Karl I. Li

Orthostatic intolerance in adolescent chronic fatigue syndrome

Objectives. To demonstrate the association between orthostatic intolerance and the chronic fatigue syndrome (CFS) in adolescents and to delineate the form that orthostatic intolerance takes in these children. Study Design. We investigated the heart rate and blood pressure (BP) responses to head-up tilt (HUT) in 26 adolescents aged 11 to 19 years with CFS compared with responses in adolescents referred for the evaluation of simple faint and to responses in 13 normal healthy control children of similar age. Results. A total of 4/13 of the controls and 18/26 simple faint patients experienced typical faints with an abrupt decrease in BP and heart rate associated with loss of consciousness. One CFS patient had a normal HUT. A total of 25/26 CFS patients experienced severe orthostatic symptoms associated with syncope in 7/25, orthostatic tachycardia with hypotension in 15/25, and orthostatic tachycardia without significant hypotension in 3/25. Acrocyanosis, cool extremities, and edema indicated venous pooling in 18/25. None of the control or simple faint patients experienced comparable acral or tachycardic findings. Conclusions. We conclude that chronic fatigue syndrome is highly related to orthostatic intolerance in adolescents. The orthostatic intolerance of CFS often has heart rate and BP responses similar to responses in the syndrome of orthostatic tachycardia suggesting that a partial autonomic defect may contribute to symptomatology in these patients.

Epidemiology and control of vancomycin-resistant enterococci in a regional neonatal intensive care unit

BACKGROUND After the occurrence of two cases of bloodstream infection with vancomycin-resistant enterococci (VRE) in our regional neonatal intensive care unit, we studied the epidemiology of VRE and applied extensive infection control measures to the unit to control VRE transmission. METHODS Infection control measures applied to the unit included weekly surveillance for VRE colonization; education; cohorting of VRE-positive, VRE-negative and VRE-exposed babies with separate personnel and equipment for each group; use of gowns and gloves on room entry; and hand washing before and after each patient contact. Risk factors for VRE colonization were determined with a stepwise logistic regression model. RESULTS Thirty-three (40.2%) babies became colonized with VRE. The VRE colonization rate was reduced from 67% to 7% after implementation of infection control measures. Prolonged antimicrobial treatment and low birth weight were significantly associated with an increased risk of VRE colonization. CONCLUSION VRE can spread rapidly among newborns in a regional neonatal intensive care unit. Strict infection control measures can reduce the rate of VRE colonization among neonates.

Neurally mediated hypotension and autonomic dysfunction measured by heart rate variability during head-up tilt testing in children with chronic fatigue syndrome.

Recent investigations suggest a role for neurally mediated hypotension (NMH) in the symptomatology of chronic fatigue syndrome (CFS) in adults. Our previous observations in children with NMH and syncope (S) unrelated to CFS indicate that the modulation of sympathetic and parasympathetic tone measured by indices of heart rate variability (HRV) is abnormal in children who faint during head-up tilt (HUT). In order to determine mine the effects of autonomic tone on HUT in children with CFS we performed measurements of HRV during HUT in 16 patients aged 11–19 with CFS. Data were compared to 26 patients evaluated for syncope and with 13 normal control subjects. After 30 minutes supine, patients were tilted to 80° for 40 minutes or until syncope occurred. Time domain indices included RR interval, SDNN, RMSSD, and pNN50. An autoregressive model was used to calculate power spectra. LFP (.04–.15 Hz), HFP (.15–.40Hz), and TP (.01–.40Hz). Data were obtained supine (baseline) and after HUT. Thirteen CFS patients fainted (CFS+, 5/13 pure vasodepressor syncope) and three patients did not (CFS-). Sixteen syncope patients fainted (S+, all mixed vasodepressor-cardioinhibitory) and 10 did not (S-). Four control patients fainted (Control+, all mixed vasodepressor-cardioinhibitory) and nine did not (Control-). Baseline indices of HRV were not different between Control+ and S+, and between Control- and S-, but were depressed in S+ compared to S-. HRV indices were strikingly decresed in CFS patients compared to all other groups. With tilt, SDNN, RMSSD, and pNN50 and spectral indices decreased in all groups, remaining much depressed in CFS compared to S or control subjects. With HUT, sympathovagal indices (LFP/HFP, nLFP, and nHFP) were relatively unchanged in CFS, which contrasts with the increase in nLFP with HUT in all other groups. With syncope RMSSD, SDNN, LFP, TP, and HFP increased in S+ (and Control+), suggesting enhanced vagal heart rate regulation. These increases were not observed in CFS+ patients. CFS is associated with NMH during HUT in children. All indices of HRV are markedly depressed in CFS patients, even when compared with already low HRV in S+ or Control+ patients. Sympathovagal balance does not shift toward enhanced sympathetic modulation of heart rate with HUT and there is blunting in the overall HRV response with syncope during HUT. Taken together these data may indicate autonomic impairment in patients with CFS.

Infections and Apparent Life-Threatening Events

The need for routine sepsis evaluation in patients who have experienced an apparent life-threatening event but lack signs of infection remains controversial. To assess their risk of a serious occult bacterial infection, records were reviewed of 95 infants in whom infections were discovered during their inpatient evaluation after an apparent life-threatening event. Noted for each patient was the presence of any suggestive findings that would have prompted a physician to consider the given type of infection in the differential diagnosis. Thirty patients had bacterial infections; all but 5 had suggestive findings. The exceptions included 1 patient with pneumonia and 4 with urinary tract infections. None of the remaining 25 patients had occult bacterial infections. In patients with an apparent life-threatening event who appear well and lack signs suggestive of a serious bacterial infection, it may be possible to forego routine sepsis evaluation beyond a chest radiograph and urine culture without risking a serious missed diagnosis.

Congenital tuberculosis with facial nerve palsy

Congenital tuberculosis is unusual, and central nervous system involvement is even more rare. We report a case of congenital tuberculosis presenting with facial palsy and purulent otorrhea.

Cokeromyces recurvatus as a human pathogenic fungus: case report and critical review of the published literature.

During the past few years several rarely encountered taxa of zygomycete fungi (Mucorales and Entomophthorales) have been implicated in the etiology of human disease. Prominent among these is Cokeromyces recurvatus Poitras, which is usually isolated from soil and from feces of the lizard and certain rodents. 2 This fungus has been implicated as a potential etiologic agent in seven human cases in which the fungus was isolated from clinical specimens including vaginal secretions, alimentary tract, bladder, urine, pleura and peritoneal fluids. Recently C. recurvatus was isolated from stool samples in two cases of severe diarrhea in which the fungal elements were also noted in the tissue sections, thus providing the first evidence of its pathogenic potential in humans. 9 Because tissue invasion was noted in only two instances, it is still not unequivocally established whether the fungus is a colonizer of the affected tissue or a chance contaminant. We describe a case in which C. recurvatus was isolated on two occasions from an abscess and drainage fluid from a 9-year-old patient with a perforated Meckel’s diverticulum. The patient responded to surgical intervention and antifungal therapy leading to full recovery.

Congenital Babesiosis After Maternal Infection With Borrelia burgdorferi and Babesia microti

We describe the cases of 2 infants with congenital babesiosis born to mothers with prepartum Lyme disease and subclinical Babesia microti infection. The infants both developed anemia, neutropenia, and thrombocytopenia, and 1 infant required red blood cell transfusion. Both infants recovered with treatment. Additional studies are warranted to define the optimal management strategy for pregnant women with early Lyme disease in geographic areas in which B microti infection is endemic.

Neurally Mediated Hypotension and Autonomic Dysfunction Measured by Heart Rate Variability in Children with the Chronic Fatigue Syndrome † 144

Recent investigations strongly suggest a role for neurally mediated hypotension (NMH) in the symptomatology of Chronic Fatigue Syndrome (CFS) in adults. Our previous work indicate that autonomic activity measured by heart rate variability (HRV) is abnormal in children with syncope (S) due to NMH during head-up tilt testing (HUT). Therefore, we performed measurements of HRV at HUT in 13 patients aged 11-18 y with CFS defined by CDC guidelines and compared results to 29 S patients. After 30 min supine, patients were tilted to 80° for 30 min or until syncope occurred. Time domain indices included standard deviation (SDNN), root mean square successive differences (RMSSD), percent exceeding 50msec (pNN50). An autoregressive model was used to calculate power spectra. Low frequency power (LFP,.04-.15Hz), high frequency power (HFP,.15-.40Hz), and total power (TP,.01-.40Hz) were compared. HRV data were obtained supine before tilt (baseline), and 5-10 min after HUT. Ten CFS patients fainted (CFS+), and 3 did not (CFS-). HRV indices were not different at baseline for CFS- vs CFS+: SDNN was 52±10 vs 62±7ms, RMSSD was 44±11 vs 51±7ms, pNN50 was 17±7 vs 25±4%, respectively. LFP, HFP, and TP were 442±143, 448±275, and 1287±461ms2 in CFS- vs 589±51, 398±86, and 1686±262 in CFS+. However, these data were strikingly decreased compared to S patients, - 17 fainted during HUT (S+) 12 did not (S-) - in which HRV indices were normal and much higher for S- compared to S+: SDNN was 123±17 vs 78±6ms, RMSSD was 127±23 vs 64±6 ms, pNN50 was 51±6 vs 31±4%, LFP, was 834±133 vs 3433±840, HFP was 3433±840 vs 834±133 and TP was 7062±1500 vs 2855±420 ms. With tilt, SDNN, RMSSD and pNN50 and spectral indices decreased in all groups. We conclude: 1. Chronic Fatigue Syndrome is associated with neurally mediated syncope; 2. All indices of HRV are markedly depressed in CFS patients whether or not syncope is induced during HUT and even when compared with already abnormally low HRV in syncopal patients without CFS. These data suggest severe autonomic impairment in all patients with the Chronic Fatigue Syndrome.

CONTROL OF VANCOMYCIN RESISTANT ENTEROCOCCI COLONIZATION IN A REGIONAL NEONATAL ICU. † 1770

Vancomycin resistant enterococcus (VRE) is potentially lethal in critically ill neonates. We studied the rate of VRE colonization and assessed the effectiveness of our control measures in our Regional Neonatal ICU (RNICU) and Intermediate Care Nursery (ICN) after finding two patients within a 3 day period with blood cultures growing VRE. RNICU and ICN are functionally separate units with their own medical and nursing staff.