (62%) patients receiving topical antibiotic were clinically cured, whereas only nine of 32 (28%) patients given placebo were cured (P less than 0.02). By 8 to 10 days, 31 (91%) of the patients given antibiotic and 23 (72%) of the placebo group were cured (P = NS). The bacterial pathogen was eradicated by day 3 to 5 in 71% and by day 8 to 10 in 79% of patients given antibiotic, compared to 19% and 31% of the placebo group (P less than 0.001). Acute bacterial conjunctivitis is a self-limited disease, but topical antibiotic therapy with polymyxin-bacitracin shortens the duration of clinical disease and enhances eradication of the causative organism from the conjunctiva.

Bacteriuria in children with neurogenic bladder treated with intermittent catheterization: Natural history

OBJECTIVE To determine whether bacteriuria unassociated with symptoms in patients with neurogenic bladder will lead to symptomatic infection and/or deterioration of the upper urinary tract if left untreated, we examined whether bacteriuria persisted in bladder urine of children with neurogenic bladder treated with clean intermittent catheterization (CIC) and whether persistence of bacteria led to symptomatic infection or deterioration of the upper urinary tract. DESIGN Weekly home visits were made during 6 months of surveillance of 14 children on the CIC regimen with a normal upper urinary tract and no reflux (as determined by renal ultrasonography, voiding cystourethrography, and serum creatinine measurement). During visits a sample of bladder urine was obtained by CIC, and signs and symptoms of urinary tract infection and all medications were recorded. RESULTS Fourteen children were observed for 323 weeks. Cultures of 70% (172/244) of the urine samples collected were positive for organisms (> or = 10(4) colony-forming units per milliliter), 152 (88%) for the usual pathogens and 20 (12%) for commensal organisms. Bacteriuria was associated with pyuria two thirds of the time, regardless of bacterial species. Carriage of the same pathogen for 4 weeks or longer, with associated pyuria, was common during surveillance. Despite frequent episodes of bacteriuria with associated pyuria, there were only five symptomatic infections during the 323 patient-weeks. Children remained clinically well during the study period, and their upper urinary tract did not deteriorate. CONCLUSION Bacteriuria persists for weeks in symptom-free children being treated with CIC for neurogenic bladder associated with a normal upper urinary tract. Before attempts are made to eradicate bacteriuria, treatment should be proved to be beneficial to this population.

Diagnostic Review : Prolonged Fever of Unknown Origin A Record of Experiences with 54 Childhood Patients

From: Department of Pediatrics, University of Virginia Hospital, Charlottesville, Virginia 22901. THE CLINICAL DILEMMAS presented by adult American patients with prolonged fever of unknown origin have been the subject of numerous reviews and in-depth discussions.’-’ As for children, IVIcClung9 and Pizzo, Lovejoy, and Smithl° have highlighted certain aspects of prolonged unexplained fever which are unique to this age. We here describe 54 such children with prolonged fever of unknown origin, with the view toward expediting the diagnostic workup of such children.

Alteration of cerebrospinal fluid findings by partial treatment of bacterial meningitis

Standard laboratory tests of cerebrospinal fluid were analyzed in 79 pediatric patients with acute meningitis. Forty-one patients were diagnosed prior to treatment as having bacterial or aseptic meningitis based on bacterial cultures of the cerebrospinal fluid and blood. Data of 38 partially treated children (prior to admission to hospital) were compared to the results of comparable tests observed in the untreated patients. Two partially treated patients had cell and differential counts characteristic of aseptic meningitis and had positive bacterial cultures; ten partially treated patients with a cellular response typical of bacterial meningitis had negative cultures. Two patients with glucose and protein values consistent with bacterial meningitis had aseptic type cellular responses and negative cultures. The apparent alteration of cell and differential counts and bacterial culture results in different patients following partial treatment suggests the possibility that all commonly employed tests could be altered by such treatment in an individual patient with bacterial meningitis.

Temporal Relationships Between Colds, Upper Respiratory Viruses Detected by Polymerase Chain Reaction, and Otitis Media in Young Children Followed Through a Typical Cold Season

INTRODUCTION. Otitis media is a frequent complication of a viral upper respiratory tract infection, and the reported co-incidence of those diseases increases with assay sensitivity and sampling density. We determined the incidence of otitis-media complications in young children when referenced to cold-like illnesses and to concurrent virus recovery from the nasopharynx. METHODS. A total of 60 children from 24 families were followed from October 2003 through April 30, 2004, by daily parental recording of illness signs, weekly pneumatic otoscopic examinations, and periodic polymerase chain reaction assay of collected nasal fluids for common viruses. RESULTS. One hundred ninety-nine cold-like illnesses were observed, but a sample for virus assay was not collected concurrent with 71 episodes. Of the remainder, 73% of cold-like illnesses were temporally related to recovery of 1 or a combination of the assayed viruses, with rhinovirus predominating. For non–cold-like illness periods, 54 (18%) of 297 assays were positive for virus, and the virus frequency distribution was similar to that for cold-like illnesses. There were 93 diagnosed otitis-media episodes; 65 (70%) of these occurred during a cold-like illness. For the 79 otitis-media episodes with available nasal samples, 61 (77%) were associated with a positive virus result. In this population, the otitis-media complication rate for a cold-like illness was 33%. CONCLUSIONS. A cold-like illness was not a prerequisite for polymerase chain reaction detection of viruses in the nose and nasopharynx of young children. Viral detection by polymerase chain reaction in the absence of a cold-like illness is associated with complications in some subjects. Otitis media is a complication of viral infection both with and without concurrent cold-like illnesses, thus downwardly biasing coincidence estimates that use cold-based illnesses as the denominator.