Kenneth Bromberg

Obturator Internus Muscle Abscess in Children: Report of Seven Cases and Review

Obturator internus muscle (OIM) abscess is an uncommon entity often mistaken for septic arthritis of the hip. We describe seven children with OIM abscess and review seven previously reported cases. The most common presenting symptoms were hip or thigh pain (14 patients), fever (13), and limp (13). The hip was flexed, abducted, and externally rotated in 11 patients. Magnetic resonance imaging and computed tomography (CT) were diagnostic for OIM abscess in the 14 patients. Associated abscesses were located in the obturator externus muscle (5 patients), psoas muscle (2), and iliac muscle (1). The etiologic agents were Staphylococcus aureus (8 patients), Streptococcus pyogenes (2), Neisseria gonorrhoeae (2), and Enterococcus faecalis (1). Three patients underwent CT-guided percutaneous drainage, and three had surgical drainage. Three patients had ischial osteomyelitis in addition to OIM abscess. The 11 children with uncomplicated OIM abscess were treated for a median of 28 days. All patients had an uneventful recovery.

Evaluation of the Measles Clinical Case Definition

An accurate system of identifying and classifying suspected measles cases is critical for the measles surveillance system in the United States. To examine the performance of the clinical case definition in predicting laboratory confirmation of suspected cases of measles, we reviewed 4 studies conducted between 1981 and 1994. A clinical case definition was examined that included a generalized maculopapular rash, fever (>or=38.3 degrees C, if measured), and either a cough, coryza, or conjunctivitis. Serological confirmation of measles was done either by hemagglutination inhibition assay, complement fixation assay, or enzyme immunoassays. The positive predictive value of the clinical case definition decreased from 74% to 1% as incidence decreased from 171 cases/100000 population to 1.3 cases/100000 population. Sensitivity was high, and for the larger studies with the most precise estimates, sensitivity was 76%-88%. The low positive predictive value of the clinical case definition in settings of low incidence demonstrates that serological confirmation is essential to ensure an accurate diagnosis of measles when measles is rare.

Phase 2 Evaluation of Parainfluenza Type 3 Cold Passage Mutant 45 Live Attenuated Vaccine in Healthy Children 6–18 Months Old

A phase 2 evaluation of live attenuated parainfluenza type 3 (PIV3)-cold passage mutant 45 (cp45) vaccine was conducted in 380 children 6-18 months old; 226 children (59%) were seronegative for PIV3. Of the 226 seronegative children, 114 received PIV3-cp45 vaccine, and 112 received placebo. No significant difference in the occurrence of adverse events (i.e., runny nose, cough, or temperature > or =38 degrees C) was noted during the 14 days after vaccination. There was no difference between groups in the occurrence of acute otitis media or serous otitis media. Paired serum samples were available for 109 of the seronegative vaccine recipients and for 110 of the seronegative placebo recipients; 84% of seronegative vaccine recipients developed a > or =4-fold increase in antibody titers. The geometric mean antibody titer after vaccination was 1 : 25 in the vaccine group and <1 : 4 in the placebo group. PIV3-cp45 vaccine was safe and immunogenic in seronegative children and should be evaluated for efficacy in a phase 3 field trial.

Pediatric Imported Malaria in New York: Delayed Diagnosis

The records of 20 children with imported malaria admitted to Kings County Hospital between October 1987 and May 1995 were reviewed. All had a history of recent travel or immigration from a malaria endemic area (West-Africa [16], Central-America [three], and the Caribbean [one]). None of the 10 children with a travel history received appropriate malaria chemoprophylaxis. The most common symptoms and signs were daily fever, chills, and hepatomegaly. Diagnosis was delayed in seven children who were initially felt to have pharyngitis or viral syndrome. Common laboratory findings were anemia and thrombocytopenia. P falciparum was identified in 70% of the patients. Other species were P malariae and P vivax. Complications occurred in six children, hyponatremia in five, seizures in three, and cerebral malaria in one patient. The high incidence of chloroquine-resistant malaria makes chemoprophylaxis difficult in children. The clinical presentation of malaria is nonspecific, and diagnostic delays occur, so a high index of suspicion is needed in children with a travel history.

Evaluation of a Treponema pallidum-specific IgM enzyme immunoassay and Treponema pallidum Western blot antibody detection in the diagnosis of maternal and Congenital syphilis

Background Congenital syphilis (CS) is a result of untreated or inadequately treated maternal syphilis. CS is more likely with early stages of maternal syphilis, but most mothers lack signs or symptoms and the risk of CS is unclear. Goal The goal of this study was to evaluate Treponema pallidum IgM Western blot (TP IgM WB) and a T. pallidum IgM enzyme immunoassay (TP IgM ELISA) in mothers with syphilis to determine if positive tests better indicate a risk of CS than a rapid plasma reagin titer ≥1:16. Study Design Ninety-seven mother–baby pairs with reactive syphilis serology were evaluated. Results TP IgM WB tests were positive in 18 pregnancies (7 of 18 babies had CS) and negative in 79 pregnancies (7 of 82 babies had CS). Thirty-two mothers had titers ≥1:16 (6 babies with CS) and 65 mothers had titers ≤1:8 (8 babies with CS). Conclusion TP IgM tests better identify mothers at risk of delivering babies with CS than maternal titer ≥1:16.

Congenital syphilis and fluorescent treponemal antibody test reactivity after the age of 1 year.

Background Manybelieve that a persistently reactive fluorescent treponemal antibodyabsorption (FTA-ABS) is manifested with congenital syphilis after the age of 1year, that it is useful in the retrospective diagnosis of children withcongenital syphilis, and that it can be used to confirm other treponemaltests. Goal Todetermine whether a reactive FTA-ABS after the age of 12 months is indicativeof congenitalsyphilis. StudyDesign Prospective outpatient follow-up evaluation until atleast the age of 12 months was conducted for 194 babies born to mothers withreactive syphilis serology at delivery, and for two additional children withcongenital syphilis diagnosed when they were younger than 1 year (total, 196children). Results Inthe study group, 54 children had reactive FTA-ABS (reactors) until the age ofat least 12 months or more, and 142 children had nonreactive FTA-ABS(nonreactors) at the age of 12 months or more. Of the 54 reactors, 17 (31%)had evidence of congenital syphilis at birth, whereas evidence of congenitalsyphilis was seen in 14 of the 142 (10%) nonreactors(P = 0.0002). At 15 months,nonreactive FTA-ABS developed in six reactors, and eventually in 15 of 44reactors (34%)tested. Conclusions Areactive FTA-ABS may be seen at 12 months in children with and withoutevidence of congenital syphilis at birth. Not all children with congenitalsyphilis will manifest reactive FTA-ABS at 12 months, and FTA-ABS reactivitywanes withtime.

Maternal immunity to measles and infant immunity at less than twelve months of age relative to maternal place of birth

Sera from infants aged 5 to 11 months and from their mothers were used to investigate the level and duration of transplacentally derived measles antibody. The infants of foreign-born, inner-city mothers were more likely to have measles antibody and were less likely to get measles. Infants of foreign-born mothers, because they are less likely to respond to measles vaccine, may require different vaccine strategies than infants of mothers born in the United States.

Pneumococcal C and type polysaccharide detection in the concentrated urine of patients with bacteremia

The C polysaccharide of Streptococcus pneumoniae was detected in the concentrated urine of 23 of 33 patients with pneumococcal bacteremia using latex agglutination. Type-specific polysaccharides were detected in the urine of 17 of these 33 patients including 4 patients lacking C polysaccharide in their urine. These 4 with the 23 detected above gave a total sensitivity of 82% (27/33). The concentrated urine from an additional 11 patients with other bacteremias were tested by C polysaccharide and type-specific reagents and were negative. C polysaccharide detection in the concentrated urine of patients may be helpful in the diagnosis of pneumococcal infections.

Cerebrospinal fluid anion gap in meningitis

CEREBROSPINAL FLUID lactic acid determination can be useful in the rapid differentiation of bacterial from viral meningitis. 1-:~ In patients with bacterial meningitis, CSF lactic acid concentrations are elevated in comparison to those in patients with aseptic meningitis, whose levels are lower but not comparable to those in controls, z Since the enzymatic determination of lactate is not routinely available in many hospitals, CSF anion gaps ([Na § + [K +] -- [C1-] -- [TCO~]) have been correlated in this study with the CSF lactic acid concentrations to determine the value of this readily available test in the rapid diagnosis of bacterial meningitis. MATERIALS AND METHODS Eighty-three CSF samples from 71 patients at the Rhode Island Hospital were tested for lactic acid, sodium, potassium, chloride, and bicarbonate (approximated by TCO:) concentrations. Patients underwent lumbar puncture as part of their clinical evaluation, and included 65 children from one month to 18 years of age, and six adults. In addition, 33 sera from 32 patients were tested for sodium, potassium, chloride, and bicarbonate concentrations. The electrolyte concentrations were determined by standard techniques ([Na +] + [K ~] by the flame photometry method, and [C1-] + [TCO~] with the Beckman analyzer) in the hospitals pediatric chemistry laboratory. For lactate measurements, CSF was precipitated in a 2:1 ratio of 0.6N perchloric acid to sample and was analyzed in triplicate by an enzymatic lactate method, using lactate dehydrogenase and 0.4M hydrazine (Lactate test combination, Boehringer Mannheim, Mannheim, West Germa

Randomized Controlled Trial of the Safety and Immunogenicity of Revaccination With Tetanus-Diphtheria-Acellular Pertussis Vaccine (Tdap) in Adults 10 Years After a Previous Dose

Abstract Background Reduced-antigen-content tetanus, diphtheria, and acellular pertussis (Tdap) vaccine is recommended in many countries for boosting immunity in adolescents and adults. Although immunity to these antigens wanes with time, currently available Tdap products are not labeled for repeat administration in the United States. Methods We performed an observer-blinded, randomized controlled trial in 1330 adults aged 18 to <65 years who received either the Tdap (n = 1002) or tetanus-diphtheria (Td) (n = 328) vaccine 8 to 12 years after a dose of Tdap vaccine administered previously. Solicited adverse events following immunization were documented for 7 days after vaccination, and serious adverse events and adverse events of medical significance were documented for 6 months after vaccination. Levels of antibodies against component vaccine antigens were measured before and 1 month after vaccination. Results A solicited adverse event was reported by 87.7% of Tdap and 88.0% of Td vaccine recipients. We found no significant differences in the rates of injection-site reactions, systemic reactions, or serious adverse events between the vaccine groups. A robust antibody response to each pertussis antigen in the Tdap-vaccinated group was found; postvaccination-to-prevaccination geometric mean antibody concentration ratios were 8:1 (pertussis toxoid), 5.9 (filamentous hemagglutinin), 6.4 (pertactin), and 5.2 (fimbriae 2 and 3). Postvaccination geometric mean concentrations of tetanus antibody (4.20 and 4.74 IU/mL, respectively) and diphtheria antibody (10.1 and 12.6 IU/mL, respectively) were similar in the Tdap and Td groups, and the rates of seroprotection against tetanus and diphtheria were >99% in both groups. Conclusions A second dose of Tdap vaccine in adults approximately 10 years after a previous dose was well tolerated and immunogenic. These data might facilitate consideration of providing Tdap booster doses to adults.