Kristina N. Feja

Management of pediatric multidrug-resistant tuberculosis and latent tuberculosis infections in New York City from 1995 to 2003.

Background: Few studies have assessed the management and outcomes of multidrug-resistant tuberculosis (MDR-TB) in the pediatric population. Treatment of children with second-line TB drugs is complicated by potential toxicities of these agents. Methods: We performed a retrospective study of children <15 years of age treated for MDR-TB or MDR-latent TB infection (LTBI) from 1995 to 2003. We reviewed the New York City Department of Health and Mental Hygiene (DOHMH) computerized TB registry to characterize demographic characteristics, clinical presentations, treatment, and outcomes of the study subjects. Results: Twenty subjects with MDR-TB (mean age 2.7 years) and 51 with MDR-LTBI (mean age 9.8 years) were studied. The most commonly used second-line TB drugs were cycloserine, quinolone agents, and ethionamide, which were used in 70%, 69%, and 54% of subjects, respectively. Sixteen (80%) of 20 MDR-TB and 38 (75%) of 51 MDR-LTBI cases completed treatment. A greater proportion of subjects receiving care at a DOH clinic completed treatment for LTBI (36/41, 88%), when compared with subjects treated at non-DOH sites [(2/9, 22%) P < 0.001]. Review of the TB registry indicated that no subjects had recurrent disease or progression of LTBI to active disease during the study period and for 2 years thereafter. Conclusions: Children with MDR-TB and LTBI were best cared for in public health settings. A multicenter registry for pediatric MDR-TB and MDR-LTBI would be desirable to obtain accurate rates of toxicity and cure.

Neonatal Herpes Disease following Maternal Antenatal Antiviral Suppressive Therapy: A Multicenter Case Series

OBJECTIVE The goal was to describe herpes simplex virus (HSV) disease in neonates whose mothers received suppressive acyclovir therapy for HSV infection. STUDY DESIGN A multicenter case series of 8 infants who developed neonatal HSV disease following maternal antiviral suppressive therapy during pregnancy. RESULTS Eight infants were identified from New Jersey (5), Maine (1), New York (1), and Texas (1) between 2005 and 2009. All 6 mothers of infants infected with HSV who were screened prenatally for group B Streptococcus were positive; 1 mother was not tested and the other had bacterial vaginosis and genital human papillomavirus infection. Six mothers had a first clinical episode of genital HSV infection during this pregnancy; mothers with a prior history of genital HSV had no clinically recognized outbreak during the pregnancy. Perinatal transmission of HSV occurred in 7 infants (despite suppressive therapy until the day of delivery in 5 instances). Seven of 8 patients were born at term; 6 infants were male. In 7 of 8 cases, HSV was diagnosed by 8 days of age. Five infants had skin, eye, and mucous membrane disease, 2 had central nervous system disease (without and with disseminated disease), and one had intrauterine/disseminated disease. CONCLUSIONS Although maternal antiviral suppressive therapy is an increasingly wide practice, physicians caring for neonates should be aware that suppressive therapy does not prevent neonatal HSV disease, which can have an atypical clinical presentation and drug resistance.

Underuse of Effective Measures to Prevent and Manage Pediatric Tuberculosis in the United States

OBJECTIVE To characterize problems with prevention and management of pediatric tuberculosis (TB) and latent TB infection (LTBI). DESIGN A multisite, cross-sectional study using data from medical records and public health logs to categorize and define use of routine prevention practices in managing pediatric TB and LTBI. SETTING Four areas of the United States. PARTICIPANTS Children younger than 5 years diagnosed with TB from January 1, 2002, through December 31, 2004, and children with LTBI reported during a continuous 12-month period in 2003 to 2004. Main Exposure Mycobacterium tuberculosis. MAIN OUTCOME MEASURES Underuse or nonuse of standard medical and public health interventions. RESULTS Almost 40% of children had a TB risk factor related to their country of birth, parental origin, or travel to a country with a high incidence of TB. Children having LTBI were less likely than those having TB to complete treatment (53.7% vs 88.6%, respectively). Almost half (46.3%) of the children with TB came to medical attention late in their course when they already had symptoms. Among 63 adult source patients, 19 (30.2%) previously had LTBI but were not treated, and none of the 40 foreign-born source patients were known to have been evaluated for TB before entry into the United States. CONCLUSIONS Prevention efforts are unsatisfactory to prevent TB in children. Effective interventions such as treatment of LTBI and TB evaluation of adult immigrants remain less than optimal.

Implementation of a pertussis immunization program in a teaching hospital: An argument for federally mandated pertussis vaccination of health care workers

BACKGROUND As pertussis disease becomes more common, health care-associated outbreaks have been reported with increasing frequency. Often, these clusters are costly and labor intensive to investigate and contain. It is clear that health care workers are among the adults who transmit pertussis to susceptible infants. Recent focus on patient safety, together with a concern for protecting employees in the workplace and those they expose elsewhere, has spurred interest in optimizing measures to prevent infection and disease transmission. Shortly after a tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed booster was licensed and became available, we designed, launched, and analyzed a campaign to immunize the employees of our institution against pertussis. METHODS To optimize acceptance of a tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed booster by employees, we adopted a program consisting of a 3-phase publicity and educational model and a 3-phase vaccine delivery approach. RESULTS Despite extraordinary resources dedicated to this program, and our institutions better than average annual uptake of influenza vaccine, less than one third of our eligible employees were immunized. A significant number of employees declined to be vaccinated for inappropriate reasons. CONCLUSION A campaign of this kind is quite labor intensive and expensive, yet limited overall vaccine uptake was achieved. A federal mandate to require pertussis immunization of all health care workers appears to be a more effective way to protect our patients, employees, families, and society.

An Adolescent With Pseudomigraine, Transient Headache, Neurological Deficits, and Lymphocytic Pleocytosis (HaNDL Syndrome): Case Report and Review of the Literature

We report a 16-year-old adolescent with 2 episodes of focal neurological deficits, pseudomigrainous headache, and lymphocytic pleocytosis due to the syndrome of transient headache and neurological deficits with cerebrospinal fluid (CSF) lymphocytosis (HaNDL), also known as pseudomigraine with CSF pleocytosis. Review of the literature identifies 13 additional cases of HaNDL in the pediatric population. These cases are reviewed and evidence for possible etiopathogenesis is discussed. This syndrome may mimic much more common conditions such as complicated or hemiplegic migraine, aseptic meningitis, meningoencephalitis, or stroke. However, HaNDL differs from complicated or hemiplegic migraine and stroke since CSF pleocytosis is uniformly present. There are many infectious conditions that can present with neurological deficits, headache, and CSF pleocytosis, but the transient nature of the deficits and lack of a consistently identifiable infectious etiology despite extensive evaluations typify HaNDL. This clinical syndrome is underrecognized and underreported. HaNDL remains a diagnosis of exclusion.

Investigation of an apparent outbreak of Rhodococcus equi bacteremia

During January to April 2007, hospital staff reported 3 patients with Rhodococcus equi bloodstream infections. Isolates were analyzed at the Centers for Disease Control and Prevention, Atlanta, GA, to confirm identification and to assess strain relatedness; 2 were R. equi but genetically distinct, and 1 was identified as Gordonia polyisoprenivorans. Rapid reference laboratory support prevented an unnecessary outbreak investigation.

Index of SuspicionCase 1: Persistent Flank Pain and Voiding Dysfunction in an 11-Year-Old BoyCase 2: Fever, Knee Pain, and Limp in an 8-Year-Old BoyCase 3: Intermittent Abdominal Pain of 1-Month Duration in a 14-Year-Old GirlCase 4: Petechial Lesions on Toes of an 11-Year-Old Girl

An 11-year-old boy presents with a long history of left flank pain and enuresis and a new finding of left renal atrophy. The patient’s left flank pain began at age 3 years during potty training. At age 4 years, he underwent computed tomography (CT) and renal ultrasonography (RUS), which revealed a thickened bladder and a smaller left kidney (left kidney, 7.1 cm; right kidney, 8.0 cm). Urinalysis was normal. A pediatric urologist at another institution thought the pain was musculoskeletal. The patient’s pain continued, and he was reevaluated at age 10 years when he began experiencing penile pain concomitant to the flank pain. Subsequent RUS revealed a lack of left renal growth. Voiding cystourethrogram (VCUG) was nondiagnostic because the patient could not void at that time. A technetium-99m-mercaptoacetyltriglycine scan (MAG3) revealed reduced radiotracer uptake on the left, which was consistent with a minimally functioning left kidney (13%) but good clearance of tracer bilaterally demonstrating no evidence of obstruction. Our pediatric urology team was subsequently consulted out of concern for infravesical obstruction from posterior urethral valves (PUVs), leading to secondary, left-sided, vesicoureteral reflux (VUR). VCUG findings (Figure 1) are abnormal in that the patient’s bladder capacity was 500 mL, greater than expected given his age, and he required 2 attempts to void to completion. No dilation of the posterior urethra, as typically seen with PUV, or VUR, was identified. Figure 1. Voiding cystourethrogram shows elevated bladder capacity and normal urethra. Arrow indicates the sphincter. Because of the patient’s difficulty voiding and decline in renal function, the patient is taken to the operating room, where a cystourethroscopy is performed, revealing his diagnosis. An 8-year-old boy is admitted with fever and a red, swollen left knee. One week before admission, he developed left knee pain and limp. There was no fever, swelling, or redness of …

A 9-Month-Old Infant With Fever and Fussiness

A 9-month-old, previously healthy, fully immunized Korean male infant had fever to 101°F (axillary) off and on for 2 weeks, fussiness, decreased activity, decreased oral intake, and vomiting after feeding. His family stated that he felt warm to touch every night and that they had measured his temperature 3 or 4 times during the 2-week period. He was reported by grandmother to have fallen out of bed 1 month earlier and she noted that he seemed to prefer sleeping on his right side since the fall. His grandmother also noted swelling of the right neck for 2 weeks, which his parents denied. Initial physical examination revealed a well-developed, well-nourished male infant in no acute distress. His temperature was 100.1°F (although his maximum temperature during the first hospital day was 101°F twice), heart rate 168 beats per minute, respiratory rate 30 breaths per minute, and oxygen saturation breathing room air 97%. His tympanic membranes were clear. His pharynx was injected. The rest of his examination was reported to be unremarkable. Laboratory evaluation included a white blood cell count of 26 600/mL, with 57% neutrophils, 2% bands, 31% lymphocytes, 10% monocytes, and platelet count 788 000/mL. Hemoglobin concentration was 11.1 g/dL. C-reactive protein was 58 mg/dL. Serum chemistries were within normal limits. Rapid antigen tests for viral infections, cerebrospinal fluid analysis, and chest radiography were negative or within normal limits. Subsequent physical examination revealed a 2 cm tender, but nonfluctuant, noninflammatory right anterior cervical lymph node. Cardiology evaluation was obtained and an echocardiogram was essentially normal. Given his age, ethnic background, fever, fussiness, unilateral cervical lymphadenopathy, leukocytosis, and thrombocytosis, a diagnosis of incomplete Kawasaki disease (KD) was made and treatment with immune globulin intravenous and aspirin was begun. On the second day of hospitalization, infectious diseases (KNF) evaluation was sought. Decreased and painful neck extension and decreased range of motion of the neck were noted. He was observed to keep his head turned to the left. Shortly thereafter, spontaneous drainage of approximately 5 mL of pus was noted from the right ear. An additional 20 mL of pus was drained by the otolaryngologist (JH) at the bedside. Computed tomography of the neck demonstrated a right retropharyngeal, peripherally enhancing abscess measuring 3.8 × 0.9 cm immediately posterior and medial to the right carotid sheath; parapharyngeal extension; associated compression of the right internal jugular vein; extension toward the right jugular foramen; mild mass effect on the adjacent airway; complete opacification of the right external auditory canal (EAC) with connection to the abscess via a defect in the exterior bony canal; but no evidence of involvement of the right mastoid air cells or middle ear cavity and no intracranial extension (Figures 1 and 2). He was started on clindamycin and vancomycin and taken to the operating room for thorough abscess drainage. There, examination revealed fullness of the right parapharyngeal space posterior to the right tonsillar pillar. An incision over the most fluctuant area released a copious amount of phlegmonous material, cultures of which were positive for methicillin-sensitive Staphylococcus aureus. His therapy was changed to oxacillin and then oral cephalosporin at the time of discharge from the hospital. He recovered completely and continues to do well.